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THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


A*S5^^^^^^0 


^■-..*Si-i  Y^'\^i^^>^. 


-*^^l>*iiV^  V  V\ 


^^^ 


1 


NEW  ELEMENTS 


OPERATIVE   SURGERY; 


WITH 


An  Atlas  of  neajrly  Three  Huxidred  engravixigs, 

BEPBESENTING 

THE   PRINCIPAL    OPERATIVE   PROCESSES,  AND   A   GREAT    NUMBER    OF    SURGICAL- 
INSTRUMENTS. 


By  ALF.  a.  L.  M.  VELPEAU. 

Surgeon  to  the  Hospital  of  la  Pitie  ;  Fellow  of  the  Faculty  of  Medicine  of  Paris; 

Surgeon  to  the  Dispensaries  of  the  Philanthropic  Society ;  Professor  of  Midwifery,  Anatomy,  Pathologicu^l 

and  Operative  Surgery ;  Member  of  the  Medical  Society  of  Emulation  of  Paris  ;  Corresponding 

Member  of  the  Medical  Societies  of  Tours,  Louvian,  &c.  &c. 


friTH  AN  APPENDIX  OF  NOTES, 

By  GRANVILLE  SHARP  PATTISON,  M.  D. 

Professor  of  Anatomy  in  Jefferson  Med.  Col.  Phila. 


?!2^asi)ingtoit : 
PUBLISHED  BY  DUFF  GREEN. 

1835. 


INDEX. 


Preface. 
Introdtjctio^-. 
Elementary  Operations. 
Chapter  I. — Divisions 
Section  I. — Cutting  instruments 
Article  1.  Manner  of  holding  the  bis- 
toury .  _  -  - 
§  1.  First  position.  Bistoury  held  as 

a  knife,  the  edge  downwards 
§2.   Second  position.  Bistoury  held 

as  a  knife,  the  edge  upwards 
§3.   Third  position.     Bistoury  held 
as  a  pen,  the   edge  downwards, 
the  point  forwards 
§4.  Fourth  position.   Bistoury  held 

as  a  pen,  the  point  backwards 
§  5.  Fifth  position.     Bistoury  held 

as  a  pen,  the  edge  upwards 
§  6.  Sixth  position.     Bistoury  held 
as  a  drill-bow        _  .  . 

Art.  2.-JHanner  of  holding  the  scis- 
sors -  -  -  - 
Sect  II. — Different  kinds  of  incisions 
Art.  1.   Simple  Incisions 

§  1.  Incision  from  without  inwards 
§  2.  Incision  fr-om  within  outwards 
§  3.  Upon  a  director 
§  4.  With  a  fold  of  the  integuments 
4  5.  Horizontally    -  -  - 

Art.  2.   Compound  incisions 
§  1.  The  V  incision 
^  2,  The  oval  incision 
§  3.  The  cross  incision 
§  4.  The  T  incision 
§  5.  The  elliptical  incision 
§  6.  The  crescentic  incision 
Art.  3.  Incisions  applied  to  abscesses, 
to  collections  of  fluids 
§  1.  Incision  from  within  outwards 
4  2.  Incision  from  without  inwards 
§  3.   Complex  incisions 
Art.  4.  Incisions  applied  to  the    dis- 
section of  tumors  and  of  subcuta- 
neous cysts  -  .  > 


Page 
III 

IX 

1 
1 
1 

1 

2 
o 


13 


§1.  Form  of  the  incision    - 

1.  Straight  incision 

2.  V  incision        .  -  - 

3.  Crucial  incision 

§  2.   Dissection  of  the  Flaps 

1.  Concrete  tumors 

2.  Cancers  .  .  _ 

3.  Cysts 

Art  5.  To   cause  the  least  possible 
pain  -  -  -  - 

Sect.  III. — Punctures 

Chapter  II. — Reunion 

Art.  1.  Suture  ... 

§  1 .  Interrupted  suture 
§  2.   The  suture  of  Le  Dran 
§  3.  Furrier's  suture 
§  4.   Zigzag  suture 
§  5.   Twisted  suture 
§  6.   Quilled  suture 

CoKPLKX  Operations. 

Title  I. — Operations  upon  the  Blood- 
vessels J  -  .  . 

Chapter  I. — Operation  for  aneurism 
in  general    -  -  -  . 

Sect.  I. — Anatomical  remarks 

Sect.  II. — Spontaneous  cvu'e 

Sect.  III. — Curative  methods 

Art.  1.   Method  of  Valsalva    - 

Art.  2.   Refrigerants  and  styptics 

Art.  3.   Compression 

§  1.   Mediate  compression  - 
§  2.  Immediate  compression 

Art.  4.   Cautery 

Art.  5,   Ligature         -  .  . 

§  1.  Nature  and  form  of  the  ligature 
§  2.   Permanent  ligature     - 
§  3.   Precautionary  ligatures 
§  4.   Temporary  ligature     - 

Operative  processes    -  -  - 

§  5.   Two  ligatures  with  immediate 

division  of  the  artery 
§  6.  Ligature  throiigli  the  artery   - 
§  7.   Mediate  ligature 
§  8.  Immediate  ligature 
iii 


'<.'-' 


i:36Q>acr 


IV 


INDEX. 


Page 
Art.  6.   Methods  of  operation  -  48 
Relative  value  of  the  three  princi- 
pal methods          -            -  -  52 
Art  7.  Maiiual           -            -  -55 
§  1.   Old  method    -            -  -55 
§2.  Method  of  Anel           -  -  56 
§3.  Results  of  the  operation  -  60 
Art.  8,  Of  the  suture              -  -  62 
Art.  9.   Torsion,  Bruising        -  -  62 
Art.  10.  Acupuncture            -  -  63 
Art.  10  {again).    Changes  occurring 
in  vessels  of  a  limb  after  the  opera- 
tion  for  aneurism     -            -  -65 
Chapter  II. — Operations  for  the  parti- 
cular aneurisms        -  -  67 
Sect.  I. — Operations  for   diseases   of 
the  arteries   of  the  inferior  extre- 
mity            -            -            -  -67 

A.  Anterior  tibial  in  the  foot  -  67 
Art.  1.  Anatomical  remarks  -  67 
Art.  2.  Surgical  remarks  -  -  68 
Art.  3.   Manual           -             -  -  68 

B.  Anterior  tibial  in  the  leg  -  69 
Art.  1.  Anatomical  remarks  -  69 
Art.  2.  Surgical  remarks  -  -  69 
Art.  3.  Manual            .            -  -  70 

C.  Posterior  tibial  -  -  71 
Art.  1.  Anatomical  remarks  -  71 
Art.  2.  Surgical  remarks  -  -  72 
Art.  3.   Manual           -             -  -  7o 

D.  Peroneal            -            -  -  74 

E.  Popliteal            -             -  -75 
Art.  1.  Anatomical  remarks  -  75 
Art.  2.  Surgical    and    historical  re- 
marks         -            -            -  -75 

Art  3.  Manual            -            -  -  78 

Result  of  the  operation           -  -  78 

F.  Femoral              -            -  -  79 
Art.  1.  Anatomical  remarks  -  79 
Art.  2.   Surgical    and    historical  re- 
marks         -            -            -  -  80 

Art.  3.   Manual           -             -  -  83 

§  1.  Inferior  half    -            -  -  83 

§  2.  Superior  half  -            -  -  84 

4  3.  Results  of  the  operation  -  84 

G.  Ligature  of  the  circumflexes  or 

of  the  profunda                -  -  85 
H.    External  iliac    -            -  -  85 
Art.  1.  Anatomical  remarks  -  85 
Art.  2.  Historical    and    surgical  re- 
marks         -            -            -  -  86 
Art.  3.  Manual           -            -  -  88 
L  Internal  iliac        -            -  -  91 
Art.  1 .  Anatomical  remarks  -  91 
Art.  2.   Surgical    and    historical  re- 
marks         -            -            -  -  91 
Art.  3.  Manual           -            -  -  92 
K.   Primitive  iliac    -             -  -  93 
Art.  1.  Anatomical  remarks  -  93 
Art.  2.  Surgical    and    historical  re- 
marks         -           -            -  -  93 


Art.  3.  Manual  ... 

L.  Abdominal  aorta 

Art.  1.  Anatomical  remarks 

Art  2.  Surgical  and  historical  re- 
marks -  .  .  . 

Art.  3.  Manual  ... 

Sect.  II. — Arteries  of  the  superior  ex- 
tremity       -  .  -  , 

A.  Arteries  of  the  hand     - 
Art.  1.  Anatomical  remarks 
Art.  2.   Surgical  remarks 

Art.  3,   Manual  ... 

B.  Arteries  of  the  fore-arm 
Art.  1.  Anatomical  remarks 

Art.  2.  Surgical    and    historical    re- 
marks .  -  -  . 
Art.  3.   Manual           ... 

C.  Artery  of  the  elbow 
Art.  1.  Anatomical  remarks 

Art.  2.   Surgical    and    historical    re- 
marks _  .  _  _ 
Art.  3.  Manual           .            .            _ 

D.  Brachial  ... 
Art.  1.  Anatomical  remarks 

Ai't.  2.  Surgical    and    historical    re- 
marks -  -  .  - 
Art.  3.   Manual            -             .             - 

E.  Axillary  -  .  _ 
Art.  1.  Anatomical  remarks 

Art.  2.  Surgical    and    historical    re- 
marks -  -  .  _ 
Art.  3.  Manual            ... 

F.  Subclavian  .  .  , 
Art,  1.  Anatomical  remarks 

Art.  2.   Surgical  remarks 

Art.  3.   Manual 

Sect.  III. — Arteries  of  the  head 

A.  Temporal  -  -  - 

B.  Facial    -  -  - 
Sect  IV. — Arteries  of  the  neck 

A.  Primitive  carotid 
Art.  1.   Anatomical  remarks 

Art.  2.   Surgical    and    historical    re- 
marks .  .  -  - 
Art.  3.  Manual            -            -            - 

B.  Internal  and  external  carotids 

C.  Facial     .  -  -  - 

D.  Thyroids 

E.  Innominata         _  -  - 
Art.  1.  Anatomical  remarks 

Art.  2.  Surgical    and    liistorical    re- 
marks _  .  -  - 
Art.  3.  Modes  of  operation     - 
Chap.  III. — Naevi   Materni,  Erectile 
Tumors           -            -            -        - 
Chap.  IV.— -Varix 
Title  II. — Of  Amputations 
Chap.  I. — Amputations  in  general 
Sect.  I. — Indications 
Art.  1.   Gangrene           -             -        - 
Art  2.  Fractures           -           -        - 


Page 
94 
95 
95 

95 
97 

98 
98 
98 
98 
98 
99 
99 

100 
100 
101 
101 

102 
104 
105 
105 

105 
106 
106 
106 

107 
108 
110 
110 
112 
113 
116 
117 
117 
117 
117 
117 

118 
120 
122 
122 
123 
123 
123 

124 
125 

127 
129 
133 
133 
135 
135 
136 


INDEX. 


Art.  3.  Luxations 

Page 
136 

A.  Flap  method 

. 

203 

Art.  4.  Caries,  Necrosis 

137 

B.  Circular  method 

- 

204 

Art.  5.  Cancerous  affections 

137 

Art.  6.  Arm 

- 

205 

Art.  6.  Aneurism 

138 

A.   Circular  method 

- 

206 

Art.  7-  Suppuration       -            -        . 

138 

B.  Flap  method 

- 

20? 

Art.  8.  White  swelling 

139 

Art.  7.   The  arm  at  the  joint 

- 

Art.  9.  Tetanus— Bite  of  a  rabid  ani- 

§1.  Manual      - 

- 

208 

mal     -            -            -            -        . 

139 

A.  Circular  method     - 

- 

208 

Art.  10.   Amputations  of  convenience 

140 

B.  Flap  method 

- 

209 

Art.  11.   Gunshot-wounds 

141 

C.   Oval  method 

- 

213 

Sect.  II. — Preliminary  attentions 

143 

§2.  Comparisonof  the  methods     - 

214 

Art.  1.   Counter-indications 

143 

Art,  8.      The   shoulder — ^Jiistory   and 

Art.  2.  Time  for  the  operation 

144 

indication 

- 

215 

Art.  3.  Point  of  amputation 

147 

Manual 

- 

215 

Art.  4.  Preparatives       -             -         - 

147 

Sect.  II. — The  inferior  extremity 

215 

Sect.  Ill, — Methods  of  operation 

150 

Art.  1.   Toes 

215 

A.  Amputations  in  continuity 

150 

Art.  2.   Metatarsus 

216 

Art.  1.  Circular  method 

150 

§  1.  In  the  continuity 

216 

§  1,  Manual     -            -             -         - 

150 

A.  First  metatai-sal  bone 

216 

§2.  Dressing     -          -             -        - 

162 

B.   Second  metatarsal  bone 

217 

§  3.  Consecutive  treatment 

167 

C.   Extraction 

218 

§  4.  Accidents             -             -         - 

169 

D.   Collectively 

218 

Art.  2.  Flap  method      - 

175 

§  2.   Disarticulation    - 

218 

Art.  3.  Oval  method 

176 

Manual 

219 

B.  Amputation  in  the  contiguity 

177 

Art.  3.  Amputation  of  a  part 

of  the 

Chap.  II.— Amputations  in  particular 

179 

tarsus 

- 

224 

Sect.  1.— The  upper  extremity 

179 

Art.  4.    Comparison  of  the  two  par- 

Art. 1.   The  fingers 

180 

tial  amputations  of  the  foot 

- 

227 

§  1.  Partial  amputation 

181 

Art.  5.    Extraction  of  a  part 

of  the 

Manual         .             .             .         - 

181 

tarsus 

- 

227 

Dressing  and  after  treatment 

183 

Art  6.   The  whole  foot 

. 

227 

§  2,  Amputation  of  the  whole  finger 

183 

Art.  7.  Amputation  of  the  leg 

- 

228 

Manual         -             -             -         - 

184 

Manual 

- 

230 

§  3.  Amputation  of  the  fingers  col- 

1. Process  of  Sabatier 

- 

233 

lectively       -            -            -        - 

186 

2.         «      of  Dr.  Physic 

. 

233 

Art.  2.  Metacarpus        -            -        - 

387 

3.         "      ofBaudenorB. 

Bell     . 

233 

§  1.  In  the  continuity 

187 

Dressing 

- 

233 

Amputation  of  the  metacarpus  in 

Flap  operation 

- 

234 

a  body      -             -             -         - 

188 

1 .  Process  of  Verduin 

- 

234 

Amputation  of  a  single  bone 

188 

2.         "       of  Hey       - 

- 

234 

§  2.  In  the  contiguity 

189 

3.         "       of  Ravaton 

. 

234 

A.  Metacarpal  of  the  thumb — Am- 

4.        "       of  y  ermale 

- 

235 

putation       -            -            -        - 

189 

5.         "       ofDupuytren 

- 

235 

Extraction 

191 

6.         «       ofRoux      - 

. 

235 

B.  Fifth  metacarpal — Amputation 

192 

7.         «      of  the  Author 

- 

235 

Extraction                -             ^        - 

192 

In  the  articulation   - 

- 

236 

C.  Middle  metacarpal — Amputa- 

[Manual 

- 

239 

tion     -        -            -            -        - 

193 

1.  Process  of  Hoin 

239 

Extraction                -            -        - 

194 

2.         «       ofLeveille 

239 

E.  Disarticulation  of  several  or  of 

3.         «       ofBlandin 

239 

all  the  metacarpal  bones  collec- 

4.        «       of  Smith 

240 

tively           -            -            -        - 

194 

5.         «       of  Rossi 

240 

1.  Anatomical  remarks 

194 

Dressing 

240 

2.  Manual      -          -             -        . 

195 

Art.  9.  The  thigh 

241 

Art.  3.  The  wrist 

196 

§  1.  In  the  continuity 

241 

A.  Circular  method 

197 

Anatomical  remarks 

241 

B.  Flap  method 

198 

Manual    - 

242 

Art.  4.  The  forearm      - 

199 

Circular  method 

242 

A.   Circidar  method                 - 

200 

Position  of  assistants 

242 

B.  Flap  method          -            w         - 

201 

Flap  operation      - 

243 

Art.  5.  The  elbow 

203 

1.  Process  of  Vermale 

244 

INDEX. 


2.  Process  of  Langcnbeck 

In  the  contig-aity 

History  and  value 

Anatomical  I'cmarks 
§  1.  Manual — Circular  method 

Eng"lish  process  - 

Flap  operation    - 

1.  Process  of  Labonette     - 

2.  «       of  Blandate 

3.  "of  Manee 

4.  «       of  Ashmead 

5.  «       of  Delpech 

6.  "       of  M.  Larry 

7.  "       of  Blandin 

8.  «       of  Lisfranc 

9.  "      of  Dupuytren    - 

10.  ««       of  Beclard 

11.  «      of  Guthrie 
C.  Oval  operation 

1.  Process  of  M.  Cornuar   - 

2.  «       ofLecoIletan     - 

§  2.  Relative  value  of  various  me- 
tliods        .  .  -  . 

Title  III. — Excision  of  the  Bones 
Chapter  I. — In  the  continuity 

1.  Recent  fractures 

2.  Wounds  from  fire-arms  - 

3.  Old  non-consolidated  fractures 
Method  of  operating 
Org-anic  lesions    - 

\rt.  1.  The  ribs 

Operation 
Art.  2.  The  sternum 
Art.  3.  Lower  inferior  jaw 

History  and  value 

Operation 

After  operation    - 
Art.  4.    Superior  maxillary  bone 
('hapt.  II. — Excision  of  the  joints 
Sect.  I. — Thoracic  members 
Art.  1.   The  hand      - 

Operation 
Art.  2.   The  wrist      - 

1.  Operation.     First  method 

2.  M.  Dubled's  method       - 

3.  Moreau  and  Roux's  method 
Art.  3.   The  elbow     - 

1.  Operation.     Park's  method 

2.  Moreau's  method 

3.  Dupuytren's  method 

4.  Author's  method 
Art.  4.   Radius 

Art.  5.   The  shoulder 

Operation.    (1st  White's)  method 
2.   Moreau's  methods 
Mancas's        " 


Sabatier's 
Bent's 
Morel's 
Lyme's 
Remarks 


Page 

244 
245 
245 
247 
248 
248 
248 
249 
249 
249 
249 
250 
250 
250 
251 
251 
251 
251 
251 
252 
252 

252 
254 
254 
254 
255 
255 
255 
256 
257 
257 
257 
258 
258 
259 
262 
262 
265 
267 
267 
267 
267 
267 
268 
268 
269 
269 
269 
269 
270 
271 
272 
272 
273 
273 
273 
273 
273 
273 
273 


Art.  6.  The  clavicle  -     -  -  275 

1.  Acromial  extremity    -  -  275 
Extirpation     -     -  -  276 

Sect.  II. — Abdominal  members  -  277 

Art.  1.   Tibio-torsal  articulation  -  278 

Operation.     1.  Moreau's  method  -  278 

2.  Roux's  method  -            -  -  278 
Value       -            -            .  -  278 

Art.  2.   Knee              -            -  -  279 

Operation.     1.  Park's  method  -  279 

2.  Moreau's  method            -  -  279 

3.  MM.  Sanson  and  Begin's  method  280 

4.  Lyme's  method               -  -  280 
Remarks               -             .  .  280 

Art.  3.   Head  of  the  femur      -  -  281 
Artificial  articulation        -  -  281 
Title  IV. — Trepanning          -  -  282 
Chapt.  L — The  cranium         -  -  282 
Parts  that  admit  of  it            -  -  284 
Apparatus,  operation,  and  1st  step  285 
2d  step         -            -            -  -  286 
3d  step  and  remarks            -  -  287 
Dressing               -            -  -  288 
Chapt.  II. — Thorax,  pelvis,  and  extre- 
mities          -             -            -  .  290 
Scapula,  spine,  and  long  bones  -  292 
Special  Operations  -             -  .  293 
Operations  on  the  head    -  -  293 
Chapt.  I. — The  cranium         -  -  293 
Method  of  operating         -  -  293 
Osseous  tumors    ..            -  .  294 
Encephalocele     ...  294 
Lupia       ....  294 
Operation             -            -  -  294 
Hydrocephalus    -            -  -  295 
Chapt.  II.— The  face              -  -  295 
Sect.  II. — The  nose   -             -  .  295 
Taleacotian  operation      -  -  295 

1.  Tagliacozzi's  method     -  -  297 
h.  M.  GrsePs          «          -  -  297 

2.  Indian                              -  -  298 
a.  By  means  of  cutaneous  flap 

from  the  rump              -  -  298 

h.  By  transplantation       -  -  298 

c.  With  the  skin  of  the  forehead-  299 

3.  French  method                 -  .  300 
Relative  value      -            -  -  300 

Art.  2.  Other  operations  on  the  nose  301 

Excision  of  tumors  -             -  .  391 

New  operations       ...  302 

Occlusion  of  nosti'ils             -  -  302 

Rhinoraphia             -            -  -  302 

Appabatus  of  Vision              -  -  303 

Art.  1.  Lachrymal  passages  -  -  303 

§  1.  Anatomical  remarks    -  -  303 

§  2.   Obstruction,  tumor      -  -  304 

Anel's  method      -            -  -  305 

Injections              -             -  -  305 

Catheterism          -             -  -  305 

Laforest's  method            -  -  305 

§  3.  Fistula              -            -  -  306 


INDEX. 


Vll 


Page 

Page 

Dilatation  of  the  natural  passages 

307 

Orbital  cavity 

. 

. 

329 

Mej  can's  method 

- 

- 

307 

Art.  4.  Globe  of  the  eye 

- 

- 

331 

Pallucce's     « 

- 

- 

307 

§  1.  Foreign  bodies 

- 

- 

331 

Caboni's       *' 

. 

308 

§  2.  Pterygium 

- 

- 

331 

Guerin's        « 

. 

. 

308 

§  3.  Cataract 

- 

. 

332 

Care's          « 

- 

- 

308 

1.  History 

- 

- 

332 

Dilatation   through    an 

'iccidental 

2.   Conditions 

- 

- 

332 

opening 

- 

- 

309 

3.  Ages       - 

- 

- 

334 

Monro's  method  - 

. 

- 

309 

4.  Simple  or  double 

- 

- 

334 

Ponteau's    «* 

. 

- 

309 

5.  Preparations 

- 

- 

336 

Lecat's        « 

. 

. 

309 

6.   Seasons 

- 

_ 

336 

Desault's     « 

- 

- 

310 

Methods  of  operating 

- 

- 

337 

B oyer's  modification 

- 

- 

310 

Depression 

- 

- 

337 

Pamard's  method 

- 

- 

310 

1.   Preliminary  attentions 

- 

• 

337 

Jurine's          " 

- 

- 

310 

Apparatus — Instruments 

- 

337 

Foumier's      " 

- 

- 

311 

2.  Operation 

- 

- 

338 

Jourdan's       " 

. 

. 

311 

Ordinary  method 

. 

. 

338 

Scarpa's         « 

- 

. 

311 

Process  of  Petit  and  Ferrein 

. 

341 

Ware's           « 

. 

- 

312 

«           the  author's 

. 

- 

342 

Permanent  canula 

- 

- 

312 

Hyalonyxis 

- 

- 

342 

Cautery   - 

- 

. 

314 

Scleroticotomy     - 

- 

- 

34:^ 

Superior  operation 

- 

- 

315 

Retroversion  or  reclinat 

ion 

- 

343 

Process  of  Harveng 

- 

- 

315 

Cutting  or  breaking  up 

3f  the  lens 

343 

Process  of  Deslande 

. 

_ 

315 

The  lens  passed  to  the  anterior 

Inferior  operation    - 

. 

. 

315 

chamber 

. 

. 

344 

Process  of  Bermond 

- 

- 

315 

Ceratonyxis 

. 

. 

344. 

Process  of  Gensoul 

- 

- 

315 

Simple  puncture  of  the 

cornea 

. 

346 

FonMATION  OF  A  NEW  CANAL 

. 

. 

316 

In  children 

- 

. 

346 

Process  of  Woolhouse 

- 

- 

317 

Consecutive  treatment 

- 

_ 

347 

«       of  St.  Yves 

- 

» 

317 

Extraction 

- 

. 

348 

«       of  Dionis 

- 

- 

317 

Operation 

- 

- 

349 

«       of  Monro 

- 

- 

317 

1.  Scleroticotomy 

- 

- 

350 

«       of  Hunter 

- 

.. 

317 

2,  Ceratotomy 

_ 

- 

350 

«       of  Scarpa 

- 

- 

318 

Inferior  keratotomy 

- 

- 

351 

«       of  Nicod 

- 

- 

318 

First  second  and  third  step 

_ 

352 

«       of  Picot 

. 

_ 

318 

Process  of  Guerin  and  Dumont 

_ 

357 

Art.  2.  Eyelids 

- 

- 

320 

Superior  keratotomy 

- 

- 

357 

§  1.  Ectropion 

- 

. 

320 

Dressing 

- 

- 

358 

Process  of  Antylus 

- 

- 

321 

Comparative  examination  of  the 

«       of  Walther 

. 

. 

322 

two  methods 

. 

. 

359 

«       of  Key 

- 

- 

322 

§  4.  Artificial  pupil 

- 

_ 

363 

Blepharoplastic  operation 

. 

322 

Methods  of  operating 

- 

_ 

363 

§  2.  Trichiasis,  Entropion 

and  Ble- 

1.  Coretomia  or  the  method  by 

n- 

pharoptosis 

- 

- 

323 

cision 

. 

. 

364 

Excision 

-  ■ 

- 

323 

Process  of  Cheselden 

_ 

. 

364 

Extraction  and  cauterization 

of 

«       of  Sharp 

_ 

_ 

364 

the  cilia 

. 

. 

323 

«       of  Odhelius 

. 

_ 

364 

Eversion  of  eyehds 

. 

- 

324 

«       ofjanin 

. 

. 

364 

Excision  of  the  edge  of  the  palpe- 

"      of  Guerin 

_ 

_ 

365 

bral                   -      . 

- 

. 

325 

"       of  Maunoir 

. 

_ 

365 

Crampton's  method 

- 

- 

325 

"       of  Adams 

. 

_ 

366 

Guthrie's             « 

- 

. 

325 

"       of  Author 

_ 

. 

366 

Saunder's             « 

. 

. 

325 

2.   Coredialysis 

. 

. 

367 

Vacca-Berlinghieri's  method 

. 

325 

Process  of  Scarpa 

. 

_ 

367 

§  3.  Tumors 

. 

. 

326 

"      of  Couleon 

- 

- 

367 

First  process 

. 

- 

326 

"       of  Assalini 

- 

. 

367 

Second  process 

. 

- 

327 

"       of  Langenbeck 

. 

S67 

Modified  cauterization 

- 

. 

327 

"       of  Reisinger 

, 

- 

367 

Cancerous  tumors 

. 

_ 

327 

"       of  Lusardi 

. 

_ 

368 

4  4.  Anchyloblepharon  and  symble- 

"       of  Donegana 

- 

- 

368 

pharon 

- 

- 

328 

3.  Corectomia 

- 

- 

369 

Vlll 


INDEX. 


Tage 

Process  of  Demours 

.    369 

Process  of  Couleon  and  Gibson 

.    369 

"*       of  Beer 

•    369 

«*      ofWalther 

369 

"       of  Dr.  Physic 

370 

Relative  value  of  the  various  me- 

thods   .            -            .            - 

370 

§  5.  Puncture — ^incision 

372 

1.  Onyx      -            .            -            - 

372 

2.  Hydrophthalmia 

372 

Operation             .            .            . 

373 

3.  Hypopyon          -            -            . 

374 

4.  Empyesis             .             -             . 

374 

§  6.  Recision 

575 

Operation              _             -             . 

375 

§  7.  Extirpation      - 

376 

Operation.  1.  Process  of  Bartisch 

377 

2.  Process  of  F.deHilden 

377 

3.         «      ofHeistei-       - 

378 

4.         "      of  Louis 

378 

First  stage 

378 

Second  stage 

378 

.    Third  stage  and  dressing 

379 

Remarks 

380 

Artificial  eyes 

380 

Sect.  III.— Mouth 

381 

Art.  1.  The  lips 

381 

§  1.   Harelip 

381 

Cheiloraphy 

382 

A.  Simple  harelip 

382 

a.  History            ... 

382 

b.  Operative  process 

385 

c.  Remarks          -            .            . 

387 

B.  Complicated  hai-elip 

390 

C.  Age  proper  for  the  operation 

391 

§2.  Excision  of  the  lip 

393 

4  3:    Eversion.      Mucous  enlarge- 

ments      -            .            -            . 

394 

§  4.  Hypertrophy 

395 

§  5.   Chciloplasm     - 

396 

Manual     -            -            -            . 

396 

1.  Ancient  process 

396 

2.  Process  of  Chopart 

397 

3.        «       of  M.  Roux  of  St.  Max- 

imin          .... 

397 

4.  Process  of  Professor  Roux 

398 

5.  M.  Lisfranc's  modification 

399 

§  6.   Genoplasm 

400 

1.  Indian  method    - 

400 

2.  French      «... 

401 

a.    Process  of  M.  Roux,  of   St. 

Maximin            ... 

401 

b.  Process  of  M.  Gensoul 

401 

c.         "       of  Professor  Roux 

401 

§  7.   Abnormal  coarctation 

402 

Art.  2.   Salivary  apparatus      - 

404 

§  1.  Fistulae 

404 

A.  Of  the  parotid  gland  or  its  ex- 

cretory ducts 

404 

B.  Of  the  duct  of  steno 

405 

C.  Of  the  submaxillary  gland 

409 

Page 

§  2.  Ranula  or  frog^s  tongue  .    410 

§  3.   Salivary  tumors  foreign  to  the 

excretory  canal  .  .    413 

Art.  3.  The  tongue    -  -  -    414 

§  1.   Filet  -  .  -    414 

§  2,  Aiichyloglossis  -  -    416 

§  3.   Excision  ...     417 

Art.  4.  Isthmus  of  tlie  fauces  .    420 

§  1.   Excision  of  the  whole  or  a  part 

of  the  tonsils  ...  420 
§  2.  Abscess — Incision  of  the  tonsils  425 
§3.  Excision  of  the  Uvula  -    425 

§4.   Staphyloraphy  -  -    427 

A.  History  -  .  -    428 

B.  Manual  .  .  -     431 

C.  Modifications  -  -  -  433 
Sect.  IV. — Olfactory  apparatus  -  434 
Art.  1.  Nasal  fossa      -             -             .     434 

§  1.  Hemorrhage — plugging  .    434 

§  2.  Polypi  .  -  -    435 

a.  First  process  of  Levret  -     441 

b.  Second     «  «  -    441 

c.  Brasdor's  process        -  -     441 

d.  Desault's         «  -  442 

e.  Process  of  M.  Boyer  -  443 
/.  «  of  M.Dubois  -  443 
g.  «  of  M.  Rigaud  -  443 
h.       "      of  M.  Felix  Hatin        -    444 

Art.  2.  Maxillary  sinus  -  -     445 

§  1.  Perforation      -  -  -    445 

§  2.   Foreign  bodies — polypi  -     448 

§3.  Frontal  sinus — perforation       -     450 

Sect,  v.— The  face  -  -     450 

Art.  1.  Osseous  cysts  -  -    450 

Art.  2.   Section  of  the  facial  nerves    -    451 

Sect.  Vl. — Auditory  apparatus  -    455 

Art.  1.  External  ear  -  -    455 

§  1.   Otoraphy         -  -  -     455 

§  2.  Otoplasmus     -  -  -    455 

§  3.  Perforation.     Dilation  of  the 

auditory  canal      ...    456 

§  4.  Foreign  bodies  -  -    457 

§  5.  Polypi  -  -  -    459 

Art.  2.  Internal  ear    -  -  -    461 

§  L   Perforation  of  the  membrana 

tympani  ...    461 

§  2.  Perforation  of  the  mastoid  cells    462 

§  3.  Catheterism  of  the  Eustacliian 

tube         ....    464 

Title  IL— Operations  on  the  Trunk    -    467 

Chap.  I.— The  neck  -  -    467 

Sect.  I. — Lateral  and  superior  regions    467 

Art.  1.  Parotid  gland  -  -    467 

Art.  2.  Submaxillary  gland    -  -     473 

Sect.  II. — Anterior  region      -  -     474 

Art.  1.  Thyroid  body  -  -    474 

Art.  2.  Air  passages  -  -     479 

§  1.  Bronchotomy  -  -    479 

A.  Surgical  and  anatomical  remarks    484 

1.  Tracheotomy      -  -  -     489 

2.  Thyroid  laryngotomy     -  -    490 


INDEX. 


IX 


Page 

3.  Laryngo  tracheotomy    -            -  490 

4.  Thyro-hyoid  laryng-otomy  -  490 
§  2.  Bronchoplasmus  -  -  491 
§3.  Catheterism     -            -            -  491 

Art.  3.  Alimentary  passages               -  491 

§  1.   Catheterism     -             -            -  491 

§  2.  Foreign  bodies             -            -  494 

Chap.  II.— The  chest              -            -  499 

Sect.  I.— Tumors       -            -            -  499 

Art.  1.  Extirpation  of  the  mamma    -  499 
Art.  2.  Extirpation  of  tumors  in  the 

axilla           -            -            -            -  505 
Sect.  I[.— Effusions                -            -  506 
Art.  1.  Empliysema                -            -  506 
Art.  2.  Wound  of  the  intercostal  ar- 
tery             -            -            -            -  513 
Art.  3.  Paracentesis  of  the  pericardium  515 
Chap.  III.—Abdomen             -             -  518 
Sect.  I. — Effusions  and  cysts               -  518 
Art.  1.  Paracentesis                -             -  518 
Art  2.  Humoral  tumors  of  the  liver  526 
Art.  3.  Cysts  and  tumors  in  the  inte- 
rior of  the  abdomen             -             -  527 
Sect.  II.— Hernia         -             -             -  530 
A.  Hernias  in  general          -             -  530 
Art.  1.  Radical  cure                -             -  530 
§  1.  Topical  applications,  compres- 
sion, position        -             -             -  530 
^  2.  Various  operations      -             -  531 
§  3.  Possibility  of  obtaining  a  per- 
manent cure,  and  whether  it  ought 
to  be  attempted                -             -  536 
§  4.  Inguinal  hernia             -             .  538 
Art.  2.  Strangulated  hernia                 -  539 
§  1.  Anatomical  remarks                 -  *541 

a.  Sac     -             -             -             -  541 

b.  Aponeuroses                -            -  544 

c.  Herniary  openings       -             -  544 
§2.  Seat  of  strangulation                 -  545 

Internal  Strangulation     -             -  549 

§  3.  Indications       .             -             -  550 

§  4.  Herniotomy  or  celotomy         -  561 

A.  Enterocele         -             -             -  561 

B.  Epiplocele         -  -  -575 

C.  Dressings           .             -             -  579 

D.  Treatment  -  -  -  581 
§  5.  Gastrotomy  -  -  -  583 
§  6.  Hernia  with  gangrene  -  585 
§  7.  Enteroraphy                 -             -  588 

Suture  on  a  foreign  body              -  589 
Suture  witli  invagination               -  591 
Raybard's  process            -             -  591 
Suture  with  contact  of  serous  sur- 
faces                -             -             -  592 
Process  of  M.  Jobert       -            -  592 
'*       of  M.  Denaus      -             -  592 
«       of  M.  Lembert    -            -  593 
Ulceration        -            _             .  594 
§  8.  Preternatural  anus      -            .  596 

A.  Suture                -            -            -  596 

B.  Compression      -            -            -  597 

B 


Page 

C.  Enterotomy  or  the  process  of  M. 

Dupuytren           -             -  _  595 

Sect.  II. — Particular  hernias  -  603 

Art.  1 .  Inguinal  hernia            -  -  603 

§  1.  Anatomical  remarks  -  603 

§  2.   Surgical  remarks         -  -  607 

Infantile  hernia                 -  -  609 

§  3.   Composition                  -  -  611 

§  4.   Operation                      -  -  613 

Art.  2.  Crural  hernia              -  -  618 

§  1.  Anatomical  remarks  -  618 

§  2.   Operation                      -  -  622 

Art.  3.   Umbilical  hernia        -  -  626 

§  1.  Anatomical  remarks  -  626 

§  2.   Operation                      -  -  628 

Art.  4.  Ventral  hernias           -  -  631 

Chap.  IV. — The  sexual  organs  -  633 

Sect.  I. — The   sexual  organs  of  fie 

male             -             -             .  -  633 

Art.  1.   Scrotum          -            -  -  633 

§  1.  Anatomical  remarks  -  633 

§  2.  Hydrocele                    -  -  635 

Operation             -            -  .  636 

§  3.   Ectomia  scroti              -  -  648 

§  4.  Castration         -             -  -  651 

Method  of  Maunoir          -  -  652 

«       ofZeller              -  -  657 

Art.  2.  Copulative  organ        -  -  659 

§  1.  Phymosis                      -  -  659 

§  2.  Paraphymosis               -  -  662 

§  3.  Strangulation  of  the  penis  -  664 

i  4.   Sectio  freni                   -  -  664 

§  5.  Adhesions  of  the  prepuce  to 

the  glans              _             ,  -  665 

§  6.  Destruction  of  the  prepuce  665 

§  7.  Amputation  of  the  penis  -  666 
Sect.  II. — The  sexual  organs  of  the 

female                      -            -  _  669 

Art.  1.  Imperforation  of  the  vulva  -  669 

Art.  2.  Puncture  of  the  uterus  -  671 

Art.  3.  Inverslo  uteri  vaginse  -  673 
Art.  4.  Reduction  of  the  uteinis  and 

vagina                       -            -  -  673 

Art.  5.  Pessaries                     -  -  674 

Art.  6.   Foreign  bodies            -  -  678 

Art.  7.  Foreign  bodies  in  the  uterus  679 

Art.  8.  Uterine  polypi            -  -  680 

1.  Tearing  out        -            -  -  682 

2.  Ligature  -  .  .  683 
Method  of  operation  -  -  683 
Remarks               -             -  -  685 

3.  Excision  -  .  .  686 
Method  of  operation        -  -  687 

Art.  9.  Cancer  of  the  cervix  uteri  -  690 

Anatomical  remarks        .-  -  692 

Amputation          -            .  -  693 

Method  of  operation        -  -  695 

Art.  10.  Extirpation  of  the  matrix  -  697 

1.  The  uterus  displaced  -  699 
The  method  of  operation  -  700 

2.  The  uterus  not  displaced  -  701 


INDEX. 


Art.  11.  Veslco-va^nal  fistula 

1.  Sutures 

Method  of  operation 

"       of  M.  Lewziski 
Catheters,  crotchet  forceps,  &c. 
Method  of  M.  Dupuytren 

"       ofLaugier 

2.  Caxiterization 

Art.  12.   Recto-vaginal  fistula 

Suture  - 

Art.  13.  Dystokia — difficult  delivery 
Symi)hyseotomy 
Method  of  operation 
Uterotomia  abdominalis.     Caesa- 
rian operation 
Metliod  of  operation 
Art.  14.   Vag-inal  uterotomy 
Chap.  V. — The  urinary  apparatus     - 
Sect.  I. — The  operation  of  cutting  for 
stone  -  .  .  - 

A.  Stone  in  man 

Diajrnosis  .  _  - 

So'Mding 

Ind  -ations  .  -  . 

Art.  1.  Stone  by  the  perineum  (the 
appar.M  is  minor) 
§1.  A  latomipal  remarks 
4  2.   M  thods  of  operation 

1.  Th  ;  lateral  method  (cystotomy 
pro]  r)  ... 
o.  1  rocedure  of  Antyllus  and  P. 

^.^inetus  ... 

b.  F  rocedure  of  Brother  Jacques 

c.  "         of  Raw 

d.  "  ofCheselden 
c.           "          of  Foubert 
/.           «          of  Thomas 

2.  Median  cutting.  Apparatus  ma- 
jor -  -  -  - 
a.  r  rocedure  of  Mariano 

h.  "         of  Vacca  Berling- 

hicri  -  _  . 

3.  Oblifjue,  or  lateralized  cutting 
a.  V ;  ')cedure  of  Franco  or  d'Hu- 

nai  It 
h.  Procedure  of  Garengeot 

c.  "  ofCheselden 

d.  "  ofBoudou 
c.  **  ofLeDran 
/          «          ofLecat 

f««  ofMoreau 

«  of  F.  Come 

i.  '*  ofGuerin 

j.  «  of  Hawkins 

k.        **  of  Thomson 

/.  **  of  M.  Boycr 

4.  Transversal,  bi-lateral  or  bi- 
oblique  cutting 

a.  Procedure  of  Chaussier 

b.  «  ofBeclard 

c.  "  of  Dupuytren 


Page 
707 
707 
708 
710 
710 
711 
711 
712 
715 
716 
718 
718 
719 

722 
727 
729 
731 

731 
731 
732 
732 

737 

738 
738 
743 

744 

744 
745 
746 
746 
746 
747 

747 
748 

749 
750 

750 
751 
751 
752 
752 
752 
753 
753 
754 
756 
757 
758 

759 
760 
761 
761 


d.  Procedure  of  Senn 
5.  Quadri-lateral  cutting 
§  3.  Recapitulation  of  the  methods  of 

operation  in  the  different  species 

of  perineal  cutting 

Apparatus 

Staff 

Forceps  ... 

Position  of  patient  and  assistants 

Introduction  and  placing  of  the 
staff 

Cutting  at  two  distinct  intervals 
Art.  2.  Recto-vesical  cutting  (poste- 
rior or  inferior) 
§  1.  Anatomical  remarks 
§  2.   Method  of  operation 
Art.  3.   Hypogastric  cutting 
§  1.   Anatomical  remarks 
§  2.   Examination  of  methods 
1.     Method  of  Rousset 


of  Douglas 

of  Cheselden 

of  Morand 

of  Le  Dran,  Winslow 

of  Baud  ens 

of  Tanchou 
^  of  Verniere 

2."        «      of  Franco 
3.  «     of  Brother  Come 

§  3.   Method  of  operation 

B.  Cutting  for  stone  in  the  female 
Art.  1.   Anatomical  remarks 

Art.  2.  Examination  of  the  methods 
§  1.   Old  procedures 

a.  Lateralized  method  or  lateral 
cutting 

b.  Method  of  Celsus  and  Lisfranc 

c.  Vesico-vaginal  cutting 
Method  of  operation 

§  2.  Urethral  methods 

a.  Method  by  dilatation 

b.  Urethrotomy 
Art.  3.   Estimate 

C.  Relative  value  of  the   different 
ways  of  cutting  for  stone  in  the 

male  .  _  , 

D.  Nephrotomy 

E.  Stones  stopped  outside  of  the 
bladder  .  _  . 

1.  Stones  in  tlie  ureter 

2.  "       in   the   thickness  of  the 
vaginal  septum 

3.  Stones  in  the  pro.state 

4.  "      in  the  Urethra 

5.  "      between  the  glands  and 
prepuce  ... 

Sect.  II.— Lithotrity 
Art.  1.    Historical 

Art.  2.   Examination  of  the  methods 
§  1.  Rectilinear  method 
a.  Perforation 


INDEX. 


XI 


b.  Excavation 

c.  Concentric  friction 

d.  Crushing' 

e.  Of  the  four  ways  of  producing 
trituration 

§  2.  Curvilinear  method 
§  3.  Accessory  apparatus 

a.  Position  of  the  patient 

b.  Injections 

c.  Introduction  of  forceps 

d.  Finding  the  stone 

e.  Open  the  forceps 

/.  Find  and  seize  the  stone  again 

g.  Apply  the  drill-bow 

Art.  5.   Remarks  on  some  points  in  the 

operation,  and  accidents  in  lithotrity 

Art.  6.  A  comparison  of  cutting   for 

stone  and  lithotrity 
Sect  III.— The  urethra 
Art.  1.  Catheterism 

§1.  Anatomical  remarks 
§  2.  Examination  of  methods  and 
instruments 

Position  of  the  surgeon  and  patient 
Difficulties  in  the  operation 
Flexible  catheters 
The  master-turn 
Catheterism  in  the  female 
Art.  2.  Stricture 

§  1.  Forced  catheterism 

§  2.  Injections 

§  3.  Incisions   and  scarifications  of 

the  part  strictured 
§  4.  Concentric  or  external  incisions 


Page 

Page 

825 

§5.  Dilation            - 

859 

825 

§  6.  Cauterization 

864 

826 

i  7.  Abnormal  dilation  of  the  ure- 

thra 

870 

827 

Sect.  IV.— Puncturing  the  bladder 

871 

828 

Art.  1.  Perineal  puncture 

871 

830 

Art.  2.  Puncture  through  the  rectum 

872 

831 

Art.  3.  Puncture  above  the  pubis      - 

874 

831 

Art.  4.  Mutual  advantages  and  incon- 

832 

veniences  of  the  species  of  puncture 

875 

832 

Sect,  v.— Fistulx  urinaria^ 

877 

832 

Chap.  VI. — Defecator  organ 

880 

832 

Sect.  I. — Vices  of  structure 

880 

833 

Art.  1.  Imperforation 

§  1.  Re-establishment  of  a  natural 

880 

835 

anus                       _             -             . 

881 

§  2.  Establishment 

883 

839 

Art.  2.   Stricture 

885 

842 

§1.   Dilation 

885 

842 

§  2.  Incision 

887 

842 

§  3.  Cauterization 

887 

Sect.  2.  Acquired  lesions 

887 

845 

Art.  1.  Foreign  bodies  in  the  anus 

887 

846 

Art.  2.   Polypi 

889 

847 

Art,  3.  Hemorrhoidal  tumors 

889 

849 

Art  4.   Prolapsus 

891 

851 

Art.  5.  Fissures 

895 

852 

Art.  6.  Fistula 

896 

853 

§  1.  Anatomical  remarks 

897 

853 

§  2.   Examination  of  methods 

900 

855 

A.  Ligature 

900 

B.   Operation,  properly  so  called 

901 

856 

Art.  7.  Cancers 

909 

858 

Metliod  of  operation 

910 

PREFACE. 


In  introducing  a  new  treatise  on  operative  surgery,  my  object  is  to  meet  a 
want  long  felt  by  those  engaged  in  the  practice  of  that  branch  of  medical 
science.  The  work  announced  in  1813,  by  M.  Roux,  has  not  been  completed. 
The  additions  of  MM.  Sanson  and  Begin,  to  the  inimitable  work  of  Sabatier,, 
cannot,  notwithstanding  their  importance,  supply  the  place  of  a  book  of  this 
character.  The  diagnostic  and  symptomatological  details  of  almost  every 
disease  requiring  surgical  aid,  in  which  the  author  has  indulged,  have  enlarged 
his  work,  by  encroaching  on  pathology  to  the  injury  of  operative  surgery. 
The  only  object  of  M.  Richerand,  in  publishing  his  nosographie,  was  to  pre- 
sent concise  views  of  surgical  science.  M.  Boyer,  in  confining  his  descrip- 
tions to  his  own  views  of  practice,  has  omitted  many  methods  which  should  be 
presented  to  the  public.  Besides,  his  work  is  not  a  special  treatise  on  the 
subject,  and  the  eleven  volumes  which  compose  it,  do  not  afford  the  student 
a  text  book  in  the  schools.  A  number  of  neglected  operations,  and  others  in- 
vented since  the  time  of  Sabatier,  and  already  known  to  the  learned  world, 
have  not  yet  found  a  place  in  our  classic  works.  Rhinoplasm,  chieloplasm, 
blapharoplasm,  otoplasm,  bronchoplasm,  staphyloraphy,  torsion,  puncture  of 
the  arteries,  lithotrity,  cauterization  of  the  urethra,  amputation  of  the  womb, 
extirpation  of  the  ovaria  and  of  the  anus,  are  among  these  operations.  Indeed, 
a  review  of  the  whole  subject  of  operative  surgery  had  become  necessary  from 
the  progress  it  has  made  and  the  changes  it  has  undergone  during  the  last 
thirty  years.  My  pursuits  for  the  last  ten  years  led  me  to  the  investigation 
of  the  subject,  and  convinced  me  of  the  deficiency  alluded  to ;  and  I  should 
have  attempted  to  remove  the  evil  sooner,  but  I  feared  the  task  was  beyond  my 
abilities.  At  first  I  conceived  the  idea  of  furnishing  a  simple  manual ;  but  I 
soon  perceived  that  this  course  would  increase  the  evil  tendency  of  our  young 
students,  to  content  themselves  with  every  possible  abridgment.  The  re- 
searches which  the  undertaking  required,  have  convinced  me,  under  existing 
circumstances,  that  in  order  to  be  useful  to  the  faculty  and  the  world,  a  trea- 
tise must  be  full  and  complete,  and  not  a  mere  manual. 

Several  volumes  had  been  written  when  the  journals  announced  the  forthcom- 
ing work  of  M.  Lisfranc.  I  then  thought  of  arresting  my  labors ;  being  pursuad- 
ed  that  from  long  experience  in  the  dissecting  room,  and  hospitals,  this  emi- 

xiii 


XIV  PREFACE. 

nent  surgeon  would  accomplish  all  that  was  wanting.  Five  or  six  years  have 
now  passed  away,  and  he  has  not  fulfilled  the  expectations  of  an  impatient 
public.  Feaiing  that  his  numerous  occupations  would  long  deprive  us  of  his 
able  and  interesting  researches,  I  have  determined  to  prosecute  my  original 
design.  Another  motive  also  induced  me  to  postpone  this  work.  Depending 
solely  on  the  experience  of  the  anatomical  colleges,  my  opinions  then  could 
have  been  but  of  little  value.  Operations  on  the  dead  body  could  not  be 
adopted,  until  they  had  passed  the  ordeal  of  the  hospitals.  My  situation  at 
that  time,  did  not  entitle  me  to  the  privilege  of  invoking  my  personal  expe- 
rience. But  a  practice  of  four  years  in  the  hospital  of  "  perfectionnement," 
two  years  superintendence  of  the  hospital  of  St,  Anthony ;  and  the  direction 
of  La  Pitie  since  1830,  have  enabled  me  to  apply  for  the  benetit  of  the  living, 
the  experience  acquired  from  frequent  operations  on  the  dead.  I  hope  I  may 
be  permitted  to  express  an  opinion  on  the  propriety,  either  relative  or  absolute, 
of  the  different  methods  of  operating,  which  ought  to  be  examined  in  a  work 
of  this  kind.  Having  witnessed  the  public  practice  of  our  great  masters  till 
within  a  few  years,  there  are  few  operations  which  I  have  not  seen  performed. 
I  have  thus  been  enabled  to  compare  the  relative  advantage  of  many  of  them, 
and  to  judge  understandingly  on  the  reasons  which  they  advanced  in  support 
of  the  process  they  pursued,  or  against  those  measures  which  they  condemned. 
Writing  for  the  sole  interest  of  truth  and  science,  I  have  examined  the  labors 
of  all  without  distinction  of  country,  of  school  or  of  person ;  reserving  the 
privilege  of  weighing  their  merits  impartially,  of  drawing  those  deduc- 
tions which  naturally  flowed  from  them,  and  in  fine,  of  pointing  out  whatever 
seemed  to  me  either  useful  or  injurious.  Under  this  point  of  view,  the  pre- 
sent epoch  presents  difficulties  which  can  only  be  felt  by  those  who  wish  to 
produce  an  impartial  history.  Cotemporaries  are  rarely  just  to  each  other. 
Animosity  is  too  often  transferred  from  the  individual  to  the  institution  which 
he  may  direct.  Instead  of  being  published  by  their  authors,  the  improvements 
and  inventions,  due  for  the  most  part  to  the  great  practitioners  occupying  the 
domain  of  science,  are  only  known  by  tradition,  or  by  the  efforts  of  candidates 
impelled  to  defend  the  pretensions  of  their  chief;  it  is  indispensable  in  making 
a  conscientious  critique,  to  investigate  carefully  true  sources  of  information. 
No  work  having  yet  been  executed  in  this  spirit — the  surgical  history  of  the 
nineteenth  century  being  yet  in  embryo — I  have  found  it  necessary  to  consult 
a  multitude  of  periodicals,  private  memoirs,  and  monographs  of  every  de- 
scription. A  work  of  such  great  extent,  in  which  all,  should  in  some  degree 
assume  the  character  of  mathematical  demonstration — treating  of  dates,  of 
inventions,  of  proceedings  which  gave  origin  to  much  discussion,  of  numerous 
controversies  of  which  the  end  and  object  of  all  have  been  presented  in  so 
many  different  lights,  interpreted  in  such  a  variety  of  versions,  requires  an 
attention,  a  care,  a  literary  labor,  and  an  extent  of  research  of  which  it  is 
difficult  to  form  an  idea  without  making  the  experiment.  In  executing  this 
work,  I  have  derived  great  assistance  from  the  General  Archives  of  Medi- 
cine, from  the  Universal  Bulletin  of  Medical  Sciences,  and  from  the 
Medical  Gazette  of  Paris,  which  laterally  has  permitted  nothing  of  interest 
to  escape  the  attention  of  its  readers.  The  pages  of  the  Lancet  have 
sometimes  afforded  me  supplies.  I  can  say  the  same  of  the  Review,  of  the 
Medical  Transactions,  of  the  Universal  weekly  Journal  of  Medicine,  besides 


PREFACE.  Xt 

every  Journal,  whether  French  or  foreign,  have  been  put  in  requisition. 
La  Bibliotheque  Chirurgicale  of  Languenbeck,  the  Journal  of  Graefe  and 
Walthen,  the  Manual  of  M.  Chelius,  and  the  Treatise  of  Zang,  have  been  very- 
useful  to  me  as  regards  the  state  of  science  in  Germany ;  and  for  the  same 
object,  I  have  consulted  the  Medico-Chirurgical  Review,  the  London  Medi- 
cal and  Surgical  Journal  and  the  Lancet  in  England,  where  the  classic  works 
are  generally  so  inferior.  In  Philadelphia,  the  IMorth  American  Journal  of 
Sciences,  &c.,  the  Quarterly  Journal  &c.,  Dorsey's  Abridgment,  Sterlings 
Appendix  to  my  Treatise  on  Anatomy,  are  the  sources  I  have  had  recourse  to 
in  the  United  States.  From  the  Annales  Universelles  of  Milan,  by  M.  Omodei, 
and  the  Journal  of  M.  Strambio,  alone,  I  have  been  able  to  gather  information 
in  relation  to  the  medical  affairs  of  Italy.  The  collections  of  Thesis  at  Paris, 
Montpelier,  and  Strasburg,  although  too  generally  neglected,  have  afforded 
me  much  valuable  information.  They  contain  a  crowd  of  suggestions,  of 
propositions  to  which  no  attention  was  paid,  of  methods  which  have  since  been 
advanced  by  different  authors,  and  appropriated  as  original,  because  the  real 
author  had  retired  and  become  forgotten  in  some  distant  province,  where  he 
had  not  the  means  of  reclaiming  the  honor  of  his  discovery.  In  fine,  that 
nothing  essential  should  be  omitted,  I  have  often  addressed  medical  men 
themselves,  particularly  those  whose  researches  had  not  been  published,  or 
those  which  had  been  written  out  by  a  third  person.  Thus,  in  order  to  be  in- 
formed about  certain  operations  of  M.  Dupuytren,  I  have  inquired  of  M. 
Mark,  his  private  student.  By  this  means  I  learned  that  the  disc-very  of 
the  lachrymal  duct  originated  in  1810,  with  the  professor  of  the  Ho^«l-Dieu, 
operating  on  an  invalid  who  had  been  afflicted  for  many  years ;  that  he  had 
removed  the  inferior  maxillary  bone  twenty  times,  and  that  the  buperior 
maxillary  had  been  removed  by  him  in  1813  ;  that  his  process  for  am  utating 
at  the  shoulder  joint  dates  in  1802;  that  he  has  tied  the  carotid  four  times 
successfully  since  1814;  that  it  was  in  1805,  and  not  in  1810,  he  arplied  a 
ligature  to  the  femoral  artery  for  a  fracture  of  the  leg;  that  his  first  operation 
for  stone  was  {hypogastrique)  at  the  Hotel-Dieu ;  and  that  he  had  atiempted 
lithotrity  eight  times. 

It  is  unnecessary  to  mention  here  the  aid  derived  from  MM.  Rou  c,  Rich- 
erand,  J.  Cloquet,  &c.  having  recorded  it  in  the  body  of  the  work.  The  same 
may  be  said  of  MM.  Lauth  of  Strasburg,  Ashmead  of  Philadelphia.  Deleau, 
G.  Pelletan,  Berard,  Blandin,  Pravaz,  Leroy,  Maingault,  and  many  p  -vincial 
surgeons,  to  whom  I  am  equally  indebted.  I  learned  also,  from  M.  .  louline 
of  Bordeaux,  the  success  attributed  to  refrigeration  in  the  treatment  ;f  aneu- 
rism ;  and  nothing  is  more  certain,  than  that  all,  or  nearly  all,  the  success  was 
due  to  the  concurrent  means  not  mentioned  in  the  report.  I  would  have 
asked  similar  aid  from  M.  Lisfranc,  my  colleague  in  the  hospital  la  Pitie, 
but  knowing  it  was  his  intention  to  publish  his  own  course  of  operative 
surgery,  I  thought  it  would  seem  indiscreet,  or  that  the  request  wt>uld  be 
disagreeable  to  him.  Though  very  desirous  of  profiting  by  his  labor-  I  have 
concluded  to  derive  my  information  from  publications  in  the  per  )dicals, 
either  in  his  own  name,  or  in  that  of  his  students ;  in  the  Thesis  sus<:r  led  for 
fifteen  years  by  the  faculty,  and  in  the  Manual  of  M.  Coster.  In  ord  r  not  to 
mutilate  his  ideas,  I  have  used  them  with  great  reserve,  hoping  hereafter  to  be 
able  to  present  them  in  his  own  language. 


XVI  PREFACE. 

In  relation  to  the  doctrine  which  is  foreign  to  modern  practice,  I  have 
anxiou  :ly  endeavored  to  trace  it  to  its  source ;  and  this  investigation  has  shown 
me  ho\  Sabatier  himself  and  particularly  Mr.  Cooper  have  been  so  often  led 
into  err  ;)r,  in  giving  the  ideas  of  those  authors  whom  they  had  consulted.  Where 
I  couh;  not  attain  my  object  from  the  scarcity  of  the  works,  or  the  foreign 
langua  e  in  which  they  were  printed,  I  had  recourse  to  the  authority  of 
Spring  e  confirmed  by  Le  Clerc,  Freind,  Dajardin,  or  of  Peyrilhe,  and  what 
is  still  more  valuable,  that  of  M.  Deizeimeris,  who,  besides,  on  many  occasions, 
procun  il  me  facilities  and  information  which  I  could  not  obtain  elsewhere, 
and  am  >ng  these  I  ought  to  mention  the  Historical  Dictionary,  with  the  praise, 
too,  wi'ch  a  book  concientiously  written  justly  merits. 

I  have  scarcely  mentioned  a  fractional  part  of  the  titles  of  the  books  and 
entire .y  omitted  the  papers  I  have  consulted.  It  seems  to  me  that  the  opposite 
course,  the  advantages  of  which  I  would  be  the  first  to  acknowledge,  would 
liave,  i'l  compiling  a  dogmatical  treatise,  a  sufficient  portion  of  inconveniences. 
In  the  first  place  it  would  cramp  the  style ;  2,  multiply  its  pages  to  an 
iuordiiite  degree;  3,  burden  the  memory;  and  4,  encourage  that  imitative 
learnin ;,  which  is  now  unfortunately  too  extensive  in  the  French  schools. 
In  abs  ining  from  quoting  the  names  of  authors,  I  would  have  fallen  into 
an  unf  rtunate  extreme,  though  most  of  our  elementary  books  are  composed 
in  this  ,  'ay.  It  is  true  the  author  finds  the  advantage  of  permitting  the  un- 
learne(.  to  remain  ignorant  of  the  authorship  of  what  he  relates,  and  igno- 
rance «  ^  historical  research  will  prevent  detection ;  but  it  seems  to  me  nothing 
can  be  more  injurious  to  the  true  interests  of  science.  Students  seeing  no 
name  i  the  text,  attribute  to  the  author  in  hand  ideas  that  have  been  pro- 
mulga  (I  for  ages,  or  recorded  by  twenty  different  writers ;  and  thus  become 
unjust  A^ithout  being  aware  of  the  fact.  Hence  that  credulity  so  skillfully 
worke.  upon  for  years,  and  more  so  than  ever,  at  present,  by  the  inventors  of 
new  m  'thods :  hence  that  academic  mystification  and  that  mode  of  fabricating 
discov  ries  by  numerous  practitioners  who  are  as  liable  to  be  mistaken astheir 
pupils  In  attaching  to  each  subject  t  discuss  the  principal  authority  connected 
with  it  1  acquit  myself  of  blame  by  rendering  rigorous  justice.  I  have  thought 
that  n  y  opinion  would  thus  acquire  an  irresistible  influence,  and  ultimately 
that  I  should  find  my  advantage  in  telling  my  readers  in  a  single  word, 
wheth  r  the  inventions  they  were  examining  were  of  a  recent  date,  or  had 
been  1  )ng  known  to  others.  To  those  who  reproach  me  with  leaving  it 
impos.-  ble  to  verify  my  quotations  with  precision,  I  would  say,  that  in  re- 
cordin  ^  the  opinions  of  others,  I  have,  in  general,  given  them  as  I  compre- 
hende  1  them,  without  rendering  others  accountable  for  my  interpretration. 
Belie\  ng  that  I  am  addressing  myself  to  students,  I  wish  to  let  them  under- 
stand •  hat  there  is  such  a  thing  as  history,  and  to  impress  upon  them  a  taste 
for  sci  intific  literature. 

The  compilation  of  this  work  is  another  point  which  requires  some  explana- 
tions. 

In  performing  surgical  operations  the  importance  of  anatomical  knowledge 
has  never  been  questioned ;  nevertheless  as  it  was  impossible  to  embrace  all 
collate  ral  knowledge  in  a  work  on  operative  surgery,  I  have  confined  myself 
to  that  which  is  indispensable,  and  have  chosen  a  form  which  seemed  best 
adapted  to  an  abridgment.  Hence  it  is  neither  on  the  anatomy  of  the  regions 
nor  no  surgical  anatomy,  so  called,  that  I  have  written,    I  have  simply  re- 


PREFACE.  XVii 

counted  in  each  operation,  the  points  which  were  absolutely  necessary — those 
not  essential  I  have  passed  unnoticed. 

Sabatier,  in  other  respects  so  perfect,  who  demonstrated  science  with  such 
clearness  and  precision,  was,  nevertheless,  defective  from  his  poverty  in  de- 
scriptive details ;  and  can  neither  satisfy  those  who  confine  their  studies  to  the 
closet,  nor  those  who  practice  in  the  anatomical  schools.  I  have  endeavored 
to  avoid  this  evil  without  loosing  sight  of  the  opposite  inconvenience;  well 
aware  how  fatiguing  from  their  dryness,  and  perplexing  from  their  multipli- 
city, are  these  interminable  details  which  we  find  in  many  of  the  recent 
publications.  In  fine,  to  satisfy  all  on  this  point,  I  have  given  to  each  case, 
as  far  as  the  limits  of  the  work  would  permit,  the  particulars,  both  practical 
and  mechanical,  under  the  head  of  manuel  operation^  absolutely  useful  in 
performing  an  operation  either  on  the  living  or  the  dead.  The  history,  exami- 
nation, discussion,  appreciation  of  method,  accidents,  consequences  and  in- 
dications, forming  the  subjects  of  so  many  distinct  heads,  will  be  a  great 
advantage  to  those  who  do  not  wish  to  read  the  whole  article.  I  have  used 
these  divisions  only  in  complicated  operations ;  omitting  them  where  the  sub- 
ject can  be  conveniently  described  in  a  few  pages,  unwilling  either  to  treat 
solely  of  the  operative  process,  or  to  write  a  book  on  surgical  pathology ;  like 
Sabatier,  I  have  confined  myself  to  the  discussion  of  the  indications,  omitting, 
without  special  necessity,  whatever  relates  to  the  pathology,  signs  or  general 
treatment  of  disease.  The  comparison  of  methods,  and  of  the  results  which 
tjiey  have  furnished,  form  another  question  hitherto  too  much  neglected  but 
of  such  unquestionable  utility  as  to  demand  all  possible  attention. 

If,  in  the  course  of  my  historical  research,  I  have  commented  on  operative 
processes  long  since  forgotten  or  justly  proscribed  ;  if  I  have  recorded  a  crowd 
of  recent  inventions  of  no  intrinsic  merit,  and  useless  to  the  cause  of  science  5 
it  is  because,  on  the  one  hand,  there  is  no  process  so  singular  but  it  may  again 
be  revived  by  some  new  inventor,  and,  on  the  other,  it  is  necessary  to  lay 
before  the  student  not  only  what  he  should  adopt,  but  also  what  he  should 
reject  in  relation  to  the  cotemporaneous  history  of  data  and  opinions  which 
he  will  daily  hear  unjustly  praised  or  condemned.  Though  I  have,  in  this 
double  relation,  endeavored  to  follow  the  course  pursued  by  men  of  talents, 
and  to  present  with  precision  and  impartiality,  the  actual  condition  of  science ; 
though  I  have  neglected  nothing  in  order  to  procure  the  best  information 
concerning  modern  improvements,  still  I  fear  that  many  useful  points  have 
been  overlooked.  Upon  this  subject,  as  well  as  upon  all  others,  I  will  cheer- 
fully bow  to  the  criticism  of  the  learned. 

The  engravings  are  not  as  numerous  as  the  nature  of  the  subject  seems  to 
render  necessary;  but  the  price  of  the  work  being  already  sufficiently  high, 
I  thought  it  ought  not  to  be  increased.  All  have  been  taken  from  nature  with 
the  greatest  care,  reduced  in  size,  and  marked  with  neatness  and  precision. 
I  have  chosen  such  views  as  will  exhibit  at  a  single  glance,  the  whole  opera- 
tion. The  object  being  to  supersede  long  graphic  details,  I  have  paid  less 
attention  to  richness  and  splendor  than  precision  and  clearness  of  design. 
The  execution  has  been  confined  to  one  of  our  most  distinguished  artists,  M. 
Chazal,  well  known  for  his  talents  in  this  line.  The  instruments  which  could 
not  be  found  in  the  Hall  of  the  Faculty,  were  procured  for  me  by  MM.Char- 
riere  and  Sirhenry,  two  of  the  most  eminent  surgical  instrument  makers  of 
C 


XVlll  PREFACE. 

Paris.    I  cannot  express  too  much  gratitude  for  their  kindness ;  and  also  for 
the  politeness  of  the  curators  of  the  museum  de  L'Ecole,  the  MM.  Thillaye. 
At  one  time  I  decided  to  collect  the  plates  into  an  atlas,  and  to  annex  an  ex- 
planatory text  for  the  use  of  the  amphitheatres ;  and  I  thought  it  also  possible 
that  I  should  make  this  subservient  to  another  work  on  the  same  subject.     The 
drawings  of  M.  Maingault  on  amputations,  of  M.  Syme  on  resection  or  opera- 
tion at  the  joints,  of  MM.  Froriep,  Manec  on  ligature  of  the  arteries,  of  M. 
DemoursandM.Weller  on  theeye,of  M.Bretoneau  and  M.  Bui  Hard  on  trache- 
otomy, of  Scarpa  on  hernia,  of  MM.  Anderson,  Houston,  Segalas,  &c.,  on  the 
genito  urinary  organs,  though  more  or  less  perfect  in  their  kind,  have  been  but 
of  little  use  to  me.    Among  others,  those  of  M.  Manec  did  not  make  their 
appearance  till  after  the  execution  of  my  own,  and  besides  being  desirous  of 
presenting  the  objects  in  a  new  light,  it  was  absolutely  necessary  that  I  should 
have  recourse  to  the  dead  subject.     Lithotrity,  staphyloraphy,  &c.,  did  not 
present  the  same  difficulties.    And  I  have  so  freely  used  the  lithography  of 
MM.  Leroy,  Civiale,  Heurteloup,  Tanchou,  Tavernier,  Roux  and  Schwerdt, 
that  I  have  often  copied  them  exactly. 


INTRODUCTION. 


Definition. — In  medicine  the  term  operation  may  be  defined  an  action 
whose  object  is  the  amelioration  of  the  organic  condition  of  man.  It  is  synon- 
ymous with  surgery ;  but  custom  has  given  it  a  meaning,  if  not  definite,  at  least 
much  more  limited.  At  present  surgery  is  translated  by  surgical  pathology, 
or  rather  pathological  surgery,  and  embraces  all  diseases  in  the  treatment  of 
which  topical  applications  form  the  principal  remedies ;  while  operative  sur- 
gery is  confined  to  the  therapeutics,  which  require  the  hand  either  alone  or 
armed  with  instruments.  One  is  a  true  science  scarcely  different  from  medi- 
cal pathology ;  the  other  leans  more  towards  the  arts.  The  first  can  only  be 
advantageously  pursued  by  those  who  are  endowed  with  great  aptitude  for 
intellectual  exertion ;  on  the  contrary,  the  hand  is  the  indispensable  and 
characteristic  agent  in  the  second.  But  it  is  impossible  to  draw  an  exact  line 
of  demarcation  between  them ;  as  we  see  them  constantly  encroaching  on 
each  other  in  works  purporting  to  be  devoted  to  each. 

If  operative  surgery  is  allowed  to  embrace  rules  for  the  application  of  cata- 
plasms, plasters,  ointments,  leeches,  cupping-glasses,  blisters,  moxas,  acu- 
puncturation,  cauterization,  seton,  bleeding,  &c.  we  cannot  see  why  the 
reduction  of  fractures  and  luxations,  the  study  of  splints  and  bandages 
should  be  excluded.  On  the  contrary  case  it  is  not  less  arbitrary  in  its  point 
of  separation.  Catheterism  in  general,  the  extraction  of  a  foreign  body  either 
from  the  ear  or  between  the  eyelids,  the  cutting  of  the  frenum  linguae,  require 
no  more  knowledge  or  address,  than  venesection  or  opening  of  an  abscess. 
The  manner  of  dividing  this  science  is  merely  a  matter  of  courtesy,  which 
every  man  may  construe  according  to  his  own  views. 

In  omitting  all  that  relates  to  dressings,  treatment  of  wounds,  &c.  in  order 
to  speak  of  operations,  I  have  had  no  other  motive  than  the  necessity  of  fol- 
lewing  a  path  already  pointed  out  by  custom.  These  branches  of  surgery 
having  become  the  subject  of  special  books  which  no  student  can  dispense 
with,  by  reproducing  them  I  would  have  labored  unprofitnbly,  as  the  details 
which  my  limits  would  have  admitted  could  not  supersede  the  special  trea- 
tises of  MM.  Legouas,  Bourgery,  and  Gerdy  on  petty  surgery  and  bandages. 

Classification > — The  necessity  of  dividing  operations  into  a  certain  number 
of  classes  has  been  felt  at  all  times.     The  ancient  classification  laid  down  by 

xix 


XX  INTRODUCTION. 

Celsus  who  referred  all  to  Dissresis,  Synthesis,  JExseresis^  or  Prothesis,  and 
which  prevailed  during  so  many  ages  in  nearly  all  the  schools  of  Europe,  can 
no  longer  be  maintained.  In  creating  eight  classes  to  supply  their  place  Fer- 
rein  is  still  less  successful.  The  reunion,  the  separation  of  tissues  accident- 
ally united,  the  dilatation  and  the  re-establishment  of  natural  canals,  the 
closing  or  obliteration  of  useless  channels,  the  extraction  of  certain  liquids, 
amputations,  extraction  of  foreign  bodies,  and  reductions  which  he  arranges 
in  so  many  different  heads,  form  a  division  in  effect  the  least  natural  that 
could  be  imagined.  DiarthrosiSy  to  remove  deformities  was  added  to  the  four 
primitive  orders  since  the  time  of  Dionis.  Dilatation  and  compression  to 
which  M.  Roux  allows  a  separate  place,  and  prothesis  rejected  by  Ferrein,  ap- 
pear unworthy  and  but  imperfectly  fill  the  outline.  The  exploration  of  the 
bladder,  eustachian  tube,  and  the  lachrymal  ducts,  the  injection  of  these  dif- 
ferent passages  and  simple  torsion  of  the  vessels  for  example,  though  important 
operations,  would  find  no  place  under  any  of  the  above  divisions. 

The  efforts  of  Lassus  and  M.  Rossi,  to  obviate  the  effects  alluded  to,  have 
been  unsuccessful ;  and  the  plan  adopted  lastly  by  Sabatier  is  attended  with 
so  much  trouble  and  inconvenience  that  no  one  will  think  of  recurring  to  it. 
Indeed,  of  what  incoherences  are  we  not  made  sensible  when  we  see  in  treat- 
ing of  the  eye,  for  instance :  fistula  of  the  corneoy  hypopion,  hydropthalmia, 
staphyloma,  scirrhus,  procidentia  of  the  iris,  foreign  bodies,  cataract,  and  arti- 
ficial pvpil,  &c,  scattered  here  and  there  to  the  middle  of  three  volumes  and 
forming  as  many  distinct  divisions  ?  By  this  arrangement  it  would  be  almost 
impossible  to  know  where  to  find  an  article  until  we  had  previously  waded 
through  an  interminable  index.  In  order  to  ascertain  how  to  open  the  ante- 
rior chamber  of  the  eye,  for  instance,  we  would  be  compelled  to  consult  by 
turns  the  second,  third,  or  fourth  volume,  according  as  it  treated  on  the  ex- 
traction of  pus,  a  foreign  body,  or  the  crystaline  lens.  In  this  point  of  view 
the  essay  of  Delpech  is  still  more  defective.  Indeed,  the  method  developed 
by  M.  Richerand  though  one  of  the  most  advantageous  for  study,  having 
genius  equally  for  its  foundation,  is  not  entirely  exempt  from  the  defects  so 
justly  attributed  to  Sabatier.  Hence  it  results  that  the  topographical  order 
recommended  by  J.  Fabricius,  and  followed  by  M.  Boyer,  notwithstanding 
the  repeated  criticism,  more  or  less  just,  to  which  it  has  been  subjected,  is  still 
in  operative  surgery  the  best,  and,  perhaps,  the  only  course  that  can  at  present 
be  of  any  assistance  to  the  reader.  This  is  the  only  plan  which  conveys  the 
same  ideas  to  every  one.  By  its  aid  all  will  know  where  to  find  trepan, 
cataract,  empyema,  lithotomy;  whilst  by  following  Sabatier  or  Delpech  after 
first  inquiring  whether  such  operations  belonged  rather  to  wounds  and  foreign 
bodies,  or  to  fractures  and  styptics,  then  to  find  in  what  order  these  different 
heads  had  been  classed  in  relation  to  each  other.  The  pathology  and  cause 
of  disease,  which  render  such  divisions  necessary,  are  too  imperfectly  known 
or  too  variable  to  serve  as  a  permanent  foundation  for  the  classification  of 
operations.  In  proceeding  exclusively  on  the  base  of  functional  apparatus, 
or  the  organic  system,  we  depart  from  fixed  rules  it  is  true,  but  then  we  are 
obliged  to  collocate  the  most  incongruous  subjects,  (salivary  fistula,  abdominal 
hernia,  polypus  of  the  rectum,  &c.)  or  to  separate  others,  (foreign  bodies  in 
the  trachea  and  oesophagus,  tracheotomy,  oesophagotomy,  &c.)  which  have 
the  greatest  analogy. 


INTRODUCTION.  '*  XXI 

We  may  present  operations  here  under  two  general  points  of  view :  1st,  as 
independent  and  classed  according  to  their  analogy  or  difference;  2d,  as 
therapeutic  resources  subject  to  the  same  divisions  as  the  diseases  which  re- 
quire them.  In  practice  the  first  is  applicable  only  to  a  few,  such  as  trepan- 
ning, amputation,  ligature  of  the  artery  and  suture.  Incisions,  extractions, 
and  special  operations  cannot  properly  be  included.  The  second  would  be 
still  more  difficult  to  generalize ;  for  if  cataract,  fistula  lachrymalis,  hare-lip, 
&c.,  may  be  taken  as  the  heads  of  chapters  in  operative  surgery,  why  not 
compound  fractures,  caries  of  the  joints,  gangrene,  and  gun-shot  wounds,  &c. 
Seeing,  from  the  difficulties  against  which  all  authors  have  in  vain  contended, 
that  it  would  be  impossible  to  form  a  systematic  classification,  I  have  con- 
cluded to  adopt  the  plan  least  embarrassing  to  the  students,  though  perhaps 
least  rational  and  less  methodical.  It  is  the  only  one,  at  least  with  some 
slight  modifications,  that  can  be  followed  in  the  anatomical  schools.  Hence 
I  have  undertaken  to  demonstrate,  that  the  numerous  operations  of  which  the 
human  body  is  susceptible,  may  be  exhibited  without  exception,  on  one  sub- 
ject. The  desire  of  attaining  this  object,  induced  me  to  introduce  ligature  of 
the  arteries  before  amputations ;  and  to  describe  them  from  the  extremity  to 
the  trunk,  without  order  or  analogy.  The  operation  of  aneurism  does  not  in 
effect  interfere  with  the  process  necessary  to  exhibit  amputation ;  while  ampu- 
tation would  render  it  impossible  to  demonstrate  the  rules  for  the  application 
of  ligatures  on  the  vessels.  If,  instead  of  passing  in  review,  the  amputation 
of  the  joints,  the  fingers,  the  hand,  the  wrist,  the  forearm,  the  elbow,  the  arm, 
and  shoulder,  I  had  treated  first  of  coniimcous  and  then  of  contiguous  ampu- 
tations, one  subject  could  not  have  afforded  the  means  of  exhibiting  all.  Be- 
sides, it  seemed  to  me  better  to  proceed  with  the  trunk  from  the  head  to  the 
pelvis ;  showing  first  the  operation,  then  the  diseases,  then  the  organs  or  parts 
subject  to  them,  as  the  guide  and  standard.  The  only  object  in  adopting  this 
method  was  to  facilitate  the  study  of  the  subject,  and  to  aid  as  much  as  pos- 
sible the  memory  of  the  reader ;  it  is  cheerfully  submitted  to  the  criticism  of 
men  of  science. 

Among  operations  all  the  data  is  given  in  advance,  but  no  rules  could 
meet  the  difficulties  of  some  operations.  The  first,  generally  termed  regular 
operations,  are  fortunately  the  most  numerous  and  important.  Under  this 
class  may  be  ranged  amputations,  operations  for  aneurism  by  the  method  of 
Anel,  of  harelip,  of  lithotomy,  &c.  The  second  comprehend  tumors  either  can- 
cerous or  otherwise,  which  devel ope  themselves  on  the  scull,  the  face,  the  neck, 
the  axilla,  the  abdomen,  and  which  require  extirpation.  There  exists  a  third 
class,  which,  in  some  degree,  holds  a  middle  rank ;  such  as  cancer  of  the  breast, 
sarcocele,  fistula  in  ano,  hernia,  re-sections*  themselves,  and  the  operation  of 
aneurism  by  the  ancient  method.  We  know  well  the  parts  to  be  divided  when 
operating  for  strangulated  inguinal  hernia;  though  we  are  often  ignorant  of 
the  pathological  condition  of  the  parts  reduced.  Thus  operations  naturally 
divide  themselves  into  three  classes.  In  thejirst,  the  instrument  acts  on  parts 
entirely  healthy  or  little  deranged  by  disease ;  in  the  second,  it  bears  on  points 
the  anatomical  relations  of  which  have  been  changed,  or  for  the  removal  of  a 
tumor  whose  limits,  if  not  naturally  fixed,  it  is  impossible  at  first  to  determine ; 
and  in  the  ilurd,  it  is  applied  to  affections  the  limits  of  which  are  easily  esta- 

*  Re-section,  indicates  the  cutting-  off  the  articular  extremity  of  the  long  bones  ;  or 
the  ends  of  bones  which  do  not  unite  after  fracture.     Tr. 


XXU  INTRODUCTION. 

blished — surrounded  by  points  fixed  and  known;  but  the  varieties  of  wlii  chare 
too  numerous  for  established  rules  of  operating  in  one,  to  apply  exactly  to  others 
Process  on  the  dead  Body. — The  convenience  of  this  division  essentially 
practical,  is  thoroughly  confirmed  by  experiments  on  the  dead  body.      It  is 
possible,  indeed,  to  exhibit  completely  the  removal  of  members,  ligatures  of  the 
arteries,  in  a  word,  all  operations  that  can  be  performed  on  the  organs  in  their 
normal  state  ;  viz.  on  all  of  theirs/ class,  nothing  of  the  kind,  however,  could 
take  place  in  sarcoma  of  the  face,  maxillary  sinus,  amputation  of  the  superior 
maxillary,  of  the  parotid  gland,  of  the  thyroid  gland,  the  cyst  of  the  ovaria  or 
the  interior  of  the  abdomen — in  fine  all  of  the  second  class.     Every  student 
knows  also  that  the  knowledge  acquired  in  the  amphitheatres*  of  ligature  of 
the  polypus,  amputation  of  the  neck  of  the  uterus,  operation  for  fistula  in  ano 
orperineo,  and  of  hernia  particularly,  is  very  imperfect,  and  but  feeble  aid 
when  called  on  to  operate  on  the  living  patient.     He  would  strangely  deceive 
himself  were  he  to  believe  himself  perfectly  master  of  all  operations,  merely 
from  repeatedly  witnessing  the  performance  of  them  in  the  dissecting  room. 
No  one  can  be  a  skilful  surgeon   without  having  a  long  time  practised  these 
operations.     They  impart  an  aptitude,  a  steadiness,  an  address  that  the  most 
precise  anatomical  knowledge  can  never  supply.     But  this  is  not  all  even  for 
operations  of  ih^  first  class.     If  the  eye  is  more  flabby,  more  loose,  less  trans- 
parent in  the  dead  body,  no  idea  of  its  mobility,  of  the  tendency  of  thevitrous 
humor  to  escape,  of  the  eyelids  to  contract  and  of  the  tears  which  constantly 
flow  during  life.  When  a  limb  is  amputated,  the  tissues  being  more  firm  and 
tense  are  more  easily  cut  before  than  after  death  ;  but  in  the  latter  case  there 
is  no  retraction  of  the  muscles,  no  blood  to  disturb  or  annoy,  and  no  difficulty 
in  ascertaining  whether  certain  hemorrhage  proceeds  more  from  the  veins  than 
the  arteries.      vSometimes,  when  an  artery  is  deeply  seated,  it  cannot  be  dis- 
covered without  dividing  vascular  ramifications,  the  blood  from  which  so  con- 
ceals the  parts  as  to  render  the  distinction  more  or  less  embarrassing;  whilst 
on  the  dead  body  nothing  analogous  is  to  be  met.     The  palpitation  of  the  ves- 
sels, which  at  the  first  glance  would  seem  to  afford  precise  information,  is  so 
uncertain,  so  vague  in  regard  to  wounds,  that  very  little  advantage  can  be  de- 
rived from  that  source.      In  tracheotomy  and  a^sophagotomy,  is  it  possible  to 
simulate  the  least  portion  of  the  embarrassment  which  arises  from  the  plexus 
of  veins  and  the  numerous  arteries  of  the  neck  ?      In  passing  to  the  two  other 
classes  we  must  add  their  special,  to  these  general  difliicuities.      We  never 
operate  for  fistula  lachrymalis  unless  the  angle  of  the  eye  is  pasted  up,  ulcer- 
ated, or  more  or  less  altered.     It  is  the   same  more  frequently  in  the  nasal 
fossa,  when  we  are  about  to  extract  polypi.     The  motions  of  the  throat,  the 
desire  to  vomit,  the  mucous  or  blood,  the  lassitude  into  which  the  patient  each 
moment  falls,  when  we  operate  for  hypertrophy  of  the  amygdalas,  bifurcation 
of  the  veil  of  the  palate,  are  never  met  with  in  operating  on  the  dead  body. 
Caries  and  necrosis,  which  render  excision  of  the  joint  absolutely  necessary, 
always  change  essentially  the  surrounding  soft  parts.    Whence  it  follows  that 
there  is  no  point  of  comparison  between  the  process  we  are  compelled  to  adopt 
on  the  living  patient,  and  the  freedom  of  our  experiment  on  the  dead  subject. 
In  each  case,  however,  we  know  the  number  and  situation  of  the  tissues  or 
organs  to  be  divided — the  part  to  be  raised  or  separated ;  but  suppose  a  mor- 
bid mass  of  considerable  volume  becomes  developed  in  the  perineum,  what 

•  The  Lecture  Room. 


INTBODUCTION.  XXlll 

assistance  would  the  surgeon  derive  from  tlie  experiments  of  the  dissecting 
room  ?  What  I  have  said  in  relation  to  the  perineum  applies  to  the  groin,  the 
axilla,  the  neck  and  every  other  part  of  the  bod  j.  Without  neglecting  it,  how- 
ever, we  ought  to  be  careful  and  not  attach  too  much  importance  to  this  species 
of  experience.  Experiments  on  living  animals  though  infinitel  j  more  important 
under  this  point  of  view,  do  not  possess  every  advantage.  In  the  first  place 
their  formations  being  rarely  alike,  the  results  obtained  by  reasoning  from  the 
analoo:y  are  generally  defective.  Hence,  in  order  to  study  an  operation  with 
the  necessary  care  and  judgment,  it  ought  to  be  practised  on  the  dead  body, 
and  also  on  the  living  animal ;  two  sources  of  knowledge  which  mutually  aid 
without  being  able  to  supersede  each  othei". 

Operative  surgery  is  then  definitely  bounded— Jirst,  on  anatomy ;  second,  on 
cadaverous  experience ;  third,  on  vivisection ;  fourth,  on  pathological  ana- 
tomy ;  and  Jifth,  on  the  habit  of  operating  on  the  living  man. 

Methods. — As  there  are  few  operations  which  cannot  be  performed  in  dif- 
ferent ways,  I  have  thought  proper  thus  early  to  explain,  by  an  appropriate 
word,  the  ensemble  of  which  each  method  is  composed.  The  terms,  method, 
process,  mode^  have  been  indiscriminately  used,  and  though  nearly  synonymous. 
these  three  words  are  used  still  in  a  variety  of  circumstances.  It  has  been 
attempted,  however,  by  M.  Roux  particularly  to  give  each  a  distinct  meaning. 
The  expression  inethod,  for  example,  is  taken  in  a  much  more  extensive  sense 
than  the  two  others.  Thus  we  say  method,  and  not  process  or  mode,  in  speak- 
ing of  extracting  or  covching  the  cateract;  while  in  performing  lithotomy  with 
the  goro;et,  use  the  term  process  and  not  method  as  indicated  by  the  modified 
operation  adopted  by  M.  Boyer.  Ligature  of  the  polypus  is  a  method,  but 
ii2;ature  of  the  polypus,  according  to  the  practice  of  such  and  such  authors,  is 
0. process.  In  fine,  we  understand,  generally,  by  the  term  method,  some  funda- 
mental principle  sufficiently  extensive  to  be  divided  and  variously  modified  ; 
while  the  word  process  is  more  restrained,  and  is  only  used  to  designate  the 
diminution  of  some  peculiar  method.  Nothing  could  more  clearly  prove  the 
propriety  of  these  distinctions,  than  the  operations  for  aneurism,  for  amputa- 
tion, hydrocele,  and  lithotomy.  To  apply  a  ligature  to  the  artery  without 
touching  the  tumor  is  called  a  method  ;  but  place  it  higher  or  lower,  and  it  is 
called  IX process.  To  open  an  abscess  is  denominated  a  method;  the  manner 
ofopeninji;  it  is  a  ;)roce55.  To  resume — 7?ie^/iOfZ  embraces  the  entire  subject; 
process  relates  to  each  of  its  modes  of  application.  In  common  parlance, 
therefore,  it  is  necessary  to  adhere  to  these  purely  arbitrary  terms ;  and  not 
to  use,  as  is  frequently  done  in  works  more  carefully  written,  the  words  pro- 
cess, mode  of  operating  in  the  place  of  method,  and  vice  versa.  Fistula  lachry- 
malis,  among  others,  proves  it  completely;  the  term  method  being  applied 
indiscrimimitely  to  the  process  of  Dupuytren,  Desault,  and  Boyer.  Hydro- 
cele, hernia,  and  lithotomy  are  equally  liable  to  the  same  remark.  Process, 
the  method  of  cauterization  and  of  injection  ;  method,  the  process  of  dilata- 
tion and  solution;  process,  the  method  of  Frere  Come  are  daily  used.  This 
subject  is  one,  however,  of  secondary  importance;  and  in  such  a  discussion 
every  one  may  reject  or  adopt  these  conventional  terms,  without  being  held  to 
account  for  it. 

1st.  Before  the  Operation* — The  first  object  which  demands  the  solicitude 
of  the  surgeon  before  performing  an  operation,  is  its  indications.     It  is  on 


XXIV  INTRODUCTION. 

this  point  that  the  most  extensive  and  most  precise  medical  knowledge  is  in- 
dispensably necessary.  After  having  satisfied  himself  that  the  cure  can  only  be 
effected  by  an  operation,  he  should  still  be  convinced  of  its  utility,  and  also 
that  the  patient  incurred  less  danger  in  submitting  to  it,  than  in  laboring  under 
the  disease.  Hence,  it  is  only  by  the  aid  of  a  diagnosis,  enlightened  by  the 
clearest  and  most  precise  knowledge  of  pathological  anatomy — of  a  prognosis 
drawn  from  what  the  soundest  judgment  may  apprehend  of  the  progress  or  of 
the  probable  issue  of  the  organic  derangements,  and  of  an  appreciation  as 
exact  as  possible  of  the  power  and  value  of  the  ordinary  therapeutic  agents 
that  the  first  problem  can  be  solved.  And,  besides,  none  of  its  relations  ap- 
pears to  me  to  be  considered  in  a  proper  point  of  view.  I  wish  to  speak  of 
the  choice  to  be  made  between  the  operation  and  the  other  therapeutic  agents 
which  we  may  wish  to  substitute  for  it.  Thus  because  the  lachrymal  tumor, 
has  lately  been  considered  not  within  the  domain  of  operative  surgery,  hav- 
ing yielded  sometimes  to  regimen  and  antiphlogistics — that  certain  tumors  of 
the  breast  having  been  dissipated  by  compression,  it  would  be,  in  my  opinion, 
highly  improper  to  conclude  that  all  this  treatment  should  precede  in  order  to 
render  recourse  to  the  knife  unnecessary.  Indeed,  it  does  not  concern  us  to 
know  if  cancer,  or  any  tumor  whatever,  can  be  removed  by  the  action  of  such 
and  such  medicines  or  by  the  knife ;  but  which,  in  the  last  resort,  offers  the 
.'greatest  advantages.  I  grant  that  the  frequent  application  of  leeches,  emol- 
lient cataplasms,  abstinence,  &c.,  cure  a  number  of  tu^^iors  and  even  fistula 
laclirymalis;  but  is  it  hence  to  be  concluded  that  the  treatment,  whose  suc- 
cess is  not  even  uniform,  and  requires  to  be  continued  several  months,  ought 
to  be  substituted  for  a  metallic  tube  in  the  nasal  canal — a  matter  which  is 
effected  in  a  second,  removing  in  two  days  a  disease  of  ten  years  standing, 
and  restoring  the  patient  to  health  in  a  great  majority  of  cases  ?  That  leech- 
ing and  regimen  may  triumph  over  some  masses  apparently  scirrhous  or  can- 
cerous I  will  not  deny ;  but  if  these  tumors  remain  movable  and  are  favorably 
situated  who  will  assert  that  the  bistoury  will  not  remove  them  with  much 
more  certainty  and  rapidity  ?  and  by  affecting  less  seriously  the  general  phy- 
siological condition  of  the  system,  diminish  the  sum  total  of  human  suffering. 
What  has  been  said  in  relation  to  cancer  and  fistula  lachrymalis  applies  to  a 
number  of  other  diseases ;  forming  the  foundation  of  a  remark  that  the  sur- 
geon ought  never  to  lose  sight  of.  If  it  is  cruel  to  use  the  knife  on  those 
who  might  be  cured  in  a  more  gentle  manner,  it  would  still  be  less  conform- 
able to  the  interests  of  humanity  to  compromise  the  future  health  of  the  patient 
under  the  vain  pretext  of  averting  a  little  present  pain. 

Nearly  all  the  preparations  to  which  patients  were  formerly  subjected  pre- 
vious to  operations  have  been  abandoned  by  the  moderns.  Still  there  are 
some  which  should  be  observed  when  the  disease  will  permit  delay.  The 
choice  of  season  is  not  certainly  a  matter  of  indifference ;  ceteris  paribus, 
spring  and  autumn  ought  to  be  preferred  to  winter  and  the  heat  of  summer; 
not  because  the  temperature  is  more  mild,  but  because  the  system  is  then 
better  able  to  resist  general  morbific  variations.  Thus  it  is  rational  and  pru- 
dent to  postpone  operations  for  the  stone,  cataract,  the  removal  of  large  tumors, 
and  all  operations  which  deeply  affect  the  vital  functions,  till  temperate  sea- 
sons; unless  from  some  peculiarity  of  the  patient,  we  have  reason  to  pursue 
another  course.    But  too  much  importance  is  not  to  be  attached  to  this  pre- 


INTRODUCTION.  XXV 

caution ;  there  is  no  time  of  itself  capable  of  destroying  the  success  of  an 
operation  ;  and  the  question  of  season  is  only  an  affair  of  better  or  lessfavor- 
abU.  No  doubt  the  appearance  of  an  epidemic  should  be  a  powerful  reason 
for  temporizing ;  and  that  the  morbific  conditions  of  the  moment  should  be 
regarded.  In  choosing  the  morning  rather  than  the  evening,  the  operator  has 
the  advantage  of  finding  his  patient  less  fatigued,  and  he  is  better  able  to 
watch  his  wants  immediately  after  the  operation ;  but,  besides  this,  there  is 
nothing  that  renders  the  morning  indispensable,  and  the  most  plausible  mo- 
tive is  that  the  forenoon  is  generally  more  convenient  for  all.  As  regards 
urgent  operations,  they  must  be  performed  when  exigency  requires,  without 
reference  to  the  seasons  or  hour ;  and  hence,  authors  have  been  led  to  establish 
a  time  of  choice  and  a  time  of  necessity. 

The  moral  precautions  vary,  and  ought  necessarily  to  vary,  with  the  indivi- 
duals. The  first  is,  to  inspire  the  patient  with  unlimited  confidence  in  the 
surgeon,  and  all  that  confidence  is  acquired  in  a  thousand  different  ways. 
The  second  is  to  convince  the  patient  that  the  operation  is  the  only  means  of 
arresting  his  suf!*erings,  and  to  disabuse  his  mind  if  he  exaggerates  the  danger. 
To  resume  it  is  necessary  to  do  every  thing,  within  the  limits  of  truth,  that 
may  induce  the  patient  to  desire  the  operation,  if  not  with  pleasure,  at  least 
with  resignation.  There  are  two  sorts  of  individuals  to  be  encouraged  on 
this  point.  One  is  of  extreme  timidity,  frightened  at  the  idea  of  the  slightest 
stroke  of  the  scalpel ;  whom  it  is  necessary  to  deceive  as  to  the  severity  and 
acuteness  of  the  pain,  and  also  to  the  dangers  to  which  he  is  exposed.  Tlie 
others  tliink  that  in  public  establishments  the  operation  will  be  performed 
nolens  volens,  and  therefore  never  speak  to  the  surgeon  but  with  a  disturbed 
air ;  and  they  remain  under  this  delusion  until  the  operator  is  able  to  remove 
the  error.  Experience  has  discovered  two  other  species  of  patients  which 
require  to  be  well  watched.  In  the  first  class  we  place  those  who  doubt  not 
their  risk,  and  who  wishing  to  exhibit  a  bravado  courage,  submit  themselves, 
in  spite  of  every  one,  to  the  knife  of  the  operator,  and  pride  themselves  in  sup- 
porting the  operation  without  complaint.  The  second  class  composes  the 
naturally  timid  or  very  susceptible,  but  who  after  long  hesitation,  have 
become  convinced  that  the  operation  is  absolutely  necessary,  and  collecting 
all  their  courage,  force  themselves  to  withhold  the  scream,  to  resist  the  most 
natural  sufferings,  and  to  stifle  even  the  slightest  complaint.  To  the  first  it 
is  necessary  to  manifest  great  seriousness  on  the  subject  which  they  appear  to 
treat  so  lightly  and  to  decide  after  much  reflection.  An  effort  should  be 
made  to  convince  the  second  that  an  affected  courage  never  supplies  the  place 
of  real  bravery ;  also,  that  it  is  as  dangerous  to  stifle  complaints  as  it  is  to 
exaggerate  them ;  that  in  suppressing  them  they  do  violence  to  nature,  which 
require  that  the  cries  of  each  suffering  organ  should  be  expressed  freely  and 
without  the  least  restraint.  Besides,  nothing  augers  so  badly  as  these  forced 
resolutions  and  bragging  of  calmness  or  resignation.  It  seems  as  if  nature  is 
weakened  by  this  turning,  as  it  were,  on  herself,  instead  of  preparing  to  parry 
the  attacks.  The  fact  is,  that  operations  performed  under  such  circum- 
stances, terminate,  generally,  less  favorably  than  others. 

Internal  Injuries. — It  would  be  unprofitable  to  enter  into  an  investigation  of 
the  preparations  in  relation  to  injuries  of  this  description,  as  it  would  tend  to 
complicate  the  principal  diseases  here  spoken  of.     We  never  attempt  any 
D 


XXVI  INTRODUCTION. 

operation,  so  long  as  the  patient  labors  under  any  formidable  functional  dis- 
ease, lest  it  should  prove  the  means  of  terminating  all  the  troubles  of  the 
human  economj.  Besides,  such  injuries  should  be  met  as  thej  arise,  before 
or  after  having  decided  on  an  operation.  The  manner  of  recognizing  and 
treating  them,  having  been  necessarily  laid  down  in  books  on  pathology,  it 
would  only  be  to  abuse  the  patience  of  the  reader  to  introduce  them  in  a 
work  on  operative  surgery.  The  preparations  are  such  as  would  be  demanded 
by  the  condition  of  the  patient,  in  other  respects  in  good  health.  Upon  this 
point  authors  are  far  from  agreeing.  Some  prescribe  scarcely  a  day's  regi- 
men, while  others  do  not  operate  till  after  having  used  ptisans,  purgatives, 
revulsives,  bleeding  or  a  diet  of  the  greatest  rigor — in  a  word,  of  the  most 
minute  precautions  for  one  or  two  weeks.  Hence,  the  difficulty  of  establish- 
ing a  general  rule  for  all  cases.  It  is  in  treating  on  the  particular  operation, 
that  this  question  ought  to  be  touched.  At  present,  I  will  merely  remark, 
that  every  operation  sufficiently  important  to  require  a  rigid  diet  for  several 
days  afterwards,  in  order  to  control  general  re-action  and  imperceptibly  to 
cjjange  the  habits  of  the  patient,  require  an  antiphlogistic  regimen,  so  far  as 
not  to  debilitate  the  patient ;  that  the  soups  and  ptisans  should  be  slightly 
diluted  and  cooling;  and  that  one  or  two  bleedings  either  by  the  lancet  or 
leeches  be  resorted  to.  If  the  patient  be  robust,  a  purgative,  or  at  least 
laxative  drinks  should  be  given,  in  order  that  the  transition  be  not  too  sudden 
and  that  there  remain  no  germ  of  morbid  derangement  in  the  system,  except 
what  follows  the  operation  itself.  The  preceding  considerations  ought  to 
apply  to  local  prejmrations.  The  only  thing  necessary  to  be  noticed  here,  is 
that  whatever  supports  the  action  of  the  instruments,  the  bandages  or  other 
dressings  ought  to  be  carefully  scraped  and  cleaned. 

Place  of  Operation. — In  hospitals,  it  is  customary  to  remove  the  patient  to 
the  amphitheatre,  in  order  that  his  companions  in  misfortune  may  not  witness 
either  his  cries  or  the  mutilation  he  undergoes.  This  place  instituted  for  the 
purpose,  besides  being  very  commodious,  has  no  other  inconvenience  than  that 
it  is  more  difficult  to  warm  than  an  ordinary  chamber;  and  it  is  the  only  one 
which  could  enable  the  assistants  to  witness  fully  the  skill  of  the  operator. 
It  is  only  used,  however,  for  the  capital  operations  and  a  few  others.  Hydro- 
cele, lithotomy,  hernia,  cataract,  fistula lachrymalis and  trepan,  can,  and  ought 
to,  be  frequently  operated  on  in  the  hall  or  even  where  the  patient  lies.  It  is 
only  for  lithotomy,  amputations  and  the  dissection  of  certain  tumors,  that  the 
amphitheatre  is  indispensably  necessary.  When  the  bed  room  of  any  patient 
is  not  suitable  for  the  operation,  we  should  select  some  other  place  more 
roomy,  better  lighted,  and  well  ventilated.  Here  the  assistants  should  be  as 
lew  as  possible,  because  those  who  are  not  actually  employed,  cause  embar- 
rassment almost  always,  by  their  indiscreet  or  ill-timed  expressions,  by 
change  of  countenance,  by  vitiating  the  air  of  the  chamber,  or  by  restraint 
on  the  patient  or  operator.  The  interest  of  students  and  of  science  require 
the  attendance  of  assistance  in  hospitals  ;  but  here  every  thing  being  public, 
the  patients  know  beforehand  what  they  have  to  submit  to,  and  resign  them- 
selves to  it  without  difficulty. 

The  assistants  deserve  the  greatest  attention,  their  number  cannot  be  fixed ; 
one  being  absolutely  necessary,  the  others  merely  useful.  In  private  practice 
as  few  as  possible  are  admitted ;  while  in  public  institutions  all  are  employed 


INTRODUCTION.  XXVll 

to  wliom  the  operation  affords  the  least  advantage.     In  country  practice  there 

is  often  a  great  want  of  assistants.  Some  of  them  may  not  have  finished 
their  medical  studies ;  and  to  those  are  confided  the  duties  which  require  only 
strength,  coolness,  a  little  address  or  intelligence.  It  is  necessary,  also,  that 
each  should  be  well  acquainted  with  the  duty  he  has  to  perform.  The  sur- 
geon should  be  careful  in  making  his  selection  in  regard  to  the  ability,  saga- 
city, stature  and  strength  of  those  he  entrusts ;  and  as  far  as  possible  to  take 
his  assistants  from  the  students  accustomed  to  his  practice,  who  can  divine 
his  tiioughts  at  the  least  sign,  and  who  have  at  heart  the  success  of  the  opera- 
tion, and  the  triumph  of  his  labors. 

The  appareil  or  apparatus,  is  another  point  that  should  not  be  overlooked. 
The  materials  which  compose  it  are  naturally  divided  into  three  orders.  The 
first,  such  as  the  garotte,  tourniquet,  pads,  compresses,  &c,  are  intended  to 
prevent  accidents  during  the  operation ;  the  second  embraces  all  that  is  neces- 
sary to  perform  it,  and  the  third  relates  entirely  to  the  dressings.  There 
should  be  in  readiness,  a  sufficient  number  of  flexible  wax  candles,  rather  than 
lighted  candles,  in  the  event  of  the  natural  light  not  being  sufficient; 
2d,  a  chaffing  dish  full  of  coals  and  cauteries;  3d,  a  little  wine,  vinegar, 
cologne  and  brandy  in  separate  vessels  ;  4th,  tepid  and  cold  water,  basins 
and  sponges  ;  5th,  the  means  of  suspending  temporarily  the  flow  of  blood  in 
the  parts  about  to  undergo  the  operation  ;  6th,  several  compresses,  lint,  ordi- 
nary bandages,  napkins  to  dress  the  patient  or  protect  certain  organs.  The 
second  series  comprehend  the  different  instruments;  such  as  bistouries, 
knives,  needles,  scissors,  saws,  ligatures,  nippers,  pincers,  &c,  which  are  placed 
on  a  waiter  or  table  in  the  order  in  which  they  are  to  be  used.  The  fillets, 
pledgets,  compresses,  bandages  and  other  dressings,  are  disposed  on  another 
table  so  as  to  be  at  hand  without  confusion,  when  they  are  required  for  use. 
Being  about  to  recur  to  these  details  in  treating  of  many  operations,  such  as 
amputations  and  aneurism  among  others,  where  their  utility  will  be  more 
fully  developed,  it  is  unnecessary  at  present  to  enlarge  on  their  advantages. 

2d.  During  the  Operation — The  situation  of  the  patient,  of  the  surgeon 
and  his  assistants,  necessarily  governed  by  the  character  of  the  operation,  the 
diseased  organ  and  the  taste  of  the  operator,  cannot  be  indicated  more  advan- 
tageously than  by  describing  each  article.  The  same  may  be  said  of  the 
hemostatic  means,  either  provisional  or  definite,  of  whatever  is  intended  to 
moderate  pain,  of  the  resources  besides  which  have  been  mentioned  under 
the  article  "  amputation." 

3.  After  the  Operation. — It  is  also  important  that  care  should  be  taken  to 
prevent  syncope,  convulsive  movements  or  spasms,  and  in  fact  every  attack 
which  may  follow  the  operation.  Being  obliged  to  pass  in  review  these  vari- 
ous chapters,  so  that  the  dressings,  the  question  of  knowing  if  the  operation 
will  unite  by  the  first  intention,  the  accidents  to  which  operations  are  princi- 
pally exposed,  and  also  the  elementary  points  in  the  removal  of  members, 
and  of  aneurism,  it  would  be  a  waste  of  time  to  describe  them  here.  I  shall, 
however,  not  stop  to  discuss  the  propriety  of  the  ancient  adage  "  cito  tuto  et 
jiiciinde,'^  which  formerly  re-echoed  throughout  the  schools.*    To  say  that  an 

*This  adag-e  belongs  to  Ascepiades  and  not  Celsus  to  whom  it  has  been  attributed.  Hip- 
pocrates and  Galen  say  :  Celerite^  jucundcy  prompter  et  eleganter  which  amounts  to  tlie 


MVlll  INTRODUCTION. 

operation  should  be  conducted  with  promptitude,  ability,  and  address,  is  a 
truism  which  there  is  no  occasion  to  repeat  in  our  day  :  the  most  important 
part  is  not  to  sacrifice  one  of  these  advantages  to  the  other ;  to  look  imme- 
diately to  the  mind,  and  to  show  for  example,  that  promptitude  is  neither  pre- 
cipitation nor  swiftness ;  but  in  surgery  that  safety  and  care  should  reign 
paramount. 

Phlebitcs  or  purulent  Absorption. — The  division  of  tissues  by  the  hand  of 
the  operator  creates  sometimes  such  a  series  of  symptoms,  which  in  latter 
times  has  so  much  occupied  the  minds  of  scientific  men,  that  it  is  impossible 
to  avoid  entering  upon  its  discussion  more  fully.  The  progress  of  disease 
in  similar  cases  is  besides  extremely  variable  ;  sometimes  it  commences  with 
a  violent  trembling  that  may  continue  for  many  hours,  sometimes  by  spasms, 
and,  in  certain  cases,  simply  by  a  coldness  of  the  extremities.  The  skin 
becomes  pale,  takes  a  yell()>4^ish  tint,  somewhat  livid,  and  soon  after  an  aspect 
more  or  less  ghastly.  To  the  difierence  of  intermittent  fevers  produced  from 
low  grounds,  marshy  places  which  have  more  than  one  trait  of  analogy,  this 
first  period  is  rarely  followed  by  a  free  re-action.  If  perspiration  succeeds, 
it  is  unequal,  often  clammy  or  heavy;  after  being  renewed  once  or  oftener 
undei-  the  shape  of  paroxysms,  these  symptoms  are  generally  followed  by 
remarkable  adynamia  and  mortification.  The  eyes  are  sunk  and  covered  with 
greyish  rheum,  the  conjunctiva  becomes  yellow,  as  well  as  the  compass  of 
the  lips,  and  the  whole  face  remains  more  or  less  dull.  The  tongue  which  is 
habitually  moist,  without  being  very  large  or  pointed,  as  is  the  casein  intes- 
tinal affections,  does  not  become,  furred  until  at  an  advanced  period  of  the  dis- 
ease ;  the  teeth  and  the  lips  become  fuliginous.  The  pulse  assumes  a  frequency 
and  hardness  without  being  quick  ;  and  becomes  by  degrees  more  and  more 
small  and  feeble.  Distention  of  the  abdomen,  sometimes  diarrhea,  (seldom 
delirium  although  nearly  always  stupor)  scarcely  ever  fail  to  exhibit  themselves. 

To  these  are  to  be  added  the  indefinite  symptoms  of  visceral  inflammation; 
it  appears  occasionally  as  a  livid  redness  of  the  cheek,  which  maybe  remarked 
for  a  moment,  at  the  same  time  accompained  by  a  slight  cough  or  pain  in  the 
breast,  and  difficulty  of  respiration ;  sometimes  as  a  jaundice,  more  or  less 
developed,  with  pain  and  derangement  in  the  hepatic  region  or  in  the  right 
shoulder ;  likewise,  with  what  is  more  rare,  a  desire  to  vomit;  with  a  par- 
ticular redness  of  the  lips  and  the  borders  of  the  tongue,  which  then  becomes 
dry,  as  in  cases  of  follicular  ulceration  of  the  intestines  or  of  typhoid  fevers ; 
as  well,  in  fine,  as  by  acute  suffering  in  some  part  of  the  members  of  the  body 
— the  great  joints  for  example.  Thirst,  is  not  generally  very  great ;  the 
breath,  often  fetid,  exhales  sometimes  the  true  odor  of  pus  ;  the  process  of 
cicatrization  is  immediately  suspended  in  the  wound,  the  borders  of  which 
become  pale  the  same  as  the  rest  of  the  surface.  However  thick  or  creamy 
it  might  have  been,  the  suppuration  becomes  all  at  once  greyish,  clotted,  or 
resembling  ill  conditioned  serous  matter.  It  is  not  rare  to  see  it  stop  sud- 
denly. The  soft  parts  shrink  up  with  iht  same  rapidity,  and  assume  the 
most  cadaverous  aspects.  The  muscles,  bones,  &c.,  fall  asunder,  as  if  the 
cellular  tissue  which  unites  them  in  the  normal  state  had  been  destroyed; 
after  a  while  a  bloody  oozing  ensues,  which  becomes  more  and  more  fluid 
until  it  terminates,  when  the  malady  has  lasted  a  long  time,  by  resembling  the 
washings  of  meat,  and  produces  hemorrhages  which  nothing  can  arrest.     In 


INTRODUCTION.  XXIX 

fine,  Ihe  subject  dies  exhausted  on  the  twelfth,  thirteenth,  or  fourteenth 
day.* 

Pathological  Anatomy. — Upon  the  opening  of  dead  bodies,  lesions  of 
different  sorts  are  found,  although  susceptible  of  being  all  traced  to  the  same 
cause  ;  these  are  often  the  seats  of  multiplied  abscesses,  in  the  proper  tissue 
of  the  viscera,  or  collections  more  or  less  abundant  of  greyish  cream  colored 
serosity,  rather  than  flakes  floating  in  the  serous  cavities.  Among  others  the 
large  articulations,  such  as  the  shoulder,  the  hip,  the  knee,  are  equally  filled 
with  pus,  which  is  supplied  frequently,  either  by  the  state  of  the  parts 
or  by  infiltration,  particularly  when  there  is  a  sufficient  quantity  of 
lax  cellular  tissue.  The  arteries  are  almost  empty,  and  the  blood  which 
they  contain  is  in  general  very  fluid ;  that  of  the  veins,  which  is  more 
abundant,  is  still  more  evidently  altered.  The  clots  which  are  found  here 
and  there,  are  a  mixture  of  black,  yellow,  white  and  green,  and  have  a 
granulated  texture,  which  escapes  in  cutting  or  even  in  pressing  them  under 
the  fingers.  They  contain  sometimes  globules  of  pus,  obvious  to  the  naked 
eye.  It  is  not  even  rare  to  meet  with  the  true  purulent  foci  in  small  clots  of 
blood.  All  the  parts  of  the  venous  system  have  offered  specimens  of  this  de- 
scription; as,  for  instance,  the  iliac  and  uterine  veins,  the  vena-cava  inferior 
below  the  liver,  and  at  its  entrance  into  the  right  auiicle,  the  vena-cava  supe- 
rior, the  different  cavities  of  the  heart,  &c.  Many  of  these  concretions  are 
yet  soft  and  evidently  of  recent  origin,  others,  on  the  contrary,  are  so  dry  and 
brittle  that  it  is  impossible  to  deny  them  a  certain  age.  Not  one  of  them  has, 
in  a  majority  of  cases,  a  pathological  relation  to  the  state  of  vessels  in  the  re- 
gion in  which  it  is  found.  It  is  entirely  different,  in  the  case  of  wounds, 
where  nothing  is  more  common  than  to  see  the  veins  inflamed,  in  full 
suppuration,  either  interiorly  or  exteriorly,  and  that  to  an  extent  extremely 
variable,  but  of  such  a  description,  however,  that  the  two  vense-cavas  remain  in 
almost  ever  J  instance  unaffected. 

The  small  abscesses  of  which  I  have  spoken  in  the  commencement,  have 
been  observed  in  all  the  organs.  A  subject  which  I  had  occasion  to  examine 
at  Tours,  in  1808,  presented  them  by  dozens  in  the  brain  and  in  the  tissues 
of  the  heart.  A  young  man  who  died  at  the  Clinique  of  the  faculty,  in  1825, 
from  the  effect  of  amputation  of  the  great  toe,  exhibited  them  even  in  the 
spleen  and  in  the  kidneys.  The  lungs  and  the  liver,  are  not  less  subject  to 
them.  It  is  there  that  at  all  times  it  has  been  known  to  exist  when  no  trace 
whatever  could  be  found  elsewhere.  Their  characters  are  so  well  marked, 
that  it  is  difficult  to  confound  them  with  the  results  of  ordinary  inflammation. 
Besides,  they  are  seldom  developed  singly,  but  much  oftener  a  large  number 
exist  in  the  same  part.  The  surface  of  the  organs  appears  to  be  more  congenial 
to  them,  than  deep  seated  parts ;  and  it  is  rare  that  they  acquire  any  great 
size.  In  this  point  of  view  they  vary  from  the  size  of  a  pin's  head,  to  that  of 
a  walnut  or  of  a  small  egg.  By  pressing  upon  them  they  can  be  distinguished 
as  so  many  large  tubercles  reaching  across  the  pulmonary  apparatus,  the 
periphery  of  which  seems  quite  superficial.  In  the  liver  they  are  enveloped 
in  a  blackish  or  livid  couche,  sometimes  several  lines  in  thickness.  In  this 
organ  they  are  situated  most  commonly  near  the  centre,  and  are  generally  of 

*  In  the  text  it  is  the  twelfth,  thirtieth,  or  fortieth  day.    Tr. 


XXX  IKTRODUCTION. 

a  larger  size  than  in  the  other  parenchymae.  The  matter  of  which  they  are 
formed  is  also  more  irregular.  Although  generally  very  fluid,  blue,  and 
flaky,  or  of  a  milky  whiteness  near  the  centre,  they  are  very  often  grumous 
or  even  hard  especially  near  the  circumference.  In  the  lungs  we  may  wit- 
ness the  various  phases  of  this  affection  still  better.  At  some  points  may  be 
discovered  slight  stains  resembling  ecchymosis.  In  others  we  see  these  stains 
or  blotches  inclosing  a  drop  of  pus.  Again,  no  ecchymosis  exists,  and  nothing 
but  grumous  pus  is  to  be  found.  Still  further  we  meet  with  others  either 
concrete  like  the  caseous  tubercles  of  lymphatic  ganglions,  or  liquid  as  in  the 
liver.  The  substance  of  some  seems  to  be  confounded  with  the  neighboring 
tissues.  Others  are  as  if  encysted.  Then  the  walls  of  the  sac  are  villous  and 
of  a  lilac  color.  At  some  lines  distance  from  them  the  organ  recovers  all  the 
attributes  of  its  normal  state.  They  are  almost  always  separated  by  inter- 
val completely  healthy.  Frequently  it  appears  after  evacuating  the  matter 
and  removing  the  cyst  as  if  the  organ  had  never  been  diseased,  or  as  if  the 
places  of  the  disease  had  been  formed  mechanically  by  a  separation  of  the 
tissues. 

The  eftusion  in  the  serous  cavities  is  also  very  remarkable.  The  pleura  is 
generally  its  seat  although  it  may  also  take  place  in  the  pericardium,  perito- 
neum, arachnoid  membrane,  &c.  In  a  few  days  it  becomes  very  abundant. 
Without  scarcely  any  alteration  the  membrane  after  being  emptied,  remains 
covered  with  a  greater  or  less  thickness  of  true  pus,  and  the  residue  of  the 
liquid,  of  an  ashy  or  earthy  appearance,  is  far  from  resembling  the  flaky  or 
lactescent  serosity  which  is  found  as  a  sequence  of  recent  pleurisy.  The 
state  of  the  tissues  in  the  articulations  is  astonishing.  Neither  the  cartilages, 
ihe  capsules,  the  ligaments,  the  cellular  envelope,  nor  any  thing,  in  a  word, 
presents  the  least  trace  of  inflammation,  and  after  removal  of  the  pus  a  sim- 
ple lavation  has  been  sufficient  more  than  once  to  cause  doubt  whether  or  not 
the  articulation  had  been  diseased.  It  may  even  happen  that  the  cartilages 
may  be  partially  destroyed,  the  synovial  membrane  and  the  ligaments  pierced 
without  the  contiguous  parts  losing  any  of  their  mobility  or  natural  color. 
The  same  may  be  said  of  the  sub-cutaneous  and  other  deposites  in  the  extre- 
flriities.  In  other  cases  these- deposits  are  surrounded  by  ecchymosis  and 
more  or  less  evident  traces  of  inflammation. 

Although  some  patients  die  with  all  these  varieties  at  once,  imbibing  pus  as 
it  were  like  a  sponge,  the  greatest  number  exhibit  only  a  part  of  them.  Some- 
times they  are  tubercle-like  as  in  the  lungs  or  liver,  without  any  efiusion. 
Sometimes  collection  in  the  pleura  exists  alone;  in  another  case  this  may  be 
found  in  the  extremities,  within  or  without  the  articulations ;  in  many  cases 
it  will  be  found  no  where,  and  then  we  must  seek  the  cause  of  death  in  the 
more  or  less  serious  alteration  of  the  blood  in  the  vessels  themselves. 

Etiology. — Every  solution  of  continuity  that  suppurates,  may  produce  the 
alterations  that  we  have  just  spoken  of:  trepaning,  a  simple  incision,  the  sec- 
tion of  a  varix,  an  ordinary  venesection,  as  well  as  the  amputation  of  the  neck 
of  the  womb,  the  excision  of  hemorrhoidal  tumors,  or  the  amputation  of  a 
member.  Nor  is  this  a  discovery  of  the  present  day.  Pare  mentioned  it, 
and  Pigrai  says,  that  in  a  certain  year  almost  all  that  died  of  wounds  of  the 
head  had  abscesses  of  the  liver.  Morgagni  describes  these  affections  with 
some  detail,  Quesnay,  Col.  de  Villars  formally  mentions  them.    J.  L.  Petit 


INTRODUCTION.  XXXI 

gives  a  very  correct  idea  of  them,  and  many  modern  surgeons  have  noticed 
them  in  their  lectures  or  their  writings,  but  they  had  not  then  fixed  the  at- 
tention of  the  profession  so  strongly  to  their  importance  as  they  now  do.  In 
saying  that  the  pus  was  transported  from  the  wound  to  the  organ  in  which  it 
was  found  deposited,  the  ancients  merely  reiterated  their  usual  humoral  hy- 
pothesis and  proved  nothing  To  believe  as  MM.  Boyer,  Roux,  and  Dupuy- 
tren  did,  that  so  many  disorders  result  from  simple  idiopathic  inflammation, 
caused  itself  by  the  sympathetic  (retentisment)  of  the  wounded  part  upon  the 
viscera,  or  by  the  anterior  existence  of  tubercles  or  other  organic  lesion  un* 
appreciable  until  then,  was  not  likely  to  excite  a  very  lively  interest  in  the 
question.  Struck,  at  the  commencement  of  my  medical  studies  with  the  fre- 
quence and  importance  of  these  aifections  I  soon  made  them  the  object  of  my 
special  attention.  Believing  from  a  fact  observed  in  the  hospital  of  Tours  in 
1818,  that  I  had  discovered  the  true  etiology,  and  confirmed  in  this  opinion 
by  what  I  afterwards  met  either  in  Tours  or  Paris,  I  took  the  liberty  of 
publishing  it  in  my  public  lectures  in  1821  and  1822,  and  in  my  Tliesis  de 
Reception  in  1823.  I  then  maintained  that  these  numerous  purulent  depo- 
sites  owed  their  existence  not  to  any  separate  idiopathic  phlegmasia,  but  to  an 
alteration  of  the  blood,  to  the  passage  of  pus  into  the  circulation  and  its  trans- 
port into  these  organs,  whether  it  came  from  the  wound  or  was  secreted  by 
the  neighboring  veins.  It  required  some  boldness  to  advance  such  idea  then 
whilst  solidism  reigned  triumphant  over  our  schools,  from  which  the  partisans 
of  the  physiological  doctrine  thought  they  had  for  ever  banished  humoralism. 
These  ideas  were  therefore  badly  received  generally.  Yet  my  own  convic- 
tion and  the  facts  that  came  daily  to  their  support  did  not  permit  me  to 
abandon  them.  My  sojourn  at  the  hospital  de  Perfectionnement  furnished  me 
numerous. occasions  to  submit  them  to  new  proofs,  to  call  them  to  the  atten- 
tion of  the  students,  and  to  show  in  what  manner  they  might  enlarge  the  field 
of  general  pathology.  The  two  memoirs  that  I  published  in  1826  in  the  Re- 
view upon  this  subject,  and  that  which  I  had  already  said  in  the  same  journal 
in  treating  of  the  alteration  of  the  fluids ;  that  which  I  had  advanced  at  the 
same  time,  or  soon  after,  in  the  Archives  and  La  Clinique  des  Hospitaux,  and  the 
discussions  that  I  caused  in  the  Academy  finally  had  its  effect,  and  I  soon  had 
the  satisfaction  to  see  that  Marechal  and  Raymond  of  Marseilles,  in  their  ex- 
cellent thesis  (1828)  and  M.  Legallois  in  a  memoir  at  the  same  time  had 
arrived  at  the  same  conclusions  that  I  did.  Whilst  M.  Dance  in  a  work  stiU 
more  complete,  was  removing  the  last  vestiges  of  objection,  opinions  supported  by' 
facts  of  the  same  kind  were  taught  at  London  by  MM.  Rose  and  Arnott.  M. 
Blandin,  who  in  a  thesis  a  little  later  than  mine  (1824)  had  adopted  the  hy- 
pothesis of  sympathetic  reaction  and  pure  simple  inflammation — MM.  Tonnelc 
and  M.  Rochoux  have  ranged  themselves  under  the  same  flag  although  their 
tkeoretical  views  are  not  exactly  alike.  In  fine,  the  pathological  meeting 
which  took  place  at  the  Faculte  de  Medicine  in  the  spring  of  1831,  having 
called  in  MM.  Berard,  Blandin,  Sanson,  and  myself,  to  examine  the  question 
c(f  metastatic  suppurations  following  traumatic  lesions,  has  in  a  manner 
forced  us  to  show  the  present  state  of  opinion  upon  this  subject,  and  to  provfe 
that  there  can  be  no  further  difference  of  opinion  upon  the  principle  with  which 
I  set  out,  viz.  that  metastatic  abscesses  caused  by  great  operations  are  the  result 
of  an  alteration  of  the  blood. 


XXXll  INTRODUCTION. 

There  is  still,  however,  a  problem  to  solve.  Marechal,  Legallois,  and 
Rochoux,  found  in  the  absorption  of  the  pus  of  the  wound  a  sufficient  expla- 
nation of  all  the  observed  phenomena.  Dance,  Arnott,  and  Blandin  on  the 
contrary  thought  that  an  inflammation  of  the  veins  always  preceded  the  gene- 
ral infection,  and  that  the  pus  which  entered  into  the  circulation  was  always 
the  immediate  product  of  phlebetis,  which  M.  Blandin  located  in  the  veinules 
of  the  soft  parts,  the  medullary  canal,  or  the  spongy  tissue  of  the  divided  bone, 
when  the  primitive  branches  offered  no  traces  of  the  affection.  Instead  of  j 
admitting  a  transport  without  decomposition,  a  true  metastatic  deposite, 
the  latter  authors  think  also  that  the  blood,  profoundly  altered  by  its  intimate 
intermixture  with  the  pathological  secretion,  and  becoming  more  irritating 
than  common,  is  simply  permitted  to  escape  here  and  there  ;  and  being  depo- 
sited in  the  tissues,  by  their  irritation  become  the  centre  of  so  many  points  of 
suppuration.  This  opinion  differs  from  mine  only  in  this,  that  it  gives  a  cause 
as  the  constant  one,  which  I  think  exists  only  in  certain  cases.  Nor  can  I 
comprehend  how  any  one  can  expect  to  make  use  of  the  labors  and  opinions 
of  MM.  Dance  and  Blandin  to  combat  mine.  In  fact,  so  far  from  denying 
phlebetis  in  such  cases,  I  expressly  said  in  1826,  (Rev.  Med.  tom.  4j  "the 
veins  of  the  diseased  member  are  full  of  a  very  fluid  greyish  pus,  and  inflamed 
from  point  to  point,  but  only  as  far  as  the  entrance  of  the  great  saphena  into 
the  crural."  Again,  I  added,  '*  the  phlebetis  was  not  sufficiently  extensive  ; 
if  it  were  even  primitive  to  play  an  important  part  as  inflammation.  In  turn- 
ing our  attention  towards  the  fluids,  on  the  contrary,  every  thing  explains  it- 
self in  the  clearest  manner,"  &c.  In  May  1827,  I  asserted  (C Unique  des 
Hopit,)  that  "  in  this  frightful  affection  authors  have  paid  attention  only  to 
one  cause  of  danger;  the  facility  with  which  the  inflammation  is  propagated 
from  the  wounded  point  towards  the  principal  veinous  trunks  ;  whilst  the  pus 
secreted  by  the  walls  of  the  vessels  continually  mingles  with  the  blood  which 
it  alters  and  decomposes,  and  thereby  produces  all  the  danger  of  the  disease." 
Finally,  in  speaking  of  the  same  fact  in  the  Archives  (August  1827,)  I  said, 
**  here  the  disease  was  incontestably  a  phlebetis ;  but  it  is  to  the  inflammation 
of  the  vein  that  we  must  attribute  all  the  symptoms.  I  think  not:  the  pus 
continually  entering  the  heart  and  distributed  to  every  organ  with  the  blood 
has  produced  the  general  affection,"  &c.  As  to  the  formation  of  the  purulent 
collections,  this  is  my  theory  which  I  gave  in  1826,  (Rev.  Med.,  tom.  4.)  "  It 
is  possible  to  explain  the  formation  of  these  collections  by  two  processes; 
1st,  the  blood  more  or  less  changed  from  its  natural  condition,  may  commence 
by  deranging  the  general  organism,  and  terminate  by  the  formation  of  a  local 
phlegmasia  of  a  peculiar  species ;  or,  2d,  the  inflammation  at  first  developed 
under  the  influence  of  ordinary  causes  compels  pus  in  a  manner  to  be  depo- 
sited at  the  point  of  the  greatest  irritation.  It  appears  to  me  demonstrated 
that  the  inflammation  when  it  follows  the  deposition  is  then  only  secondary, 
and  that  it  is  produced  by  an  extravasated  portion  of  foreign  matter,  which 
forms  the  point,  and  that  this  is  at  least  a  phlegmasia  altogether  sui  gene- 
ris,'' &c. 

Thus,  in  my  opinion,  the  question  may  be  reduced  under  two  heads ;  1st, 
the  mixture  of  pus  with  the  blood  as  the  cause  of  the  observed  visceral  altera- 
tions; 2d,  the  origin  of  the  pus  whether  in  the  blood  or  in  the  organs.  The 
first,  of  which  I  was  the  first  to  venture  on  the  demonstration  of  its  truth,  [% 


INTRODUCTION.  XDdSL 

now  generally  admitted  as  incontestable.  For  the  other  I  have  not  felt  the 
same  interest  it  is  true.  The  object  of  my  efforts  being  to  prove  that  the  pus 
could  circulate  with  the  blood,  and  infect  the  system  like  a  poison,  I  cared 
little  at  the  moment  about  proving  whether  it  penetrated  into  the  veins  by  ab- 
sorption or  was  simply  formed  on  the  inflamed  surface  of  these  canals,  pro- 
vided it  was  admitted  to  be  transported  a  certain  distance  from  the  point  of 
departure.  The  preceding  quotations,  however,  are  sufficient  to  show  that  I 
had  not  altogether  neglected  these  secondary  questions.  The  effect  of  phle- 
betis  upon  the  composition  of  the  blood  are  so  evident  that  it  appeared  to  me 
superfluous  to  enter  into  any  detail  for  their  exhibition.  The  same  cannot  be 
said  of  absorption,  as  many  yet  refuse  to  admit  it ;  it  is,  therefore,  after  leaving 
this  part  of  the  question,  that  a  real  difference  seems  to  exist  between  M. 
Dance  and  myself.  According  to  this  author,  the  phlebetis  is  the  first  and 
almost  only  cause  of  these  metastatic  /od,  and  the  veins  alone  secrete  the 
pus  that  alters  the  blood.  On  the  contrary,  I  said  at  first,  as  I  believe  now, 
that  the  inflammation  of  the  veins  so  often  met  with,  whether  cause  or  effect, 
were  not  indispensable;  that  the  pus  and  other  morbid  matters  of  the  trau- 
matic surface  enters  sometimes  into  the  circulation,  either  by  lymphatic  absorp- 
tion, by  imbibition,  or  by  the  orifices  of  the  veins  remaining  patulent  at  the 
amputated  surface.  The  proof  of  its  truth,  in  my  opinion,  is,  that  I  have 
frequently  found  abundance  of  pus  in  the  midst  of  the  viscera  although  the 
veins  plunging  into  the  exterior  lesion  were  scarcely  phlogosed,  and  without 
any  trace  of  phlebetis  at  any  other  point  of  their  whole  course.  And  since 
the  possibility  of  this  has  been  denied,  I  have  proven  it  upon  thirteen  sub- 
jects ;  among  others,  in  a  woman  who  died  in  consequence  of  a  serious  trau- 
matic lesion  of  the  foot  at  the  hospital  Saint  Antoine  in  1829,  who  was  opened 
in  presence  of  M.  Dezeimeris,  an  avowed  partizan  of  M.  Dance's  ideas ;  and 
again,  upon  one  of  the  wounded  heroes  of  July,  who  died  on  the  twentieth  day 
of  an  amputation  of  the  thigh  in  1830,  at  la  Pitie,  in  which  I  exhibited  tlie 
total  absence  of  phlebetis  to  M.  Berard,  who  had  also  adopted  the  hypothesis 
of  veinous  phlegmasia  as  the  first  cause  of  metastatic  abscesses. 

As  to  the  mechanism  of  these  abscesses  themselves,  I  said  that  the  pus  tra- 
versing the  tissues  might  be  deposited  naturally,  or  by  its  presence  irritate 
sevei-al  points  of  the  viscera,  and  thus  form  so  many  phlegmasia!  and  puru- 
lent foci.  M.  Dance  rejects  the  first  of  these  two  modes,  and  seems  even  to 
deny  its  possibility.  With  all  the  reasoning  and  objections  that  he  produces, 
I  cannot  submit  to  his  opinion.  If  he  thinks  that  the  blood,  rendered  more 
fluid  and  altered  by  the  pus,  begins  always  by  producing  a  small  echymosis, 
and  soon  after  a  true  inflammation,  before  producing  an  abscess — ^a  mechanism 
that  I  have  pointed  out  myself  for  the  majority  of  cases — then  he  has  not 
seen,  as  I  have,  these  foci,  not  larger  than  a  hemp  seed,  in  the  head,  the 
spleen,  the  kidneys,  the  lungs,  and  the  liver,  and  around  which  the  most  atten- 
tive and  minute  examination,  did  not  enable  me  to  discover  the  least  lesion  of 
the  organic  elements ;  nor  those  purulent  collections  that  I  have  so  frequently 
met  with  in  the  cellular  tissues  or  certain  articulations,  and  which  after  eva- 
cuation and  lavation,  leaves  not  the  least  trace  of  their  existence.  If  the  little 
veins  around  each  purulent  focus  are  sometimes  inflamed  it  is  certainly  erro- 
neous to  say  that  they  are  always  so,  and  we  may  admit  the  capillary  phlebetis 
pointed  out  by  M.  Cruveilher  as  happening  in  similar  cases.  Moreover,  if  we 
E 


XXXIV  INTRODUCTION. 

admit  the  deposition  of  one  molecule  of  morbid  matter,  we  cannot  refuse  to 
admit  that  there  may  be  a  great  number.  The  pus  mingled  with  the  blood  is 
a  heterogeneous  matter,  which  tends  continually  to  escape  by  one  way  or 
another.  Whilst  it  is  inclosed  in  the  large  vessels,  and  the  circulation  has 
lost  nothing  of  its  activity  it  injures  nothing;  but  in  the  capillary  system 
where  the  movement  of  the  fluids  are  only  a  sort  of  oscillation,  where  are 
produced  nutrition,  the  various  secretions,  a  thousand  new  combinations, 
compositions,  and  decompositions,  must  not  its  elements  make  some  efforts  to 
agglomerate,  to  reunite,  and  cease  to  flow  with  the  other  fluids  ?  This  chemi- 
cal aggregation  made,  will  it  not  constitute  a  centre  of  attraction  for  other 
similar  molecules  ?  Is  any  thing  else  necessary  to  determine  the  seat  of  an  ab- 
scess ?  There  is  nothing  in  this  more  difficult  to  comprehend  than  in  the 
formation  of  bile,  urine,  saliva,  or  mucus.  These  are  natural  secretions  and 
exhalations ;  that  on  the  contrary,  is  a  pathologic  secretion  or  exhalation.  This 
is  all  the  difference. 

Prognostic. — Let  the  matter  be  explained  as  it  may,  these  metastatic 
collections,  are  the  effect  of  serious  operations,  and  always  produced  by  the 
passage  of  a  certain  quantity  of  pus  into  the  general  circulation  ;  and  thereby 
justifying  an  extremely  unfavorable  prognostication.  The  name  tuberculous 
that  I  first  gave  these  collections,  related  to  their  form,  and  I  am  astonished 
tliat  any  person  should  have  attributed  to  me  the  idea  of  comparing  them  to 
tfie  tubercles  of  the  lungs  under  any  other  aspect.  The  silent  and  often  rapid 
march  of  these  lesions  rarely  permits  us  to  detect  them  in  their  origin,  and 
when  at  last  the  fact  of  their  existence  is  no  longer  doubtful,  they  are  gene- 
rally beyond  the  reach  of  art.  As  soon  as  the  surgeon  discovers  the  existence 
of  violent  chills  with  alteration  in  the  expression  of  the  face,  a  continued 
fever,  whether  attended  or  not  by  pains  in  certain  parts  of  the  body,  or  whe- 
ther following  or  not  following  a  diarrhea,  in  a  patient  recently  operated 
upon,  or  who  is  suffering  from  an  extensive  suppuration  of  any  kind,  attended 
with  traumatic  lesion,  he  may  expect  the  most  serious  consequences  and  fear 
that  death  will  be  the  inevitable  termination.  Yet,  if  such  phenomena  exist 
'only  for  two  or  three  days,  and  at  the  end  of  this  time  a  general  sweat  or  some 
other  critical  evacuation  extinguishes  the  fever  and  calms  the  above  men- 
tioned  organic  derangements,  he  will  have  some  cause  to  hope.  I  have  seen 
persons  recover  after  having  had  the  true  shiverings  as  well  as  other  symptoms  of 
a  purulent  infection.  The  examples  are  rare,  it  is  true,  but  they  have  occur- 
red, and  the  surgeon  should  not  forget  them. 

The  mode  of  treatment  is  yet  unsettled.  Sanguinary  evacuations  either  by 
phlebotomy,  leeching,  or  cupping,  is  only  applicable  in  the  onset  of  the 
disease,  and  in  robust  and  plethoric  cases,  unless  there  be  some  pain  or  well 
determined  local  inflammation  j  I  have  seen  them  used  and  pushed  as  far  as 
possible  in  a  number  of  cases  without  discovering  any  sensible  advantages. 
Those  who  have  suffered  from  hemorrhage  either  of  the  wound  or  the  mucous 
surfaces  were  not  more  fortunate.  Purgatives  administered  early,  have  ap- 
peared to  luc  to  succeed  sometimes.  Vesication  either  of  the  thighs,  legs,  or 
painful  parts  of  the  chest  or  abdomen,  deserves  to  be  remembered.  Nor  is 
tiie  sulphate  of  quinine  without  some  utility  when  there  arc  any  intermissions 
and  the  stomach  not  too  irritable.  Tartrite  of  antimony,  in  large  doses,  first 
recommended  by  Laennec,  and  since  by  M.  Sanson,  did  not  prevent  the  death 


INTRODUCTION.  XTTt 

of  three  patients  on  whom  I  tried  it.    As  to  the  preparations  of  opium,  cam- 
phor, ether,  ammonia,  and  other  diffusible  and  exciting  substances,  they  have 
'  always  appeared  to  me  to  increase  the  symptoms,  and  hasten  the  fatal  ter- 
mination. 

Finally,  when  the  derangements  above  indicated  manifest  themselves,  every 
exertion  should  be  made  to  attract  the  fluids  towards  the  wound.  If  it  be  an 
amputation,  it  should  be  first  enveloped  night  and  morning  in  a  large  linseed 
cataplasm,  applied  naked  to  the  skin.  At  the  same  time,  one  or  more  blisters 
are  to  be  applied  to  the  legs,  and  a  light  warm  infusion  of  linden  or  elder  pre- 
scribed as  a  drink.  A  bleeding  to  the  extent  of  eight  or*  ten  ounces  if  the 
pulse  has  sufficient  force,  or  the  patient  be  not  already  too  weak.  If  the 
wound  be  very  pale  and  the  tissues  have  lost  their  consistency,  it  will  be  ne- 
cessary at  each  dressing  to  make  use  of  a  lotion  strongly  charged  with 
cinchona,  and  then  cover  it  with  a  pledget  of  storax  or  of  balsam  d'Arcceus, 
mixed  with  cerate.  A  blister  to  the  stump,  scarification,  and  leeching,  if 
there  be  at  the  onset  any  swelling,  inflammation,  or  external  evidence  of 
phlebetis,  will  be  indicated.  Compression  by  means  of  a  roller  from 
the  origin  of  the  m.ember  towards  the  solution  of  continuity  should  also  be 
tried  if  the  disease  has  not  affected  the  system  and  is  still  local.  After 
these  Seidlitz  water  may  be  administered  as  a  purgative  if  the  tongue  con- 
tinue soft  and  not  red.  The  stimulant  emetic  should  only  be  used  after- 
wards, when  stupor,  swelling  of  the  abdomen,  and  a  fuliginous  state  of  the 
mouth  have  made  their  appearance.  Cinchona,  either  in  decoction  or  substance, 
is  only  to  be  used  in  well  marked  adynamia.  Gum,  and  rice  water  should  be 
combined  withitwhen  diarrhea  exists,  or  when  the  digestive  tube  seems  disposed 
to  revolt  against  it.  The  sulphate  of  quinine  in  a  dose  of  five  or  eight  grains  at 
the  termination  of  each  paroxysm  will  answer  better  if  there  be  intermission 
and  sweat.  The  drinks  must  be  varied  according  to  the  predominating  symp- 
toms and  the  taste  of  the  patient.  Such  as  lemonade,  decoction  of  tamarinds, 
&c.,  rf  the  thirst  be  great,  or  light  bitter  aromatic  infusions  in  the  contrary 
case.  The  decoctions  of  rice,  barley,  ratany,  the  white  decoction,  disascor- 
dium,  gum  kino  catechu,  or  extract  of  ratany  are  no  longer  to  be  dispensed 
with  when  the  alvine  evacuations  are  frequent  and  threatening  to  the  patient. 
In  a  word,  the  whole  of  this  treatment  being  exactly  the  same  as  that  for 
phlebetis,  and  the  absorption  of  pus  in  general  can  only  be  incompletely  ex- 
posed here.  The  details  must  be  sought  in  the  treatises  on  pathology.  I  have 
only  felt  it  necessary  to  give  a  summary,  such  as  was  indispensable  to  excite 
the  solicitude  of  the  surgeon,  and  premonish  him  against  the  dangers  of  a 
false  security  in  the  therepeutics  whose  eflficacy  is  still  so  uncertain. 


NEW  ELEMENTS 


OPERATIVE    SURGERY. 


ELEMENTARY  OPERATIONS. 

The  greater  number  of  operations  are  made  up  of  several  separate  steps,  each 
of  which  often  constitutes  in  itself  a  distinct  operation.  Throughout  operative 
surgery  are  found,  incisions,  dilatations,  extractions,  and  reunions,  whether 
separate  or  variously  combined.  As  dilatation  and  extraction  require  in  each  of 
the  particular  operations  in  which  they  are  practised  different  instruments  or 
processes,  it  would  be  superfluous  to  examine  them  here  as  general  indications. 
But,  there  are  few  operations  which  do  not  be^in  by  a  division,  or  do  not  end 
in  a  reunion.  I  have  thought  it  best  therefore  to  begin  by  saying  a  few 
words  of  diarjesis  and  syntheses. 


CHAPTER  I. 

DIVISIONS. 

SECTION    I. 

Cutting  Instruments. 


Laying  aside  laceration,  pulling  out,  and  rupture,  which  nevertheless  are 
also  divisions,  diaeresis  requires  no  other  agents  than  the  bistoury,  the 
scissors,  and  certain  instruments  designed  to  answer  particular  indications. 

ARTICLE    I. 

Manner  of  Holding  the  Bistoury, 

The  bistoury  is  of  itself  worth  all  the  rest  of  the  surgeon's  armory.  If  it 
were  absolutely  necessary,  it  could  supply  the  place  of  all  other  cutting 
instruments.  To  use  it  skillfully  then,  is  an  art  which  the  surgeon  should 
make  it  his  first  endeavor  to  acquire.  There  are  three  principal  ways  of 
holding  the  instrument;  first  as  a  table  knife,  secondly  as  you  would  hold  sl 


S  NEW   ELEMENTS   OF 

h 

pen,  and  thirdly  as  a  drill -bow.    Each  of  these  modes  presents  varieties 
which  I  intend  briefly  to  point  out,  giving  to  each  the  name  of  position. 


FIRST   POSITION. 

Bistoury  held  as  a  Knife,  the  Edge  downwards. 

In  this,  which  is  the  most  frequent  position,  the  handle  of  the  instrument 
enclosed  in  the  palm  of  the  hand,  and  retained  there  by  the  ring  and  little 
fingers,  is  pressed  on  either  side  by  the  thumb  and  middle  finger,  at  the 
junction  of  the  blade  with  the  handle,  whilst  the  fore-finger  rests  upon  the 
back  of  the  blade:  thus  held,  it  presents  the  utmost  firmness  and  security, 
and  it  can  be  guided  in  every  possible  direction  ;  if  it  is  necessary  to  employ 
much  force,  to  cut  into  solid  tissue,  to  cut  out  large  flaps  or  vast  and  indu- 
rated tumors,  or  to  pair  off"  some  dense  excrescence,  nothing  would  be  easier 
than  to  bring  the  middle  and  index  fingers  before  the  others,  upon  the  side  of 
tlie  handle,  and  to  hold  the  instrument  in  full  grasp. 


SECOND    POSITION. 

Bistoury  held  as  a  Knife,  the  Edge  upwards. 

Instead  of  being  held  towards  the  tissues,  as  in  the  preceding  position,  the 
edge  of  the  bistoury  should  be  sometimes  turned  in  the  contrary  direction. 
In  that  case,  the  front  and  not  the  back  part  of  the  handle  is  pressed  against 
the  palm  of  the  hand,  and  the  thumb  with  the  fore-finger  presses  the  sides, 
while  the  middle  is  beneath  the  handle  with  the  third  and  little  fingers. 
Thus,  turned  upwards,  or  in  the  direction  of  the  back  of  the  hand,  it  is  in 
the  best  position  for  cutting  from  within  outwards,  in  certain  cases  where 
more  force  than  celerity  is  required  in  the  movement. 


THIRD    POSITION. 

Bistoury  held  as  a  Pen,  the  Edge  downwards  and  the  Point  forwards. 

In  this  position  the  handle  of  the  bistoury  passes  from  the  back  of  the  hand 
on  the  radial  side  of  the  first  metacarpal  bone,  to  be  held  as  in  the  fii-st 
position  by  the  thumb  and  the  first  two  fingers.  The  remaining  fingers  are 
left  free  to  find  some  point  of  rest  near  the  part  to  be  divided. 

FOURTH   POSITION. 

Bistoury  held  as  a  Pen,  the  Point  backwards. 

If  the  edge  of  the  instrument  be  turned  towards  the  tissue,  and  the  point 
directed  forwards,  it  will  be  found  to  be  held  exactly  in  the  same  manner  as 
a  pen,  and  this  is  the  characteristic  of  the  preceding  position. 

Manner  of  Holding  the  Bistoury. 

But,  in  the  fourth  position,  the  middle  finger  is  pushed  forwards  on  one 
side  of  the  blade,  and  then  flexed,  turning  the  point  of  the  instrument  by  this 


OPERATIVE    SURGERY.  •  3 

motion  towards  the  body  or  wrist  of  the  operator,  so  that  its  edge  looks 
towards  the  palm  of  the  hand,  from  which  it  is  separated  by  a  triangular 
space  varying  in  the  dimensions  of  its  posterior  base.  The  greater  part  of 
delicate  incisions  and  dissections  require  the  first  mode  ;  the  second  is  more 
applicable  when  it  is  necessary  to  pierce  some  deep  part,  and  cut  outwards 
from  the  puncture. 

FIFTH    POSITION. 

Bistoury  held  as  a  Pen,  the  Edge  upwards. 

To  dissect  or  to  cut  forwards,  in  order  to  enlarge  certain  openings  which 
are  deeply  situated,  we  are  often  obliged  to  change  the  position  of  the  edge 
of  the  bistoury,  and  turn  it  in  the  same  direction  with  the  dorsel  aspect  of  the 
hand,  and  to  present  the  back  towards  the  palmar  side  ;  and  except  that  it  is 
necessary  to  substitute  the  index  for  the  middle  finger,  the  instrument  may 
be  held  with  the  point  either  forwards  or  towards  the  wrist  of  the  operator,  as 
the  fingers  may  be  flexed  or  extended,  and  as  it  may  be  desirable  to  carry  a 
continued  incision,  or  merely  to  divide  attachments. 

SIXTH    POSITION. 

Bistoury  held  as  a  Drill-bow. 

The  sixth  position  holds  in  some  sort  a  middle  place  between  the  first  and 
the  second.  As  in  the  one,  the  handle  of  the  instr^iment  rests  on  the  interior 
of  the  hand,  and  as  in  the  other,  it  is  held  only  by  the  ends  of  the  fingers. 
This  mode  differs  nevertheless  from  both  in  the  fact,  that  with  regard 
to  the  axis  of  the  fore-arm,  the  bistoury  is  held  in  a  horizontal  plane,  and  that 
the  pulp  of  the  extended  fingers  supports  it  on  one  side,  whilst  the  thumb  is 
applied  upon  the  other.  The  three  varieties  of  this  position  are  easily 
distinguished.  In  the  first,  the  edge  of  the  bistoury  looks  downwards.  In 
the  second  variety,  which  approaches  nearer  to  the  second  position^  it  is  turned 
upwards,  and  in  the  third,  it  is  turned  to  the  riglit  or  the  left,  while,  instead 
of  holding  the  handle  by  its  flat  faces,  the  finders  and  the  thumb  press  against 
the  back  and  front.  The  first  of  these  positions,  giving  facility  to  light  and 
delicate  strokes,  is  particularly  indicated  in  scarifications,  such  as  of  inflam- 
matory erysipelas,  where  we  have  decided  to  operate  by  incisions,  and  also 
for  laying  open  large  subcutaneous  abscesses.  Recourse  is  rarely  had  to  the 
second  position,  unless  for  the  purpose  of  cutting  small  lamellae,  guiding  the 
bistoury  along  the  groove  of  a  director.  The  utility  of  the  third  position 
also,  is  only  acknowledged  in  a  small  number  of  cases,  when,  for  fear  of 
wounding  some  subjacent  organs,  it  is  thought  necessary  to  cut  horizontally' 
by  successive  laminae,  as  in  the  operation  of  planing. 

Manner  of  holding  the  Scissors. 

The  manner  of  holding  the  scissors  is  familiar  to  all.  It  is  not  necessary 
for  me  to  point  it  out.  I  will  only  say,  that  instead  of  the  index  or  middle 
finger,  the  fourth  or  little  finger  and  the  thumb  should  hold  the  rings  of  the 
instrument ;  the  two  first  fingers  being  placed  before,  either  about  the  handles, 
or  upon  one  of  the  flat  faces,  add  to  the  firmness  and  precision  of  the  move- 
ments. The  use  of  knives,  or  of  particular  bistouries,  will  not  be  described 
except  in  connexion  witli  the  operations  which  require  them. 


4  NEW    ELEMENTS    OF 

SECTION    II. 

Different  Kinds  of  Incisions. 

All  incisions  are  made  in  one  or  other  of  two  general  modes,  the 
definition  of  which  will  serve  as  a  principle  of  classification.  The  first  class 
of  incisions  consists  of  those  which  are  made  from  the  skin  towards  the  deep 
parts,  and  is  called  from  without  inwards;  the  other  class,  are  those  which 
are  made  from  the  midst  of  the  or2;ans  towards  the  exterior,  and  are  called 
incisions  from  within  outwards.  The  choice  of  the  first  or  second  of  these 
modes  must  be  decided  by  a  variety  of  circumstances,  whicii  will  in  their 
proper  order  be  developed  in  the  sequel,  and  which  will,  in  the  discussion  of  the 
opening  of  abscesses,  be  in  a  great  measure  recapitulated.  Whichever  method 
is  adopted,  incision  is  practiced:  first,  towards  the  operator;  secondly,  from 
the  operator ;  thirdly,  from  left  to  righty  when  the  handle  or  point  of  the  bistoury 
is  directed  either  immediately  across,  or  obliquely  backwards  and  outwards 
M'ith  the  right  hand,  the  fingers  bent,  and  the  wrist  or  fore-arm  previously 
extended  ;  fourthly,  from  right  to  left,  if  with  the  same  conditions,  the  left  hand 
is  used.  The  direction  from  left  to  right  being  the  most  natural,  is  of  course  the 
most  usually  followed,  so  that  the  others  might  strictly  be  ranked  amongst  the 
exceptions,  and  are  at  least  not  so  frequently  indispensable.  A  single  or 
simple  mch'ion ,  is  that  which  is  made  in  the  same  direction  throughout,  and 
which  can  be  terminated  by  a  single  stroke  of  the  bistoury.  It  is  nearly  always 
made  to  the  right;  and,  by  repetition  and  combination  varied  in  a  thousand 
ways,  gives  rise  to  those  complex  and  multiplied  incisions,  whose  forms, 
heretofore  so  various,  are  now  reduced  to  the  V,  the  T,  the  -f,  the  ellipse, 
the  oval,  the  crescent,  and  the  L. 


Art.  1. — Simple  Incisions. 

Direction. — Tn  the  absence  of  special  indication,  the  incision  should  be 
parallel ;  first,  to  the  greatest  diameter  of  the  part ;  secondly,  to  the  direction 
of  the  arteries,  the  large  veins,  or  the  principal  nerves  ;  thirdly,  to  the  direc- 
tion of  the  fleshy  fibres,  the  muscular  masses  of  the  tendons  ;  fourthly,  to  the 
natural  folds  of  the  teguments ;  or,  fifthly,  to  the  great  axis  of  the  tumor. 

On  the  dorsal  and  plantar  surfaces,  and  on  the  sides  of  the  foot,  about  the 
knee,  before,  behind,  and  on  the  outside  of  the  thigh,  it  is  made  in  a 
direction  parallel  to  the  axis  of  the  limb,  because  the  vessels,  the  nerves,  the 
muscles,  and  the  tendons  there  have  mostly  that  direction.  Behind  the 
ankles  it  is  made  somewhat  concave  forwards,  because  in  this  part  the  same 
organs  are  necessarily  somewhat  cui-ved  in  order  to  reach  the  sole  of  the  foot; 
on  the  inner  side  of  the  thigh  it  should  be  oblique,  to  correspond  with  the 
course  of  the  muscles  of  the  leg,  of  the  saphena  vein,  or  of  the  femoral  artery; 
in  the  groin  it  is  never  made  in  the  direction  of  the  great  furrow  of  that  part, 
except  when  they  are  intended  to  go  no  deeper  than  the  subcutaneous  cellular 
tissue. 

On  the  breech  the  muscles  serve  as  guides,  and  the  same  is  true  on  the 
sides  of  abdomen,  while  before  and  behmd  this  cavity,  the  incision  should 
follow  the  axis  of  the  body  ;  the  chest  requires  the  observation  of  the  same 
rules,  except  towards  the  arm -pit,  where  it  is  better  to  follow  the  axis  of  the 
trunk  than  the  fibres  of  the  serratus.  In  the  hand,  reference  should  be  had 
to  the  wrinkles  of  the  palm,  and  in  the  bend  of  the  arm,  to  the  arrangement 


OPERATIVE    SURGERY.  5 

of  the  veins,  muscles,  or  arteries,  rather  than  to  the  axis  of  the  limb.  About 
the  neck  incisions  should  correspond  in  direction  with  the  muscles,  the  vessels, 
or  the  axis  of  the  part,  as  the  circumstances  of  each  case  may  require  ;  and 
it  is  seldom  or  never  right  to  cut  directly  across,  except  in  the  bottom  of  the 
fossa,  above  the  collar  bone.  On  the  cranium  they  should  be  parallel  to  the 
muscles,  or  the  principal  arteries.  About  the  eye-lids  they  should  be  made  in  a 
semilunar  curve,  concave  towards  the  eye,  to  correspond  with  the  muscles, 
the  wrinkles,  and  the  arteries:  it  is  much  the  same  with  the  lips.  They 
should  be  straight  on  the  nose,  and  oblique  in  this  or  that  direction  upon  the 
other  parts  of  the  face,  according  to  the  wrinkles  on  which  they  fall,  or  to  the 
vessels  or  the  muscles  over  which  they  are  to  pass.  Lastly,  on  the  ear  the 
projections  of  that  organ  should  regulate  the  direction  of  the  incision. 
'  The  nature,  the  comparative  depth,  and  the  form  of  the  disease  are  the  only 
circumstances  which  can  justify  an  infringement  of  these  rules. 

Stretching  the  Skin. — There  are  several  ways  of  fixing  the  skin  in  order  to 
make  a  simple  incision. 

1st.  With  the  cubital  side  of  the  left  hand,  the  thumb  acting  in  the  opposite 
direction. 

2d.  By  graspino;  the  part  underneath  with  the  whole  hand. 

3d.  With  the  extremity  of  the  four  fingers  placed  in  a  line  parallel  to  that 
in  which  the  bistoury  is  to  pass. 

4th.  By  taking  up  a  fold  of  the  integuments. 

5th.  Causing  the  tissues  to  be  stretched  by  assistants  in  order  to  keep  both 
hands  free. 

6th.  In  drawing  on  one  side  whilst  the  assistant  pulls  the  integuments 
towards  the  other. 

With  the  thumb  and  little  finger  the  part  must  be  accurately  supported, 
and  the  tension  is  seldom  equal  on  every  point,  unless  we  use  the  assistance 
of  the  index  and  even  that  of  the  two  other  fingers.  To  grasp  the  organ  is  a 
method  which  can  only  be  applied  to  limbs,  or  to  certain  tumors  which  are 
verv  prominent  or  pendulous. 

With  the  ends  of  the  fingers  the  skin  is  firfhly  fixed,  and  the  nails  give 
support  to  the  instrument,  but  the  tension  is  incomplete,  and  is  only  made  on 
one  side.  To  take  up  a  fold  of  the  integuments  is  only  proper  in  a  few  cases, 
and  is  not  always  practicable.  The  hands  of  assistants  or  of  one  assistant  are 
never  so  safe  as  that  of  the  operator  himself,  and  should  never  be  put  in  requi- 
sition, except  in  cutting  around,  or  on  the  surface  of  tumors,  and  large  masses 
of  flesh  ;  the  first  mode  is  therefore  the  best,  and  it  is  for  the  surgeon  to  decide 
under  what  circumstances  it  will  be  necessary  to  resort  to  either  of  the  others. 

§  1.  Incisions  from  Without  Inwards, 

To  cut  from  without  inwards,  the  bistoury  maybe  held  in  the  first, third,  or 
sixth  position,  according  to  the  degree  of  force  to  be  emploved,  the  situation 
of  the  disease,  or  the  extent  to  which  the  incision  is  to  be  carried.  The  convex 
bistoury  which,  all  things  being  equal,cuts  better  and  with  less  pain,  has  neverthe- 
less the  inconvenience  of  leaving,  more  commonly  than  other  kinds  of  bistoury, 
portions  at  the  two  extremities  of  the  incision  imperfectly  divided,  and  is  ill 
adapted  to  operations  somewhat  delicate,  which  pass  deeper  than  the  skin,  and 
to  incisions  made  upon  excavated  surfaces,  and  require  that  tlie  instrument 
should  act  principally  witli  the  point.  The  straight  bistoury,  tliough  less  rapid 
in  the  commencement  of  the  incision,  is  nevertheless  afterwards  incomparably 


O  NEW   ELEMENTS   OF 

in  the  commencement  of  the  incision,  is  nevertheless  afterwards  incomparably 
more  convenient,  and  could  strictly  be  substituted  for  the  other  in  ^very  case. 

In  the  first  position  the  convex  bistoury  is  rested  with  the  most  prominent 
point  of  tlie  blade  on  the  middle  of  the  space  supported  by  the  thumb  and 
fore-finger,  and  then  drawn  from  left  to  right,  as  far  as  the  point  where  the 
incision  is  to  terminate,  so  as  to  divide  the  entire  thickness  of  the  skin  at  the 
lirst  sweep,  and  even  deeper  still  if  no  important  organ  be  situated  beneath. 
In  order  to  leave  as  small  a  trace  as  possible  imperfectly  divided,  care  should 
be  taken  to  apply  the  instrument  with  firmness  in  the  beginning,  and  to  raise 
the  wrist  in  terminating  the  incision.  Held  in  the  third  position  the  bistoury 
will  cut  more  with  the  extremity  than  with  the  prominence  of  the  blade,  and 
will  be  less  likely  to  wound  or  injure  the  parts  beneath,  or  to  leave  long  traces 
at  the  ends  of  the  incision,  but  it  loses  much  of  its  lightness  and  of  its  other 
advantages.  In  the  sixth,  it  cuts  like  a  razor,  dividing  with  case  the  finest 
:ind  softest  layers,  as  well  as  the  thickest  and  most  tense,  but  its  stroke  wants 
firmness,  and  seems  like  cutting  upon  air. 

The  straight  bistoury,  held  in  the  first  position,  pressed  like  the  other,  and 
drawn  and  witlidrawn  in  the  same  manner,  acts  principally  with  the  point. 
Jt  does  not  penetrate  so  well,  but  cuts  more  equally  and  leaves  scarcely  a 
trace  not  fully  divided.  In  the  third  position,  the  point  should  be  sunk,  by 
puncture,  to  the  intended  depth  of  tlie  incision,  the  hand  being  raised  for 
!hat  purpose :  in  continuing  the  incision,  the  wrist  should  be  brought  down  by 
degrees,  but  again  elevated  at  the  end  of  the  operation,  so  that  the  edge  may 
be  at  that  point  perpendicular  to  the  surface  cut.  The  whole  process  begins 
v^itli  a  motion  like  that  of  a  scale-beam  descending-,  and  ends  with  a  corre- 
sponding motion  upwards.  In  this  position,  the  little  finger,  placed  on  the 
right  of  the  incision,  serves  as  a  support  for  the  hand,  and  gives  steadiness 
and  security  to  the  successive  stages  of  the  operation. 

Lastly,  when  held  in  the  sixth  position,  the  straight  bistoury  acts  in  the 
same  way  as  the  convex  when  held  in  the  same  manner ;  with  this  difference, 
that  it  does  not  penetrate  so  t[uickly  nor  so  well. 


§  2.  Incisions  from  Within  Outwards. 

An  incision  of  this  class  is  sometimes  made  without  the  aid  of  a  conductor, 
at  other  times  with  ;  sometimes  with  the  bistoury,  and  sometimes  with  the 
scissors ;  sometimes  in  a  part  yet  undivided,  and  sometimes  through  a  previous 
division. 

WithmU  the  conductor,  with  the  bistoury — without  a  previous  division,  inci- 
sions are  made  either  towards  or  from  the  operator.  When  the  incision  is 
made,  the  instrument  is  held  in  the  second  position  and  entered  by  puncture, 
after  which  the  wrist  is  quickly  raised,  so  that  the  bistoury  may' divide  the 
tissues  from  its  heel  to  the  point,  acting  as  a  lever  of  the  second  kind  ;  or  else 
we  raise  the  point  by  depressing  the  hand,  so  as  to  pierce  the  skin  a  second 
time,  and  finish  by  drawing  the  bistoury  towards  the  operator  with  the  edge 
upwards,  so  as  to  divide  the  parts  between  the  points  or  the  entry  and  exit  of 
the  instrument,  causinj^  it  to  move  as  a  lever  of  the  third  class.  When  the 
incision  is  made  in  a  direction  towards  the  operator,  the  instrument  is  held  in 
the  fourth  position,  with  the  ring-finger  fixed  on  the  side  of  the  blade  at  such 
a  distance  from  the  point  as  properly  to  limit  its  progress.  It  is  then  entered 
b}^  puncture,  and  wlien  it  has  penetrated  to  a  sufficient  depth,  it  is  rapidly 
brought  to  a  perpendicular  position,  acting  like  a  lever  of  the  second  class. 


OPERATIVE    SURGERY. 


§  3.  Upon  a  Director. 

When  there  exists  a  previous  opening,  the  instrument  is  passed  through 
that,  either  towards  or  from  the  operator,  without  a  conductor,  when  this  can 
be  easily  done ;  otherwise  laid  flat  on  the  fore  finger,  or  guided  by  a  grooved 
director,  if  the  finger  would  occupy  too  much  space.  After  this  is  done,  the 
operation  is  performed  as  mentioned  above.  The  director  is  held  in  tlie  left 
hand,  like  a  scale-beam  or  a  lever  of  the  first  class,  of  which  the  fore-finger 
placed  beneath  forms  the  fulcrum,  the  thumb  upon  the  plate  the  power,  and 
the  layers  which  the  point  tends  to  elevate  the  resistance.  To  glide  along  the 
groove  with  ease,  the  bistoury  must  then  be  held  in  the  second,  fourth,  or 
sixth  position,  with  the  edge  upwards.  Those  which  have  no  cul  de  sac, 
present  no  obstacle  to  the  point  of  the  instrument,  which  then  can  be  passed 
directly  onwards  until  it  emerge  by  piercing  the  skin ;  but  where  there  is  a 
cul  de  sac,  the  bistoury  must  be  raised  as  a  lever  of  the  second  grade.  The 
narrower  the  bistoury  the  more  easily  it  advances.  The  convex  bistoury  is 
not  adapted  to  such  cases,  because  its  extremity  is  too  lar^e,  and  its  point, 
depressed  too  far  behind,  easily  comes  against  the  groove  of  the  director. 

After  having  placed  the  director,  another  method  maybe  used;  feel  for  the 
end  of  that  instrument  through  the  skin,  and,  having  ascertained  the  point  under 
which  it  projects,  cut  upon  it  by  a  slight  transverse  incision,  so  as  to  make  a 
counter  opening.  The  point  of  the  instrument,  guided  by  the  groove  of  the 
conductor,  is  then  slipped  towards  the  handle,  or^from  right  to  left ;  or  even, 
without  making  a  previous  incision,  the  point  of  the  bistoury  held  in  the  fourth 
position,  may,  by  puncture,  be  brought  in  contact  with  the  director  near  its 
beak,  and  carried  in  the  fourth  position  rapidly  along  the  groove  towards  the 
body  of  the  operator. 

In  using  the  scissors  you  introduce  one  branch  upon  the  finger,  or  upon  a 
director,  leaving  the  other  on  the  outside,  and  then  cut  from  you  as  briskly  as 
possible  all  that  you  design  to  divide. 

§  4.  With  a  Fold  of  the  Integuments, 

With  timorous  or  refractory  subjects,  if  the  skin  is  very  unsteady  or  waver- 
ing, or  if  it  is  desirable  not  to  penetrate  beyond  it,  it  is  sometimes  necessary 
to  take  up  a  fold  of  it  before  cutting.  This  fold,  which  varies  according  to 
the  extent  to  which  the  incision  is  to  be  carried,  should  be  held  on  one  side 
by  an  assistant  placed  in  front,  and  on  the  other  by  the  operator.  It  is  then 
divided  from  its  free  edge  towards  its  base,  as  in  the  incision  from  without 
inwards,  or  by  puncture  in  the  contrary  direction  ;  that  is,  passing  through 
from  the  confined  towards  the  free  edge  as  in  making  an  incision  from  within 
outwards.  The  pressure  made  upon  the  integuments  in  folding  them  up, 
deadens  their  sensibility,  and  consequently  renders  the  pain  less  acute.  Besides, 
as  the  bistoury  only  pierces  the  parts  like  an  arrow,  there  is  no  risk  of  failure 
or  embarrassment  from  the  movements  of  the  patient.  The  objection  to  this 
mode  of  practising  incisions  is,  that  there  is  rather  less  certainty  of  giving 
exactly  the  suitable  extent  than  in  those  above  described. 

§  5.  Horizontally, 

The  horizontal  incision  is  that  which  is  most  rarely  practised,  and  only  when  it 
16  desirable  to  cut  out  successively  over  some  one  point  the  various  laminae 


NEW    ELEMENTS    OF 


concealing  an  organ,  which  is  to  be  avoided.  The  bistoury  is  then  held  in  tlie 
sixth  position,  with  the  edge  on  one  side;  the  left  hand  armed  with  fine  pincers, 
lifts  up  successive  layers  of  tissue,  while  the  right  hand  shaves  oft' the  portions 
thus  raised  with  the  bistoury  held  horizontally  below  the  beak  of  the  forceps. 

This  kind  of  incision  is  almost  exclusively  reserved  for  herniotomy,  but  is 
yet  occasionally  used  in  some  other  operations,  such  as  those  for  aneurism. 

Art.  2. —  Compound  Incisions, 

Complex  incisions,  being  but  a  combination  of  simple  ones,  are  necessarily 
subject  to  the  same  rules  of  practice,  and  may  in  the  same  manner  be  executed, 
from  without  inwards,  or  from  within  outwards,  and  with  or  without  a  director. 

1.  The  V  incision  is  composed  of  two  straight  incisions,  which,  starting 
from  the  same  point,  terminate  at  a  greater  or  less  distance  apart,  according 
tc  the  extent  of  the  triangular  space  which  is  to  be  included  between  them. 
The  angle  should,  in  the  absence  of  particular  counter-indications,  be  turned 
towards  the  lowest  part,  and  the  incisions  should  be  made  towards  and  not 
from  that  point.  The  reason  of  this  rule,  which  at  the  first  glance  seems 
inconsistent  with  the  aim  proposed,  is,  notwithstanding,  easily  comprehended. 
If  the  bistoury  were  applied  to  the  extremity  of  the  first  incision,  in  order  to 
execute  the  second,  it  would  press  upon  or  weigh  down  the  edge  now  deprived 
of  support  before  it  could  cut,  occasioning  more  pain  than  is  necessary,  and 
producing  a  contused  and  irregular  incision.  If  the  convex  bistoury  were 
used,  there  would  be  the  additional  inconvenience  of  making  a  scratch  beyond 
the  external  border  of  the  first  incision,  or  leaving  the  second  imperfect  near 
the  angle.  In  beginning  at  the  base  of  the  triangle,  no  inconvenience  of  this 
kind  will  be  sustained.  The  skin  maybe  as  easily  held  tense  tor  the  second 
incision,  as  for  tlwi  fii'st.  Tiie  bistoury  itself  stretches  it  in  some  measui  e  in 
approachin;^  the  apex  of  the  triangle,  which  it  isolates  and  completes  without 
difficulty,  if  the  surgeon  take  the  precaution  of  raising  the  wrist  in  finishing. 
To  detach  the  flap  of  integuments,  which  has  been  limited  by  such  an  incision,, 
it  must  be  seized  at  the  point  with  the  pincers,  for  which  it  is  well  to  sub- 
stitute the  fore-finger  and  thumb,  as  soon  as  it  is  practicable.  The  right  hand 
provided  with  the  straight  or  convex  bistoury  (no  matter  which),  is  held  in 
the  third  position  when  you  intend  to  cut  towards  yourself,  or  by  bending  the 
fingers;  in  the  fifth  position,  on  the  contrary,  if  you  intend  to  cut  from  youy 
or  by  the  extension  of  the  fingers  ;  dissect  up  the  flap  by  free  sweeps  from 
below  upwards,  or  from  the  apex  to  the  base,  taking  care  to  raise  with  ita 
layer  of  cellular  tissue  as  thick  as  possible.  Formerly  the  V  incision  was 
thought  indispensable  in  the  operation  of  trepanning  the  temple  ;  at  the  present 
day  it  is  absolutely  required  nowhere,  but  is  occasionally  wsed  in  the  removal 
of  certain  tumors,  and  in  certain  disarticulations. 

2.  The  oval  incision,  which  will  be  discussed  under  the  article  of  Ampu- 
tations, differs  from  the  incision  V  in  this,  that  it  continues  from  one  branch 
of  that  incision  to  the  other,  passing  round  the  base  of  the  flap,  which  is  thus 
completely  isolated. 

3.  The  cross  incision  consists,  as  its  name  indicates,  of  two  simple  incision» 
which  cross  each  other  at  right  angles.  Only  the  second  of  these  incisions, 
needs  to  be  described.  It  is  commenced  at  the  left  side  of  the  first  division 
-with  the  same  precautions  as  in  all  other  straight  incisions ;  but,  instead  of 
being  carried  across  without  interruption,  it  is  terminated  with  an  elevation  of 
the  wrist  at  the  point  where  it  touches  the  first  incision,  of  which  it  cuts  only 
the  left  lip.     To  complete  it  the  operator  changes  the  position  of  the  bistoury^ 


OPERATIVE    SURGERY.  if 

unless  he  prefers  to  take  it  in  the  other  hand,  and  repeats  on  the  right  the 
operation  which  he  has  just  performed  on  the  left.  In  short,  it  is  an  incision 
made  in  two  separate  steps,  of  which  the  two  portions,  having  a  common 
termination,  meet  in  the  middle  of  the  first  incision  ;  and  which  does  not  allow 
the  instrument  to  roll  or  fold  under  its  edge  the  second  lip  of  the  first  incision, 
as  it  would  almost  inevitably  do  in  passing  from  the  left  to  the  right,  so  as  to 
complete  the  incision  at  a  single  stroke. 

The  dissection  of  the  four  triangles  which  result  from  this  double  division, 
is  but  a  repetition  of  that  which  has  been  already  mentioned  in  speaking  of 
the  V  incision. 

4.  The  T  incision  difters  from  the  crucial  incision  in  but  one  point,  that  is, 
instead  of  passing  on  both  sides  the  second  incision  stops  upon  the  first, 
forming  with  it  only  two  right  angles  ;  so  that  it  consists  of  two  cuts,  instead 
of  the  three,  which  form  the  crucial  incision.  For  the  rest,  the  same  precautions 
are  to  be  taken  in  the  division  of  the  tissues  and  in  the  dissection  of  the 
flaps,  and  the  manner  of  holding  the  bistoury  is  the  same  in  both  cases. 
The  crucial  incision,  and  the  T  incision,  being  mere  modifications  of  each 
other,  are  indicated  whenever  a  straight  incision  is  insufficient  to  expose 
the  tissues  which  it  is  intended  to  isolate  or  remove.  The  relative  value  of 
either  should  be  determined  by  the  size  of  the  part  to  be  exposed. 

The  bistoury,  carried  flat  between  the  integuments  and  the  tissues  beneath, 
and  there  turned  so  as  to  cut  from  within  outwards,  or  otherwise,  conducted 
along  the  groove  of  a  director,  would  convert  a  simple  straight  incision  into  a 
complex  one,  as  securely  as  if  it  were  directed  upon  the  skin  cutting  from 
without  inwards.     This  method  is  indeed  sometimes  preferred. 

The  elliptical  incision,  which  becomes  in  almost  every  case  necessary  in 
the  operation  on  a  subcutaneous  tumor  where  it  is  thought  proper  to  remove 
a  portion  of  the  integuments,  is  formed  by  the  union  of  two  curved  incisions, 
with  the  concavity  of  each  presented,  towards  the  othei*.  To  trace  out  the 
direction  with  ink  has  no  other  inconvenience  than  that  of  being  useless, 
except  in  certain  rare  cases,  where,  by  the  least  deviation  of  the  bistouj^, 
great  hazard  would  be  incurred.  This  is  a  case  where  the  hand  of  an 
assistant  is  of  advantage  to  hold  the  skin  on  one  side,  whilst  the  surgeoa 
stretches  it  upon  the  other.  The  rule  demands  that  the  lower  incision  should 
be  first  made,  so. that  the  bleeding  which  might  be  occasioned  by  the  operatioa^ 
should  not  interfere  with  the  performance  of  the  other.  It  is  made  by 
cutting  from  left  to  right,  or  towards  the  operator,  while  the  assistant  raises- 
the  tumor,  and  the  operator  stretches  with  the  left  hand  the  integuments 
beneath.  This  arrangement  is  reversed  in  making  the  second  incision  ;  for 
here  the  surgeon  himself  usually  draws  towards  him  or  depresses  with  the 
ends  of  his  fingers  the  mass  to  be  excised,  while  the  assistant  stretches  the 
skin  above,  taking  care  at  the  same  time  that  this  tension  is  exerted  at  one 
time  in  a  transverse  and  at  others  in  a  longitudinal  direction,  in  such  a  manner 
that  the  instrument,  carried  to  the  left  extremity,  or  to  the  upper  part  of  the 
inferior  incision,  can  make  the  incision  as  neatly  in  the  beginning  as  in  the 
middle  of  its  progress,  and  will  have  no  folds  of  skin  rolling  before  it  towards 
the  end..  It  should  not  be  forgotten,  moreover^  tliat  this  upper  incision  being^ 
carried  above  a  depressed  part,  needs  but  a  slight  degree  of  curvature  during, 
the  passage  of  the  knife  to  become  deeply  concave  immediately  afterwards, 
when  the  parts  are  left  to  assume  their  natural  posltioui 

Crescentic  incision, — Some  persons   have  thought  of  late,  that  a  double 
curved  incision,  with  both  parts  convex  in  the  same  direction,,  could  be,  in 
2 


10  NEW   ELEMENTS   OF 

certain  cases,  advantageously  substituted  for  an  elliptical  incision.  The 
crescentic  portion  which  it  circumscribes,  leaves  a  wound  with  a  loss  of 
substance,  the  convex  edge  of  which  may  be  dissected  and  turned  over  on 
its  base,  so  that  it  can  be  afterwards  applied  to  the  concavity  of  the  other 
edge,  and  over  the  bottom  of  the  hollow  left  by  the  operation.  Might  it  not 
be  adopted  for  the  extirpation  of  extensive  tumors  where  it  is  possible  to 
preserve  nearly  all  the  skin,  and  where  a  straight  incision  would  not  suffi- 
ciently expose  the  disease?  It  would  afford  the  same  advantages  as  an 
elliptical  incision,  without  opposing  so  strongly  an  immediate  reunion. — 
The  dissection  of  the  flap  described  by  a  simple  semilunar  incision,  where 
no  skin  is  to  be  removed,  may  be  performed  in  the  manner  above  described 
under  the  T,  the  V,  and  the  crucial  incisions,  for  which  this  is  frequently 
substituted.  In  conclusion,  I  will  add,  that  by  dissecting  up  the  lips  of  any 
incision  whatever,  from  the  subjacent  parts  to  the  extent  of  an  inch  or  more, 
according  to  the  wants  or  situation  of  the  wound,  you  are  often  able  to  cover 
extensive  losses  of  substances,  since  the  integuments  thus  raised  may  be 
stretched  to  an  astonishing  extent,  and  permit  us  to  bring  into  contact  the 
borders  of  an  assemblage  of  wounds  which  would  have  been  thought  incapable 
of  meeting. 

The  L  incision,  which  is  used  in  exposing  some  large  arteries,  as  the 
carotid  and  subclavian,  need  not  be  here  described. 

Art.  3. — Incisions  applied  to  Abscess — to  Collections  of  Fluids. 

It  may  be  boldly  asserted  that  the  bistoury  is  the  sovereign  remedy  for 
abscesses,  whether  hot  or  cold,  diffused  or  circumscribed,  vast  or  incon- 
siderable. The  pain  which  it  produces  is  nothing  in  comparison  to  the  acci- 
dents which  it  prevents ;  and  I  can  scarcely  comprehend  why  it  is  that 
its  use  is  so  often  abstained  from,  merely  because  fluctuation  continues 
obscure  in  the  sequel  of  phlegmonous  inflammations.  Since  it  is  a  very 
eflfective  means  in  the  treatment  of  subcutaneous  inflammations  themselves, 
suppose  even  that  the  sac  is  not  opened,  what  evil  can  result  from  its 
application  ?  It  is  a  perfectly  simple  wound,  winch  relieves  engorgements, 
and  presents  no  obstacle  to  the  disappearance  of  the  original  malady  ;  but,  on 
the  contrary,  favors,  in  almost  every  case,  its  progress  towards  recovery. 
After  having  witnessed  the  ravages  secretly  committed  by  the  presence  of 
pus,  either  infiltrated  or  effused  into  the  organs  by  the  absorption  of  this  fluid, 
or  by  its  migrations  through  long  tracts  of  cellular  tissue,  it  is  impossible  to 
hesitate  between  such  dangers  and  the  fear  of  making  a  useless  incision. 

Every  kind  of  straight  incision  is  applicable  to  abscess,  the  further  treatment 
of  which  I  shall  not  here  discuss.  The  large  abscess  lancet,  which  was 
formerly  thought  so  indispensable,  has  entirely  fallen  into  disuse  for  this  half 
century  past.  The  common  lancet,  which  sometimes  takes  its  place,  is 
insufficient,  except  for  a  very  few  cases ;  as  where  the  skin  is  very  thin,  and 
the  abscess  very  superficial  or  small  ;  and  even  then  the  bistoury  should  be 
preferred,  if  there  were  not  certain  beings  occasionally  to  be  found  who  are 
terrified  at  the  very  name  of  **  bistoury,"  but  who  would  submit  without 
reluctance  to  the  stab  of  a  lancet. 

§  1.  Incision  from  Within  Outwards. 

There  is  no  circumscribed  abscess  which  cannot  be  opened  from  within 
outwards.    The  operation  is  rapid,  and  gives  but  little  pain ;  the  instrument 


OPERATIVE    SURGERY.  11 

penetrates  by  puncture  ;  its  point  plays  in  the  interior  of  the  sac,  and  its  edge 
being  raised  so  as  to  cut  from  heel  to  point,  stretches  the  cutaneous  covering 
as  fast  as  it  divides  it,  instead  of  pressing  it  down.  In  a  case  of  this  kind, 
the  straight  bistoury  is  the  only  one  that  should  be  used.  It  is  never  held  in 
the  fifth  position,  except  to  cut  from  you  at  the  bottom  of  some  cavity,  as  for 
instance,  in  certain  abscesses  in  the  hollow  of  the  cheek.  But  it  is  very 
frequently  used  in  the  second  position.  When  it  is  thus  held,  it  affords  all 
necessary  force  and  ease  ;  it  penetrates  with  great  facility  in  a  direction  from 
the  operator  with  any  degree  of  obliquity  that  may  be. desired,  and  nothing  is 
more  simple  than  to  sway  it  as  a  lever  of  the  second  class,  by  raising  the  wrist 
at  the  proper  moment  for  terminating  the  incision.  The  fourth  position  is 
still  more  convenient;  the  support  which  is  given  to  the  hand  by  means  of 
the  ring  and  little  fingers,  is  an  advantage  which  the  second  does  not 
present  in  the  same  degree.  The  puncture  is  made  towards  the  surgeon  with 
the  hand  and  fingers  flexed ;  it  is  only  necessary  to  extend  these  at  the  same 
time  that  the  handle  of  the  bistoury  is  drawn  back  to  assimilate  it  to  a  lever 
of  the  second  class,  as,  in  the  previous  case,  to  make  the  incision  from  heel  to 
point,  and  to  divide  the  outer  wall  of  the  abscess  through  its  whole  extent 
with  equal  firmness  and  celerity.  This  is  the  position  which  incurs  the  least 
risk  from  inconsiderate  movements  or  refractory  behavior  in  the  patient,  and  I 
have  been  long  in  the  habit  of  using  this  in  preference  to  the  others,  where 
there  was  no  special  indication  to  the  contrary.  The  puncture  being  made, 
the  remainder  of  the  incision  takes  place  almost  spontaneously.  Upon  occa- 
sion, this  position  will  be  as  convenient  as  the  second  for  transpiercing  through 
and  through  a  hard  or  superficial  sac,  as  it  is  sometimes  proper  to  do  in  cases 
of  furunculus  or  anthrax,  and  of  some  prominent  abscesses  on  the  limbs, 
covered  by  an  extenuated  portion  of  skin.  The  best  bistoury  in  such  a 
case,  and  indeed  generally  for  opening  abscesses  from  within  outwards,  is 
one'with  a  narrow  blade  accurately  grooved  and  perfectly  keen.  It  is  held 
more  or  less  obliquely,  according  as  the  deeper  wall  of  the  abscess  is  more  or 
less  distant  from  the  surface  ;  if  this  were  touched,  and  cut  with  the  point  of 
the  instrument,  the  inconvenience,  in  ordinary  cases,  would  scarcely  merit 
attention  ;  but  the  danger  would  be  so  great,  when  the  abscess  lies  before 
one  of  the  larger  arteries  or  an  important  viscus,  that  the  mere  idea  of  such  an 
accident  is  dreadful.  It  is  a  precaution,  then,  of  prudence,  if  not  of  necessity, 
at  once,  as  soon  as  the  cessation  of  resistance  or  any  other  circumstance  gives 
notice  that  the  instrument  has  entered  the  cavity  of  the  abscess,  to  turn  it  into 
a  position  more  nearly  parallel  to  the  axis  of  the  limb  or  of  the  diseased  part, 
and  to  prolong  the  incision  only  by  raising  and  withdrawing  the  bistoury. 
In  practising  this  mode  of  incision,  the  stretching  of  the  parts  with  the  left 
hand,  whilst  the  right  hand  operates  with  the  bistoury,  although  useful  is  not 
always  necessary.  If  the  collection  is  large,  superficial,  or  situated  at  a  great 
distance  from  any  delicate  part,  you  may  even  dispense  with  the  support  of 
the  fingers,  and  depend  solely  upon  the  movements  of  the  hand,  as  if  you  were 
swaying  it  in  the  air.  After  a  little  practice  in  the  use  of  the  instruments,  one 
of  the  fingers  detached  from  the  others,  and  placed  upon  the  side  of  the  blade, 
secures  you  against  the  danger  of  pushing  the  point  of  the  bistoury  to  too 
great  a  depth,  and  takes  the  place,  in  the  greater  number  of  cases,  of  every 
other  precaution. 


12  NEW    ELEMENTS    OF 


§  2.  Incision  from  Without  Inwards. 

The  diffused  abscess,  the  deep  abscess,  and  those  which  develop  themselves 
around  the  articulations,  upon  the  passage  of  vessels,  and  upon  the  surface  of 
organs,  which  it  would  be  dangerous  to  touch  or  pierce,  usually  require  that 
the  opening  should  be  made  from  without  inwards.  The  first  require  large 
incisions,  either  with  the  straight  bistoury  in  the  first  or  in  the  third  position, 
or  the  convex  bistoury  held  in  the  same  manner.  With  the  straight  bistoury 
in  the  first  position,  the  incision  is  made  by  applying  the  whole  length  of  the 
edge  upon  the  skin,  as  for  deep  scarifications,  and  it  is  drawn  backwards,  and 
at  the  same  time  pressed  so  as  to  cut  rapidly  from  heel  to  point.  In  the  third 
position  the  point  is  at  first  plunged  directly  into  the  sac,  and  the  incision  is 
then  continued  by  bringing  down  the  heel  and  the  rest  of  the  edge,  the  point 
remaining  stationary.  The  bistoury  becomes  thus  a  lever  of  the  second  class, 
but  working  from  above  after  the  manner  of  a  straw-cutter.  With  the  convex 
bistoury,  held  in  the  first  position,  you  cut  quick  and  deep;  it  suits  generally 
better  than  any  other  such  a  purpose  as  this,  and  is  particularly  well  adapted 
by  its  form  to  cases  in  which  it  is  necessary  to  make  several  incisions  at  some 
distance  apart,  over  the  surface  of  a  purulent  collection.  The  second  class  of 
abscesses  divides  itself  naturally  into  two  orders: — 1st.  Those  which  are 
covered  over  with  a  thick  and  dense  layer,  and  do  not  lie  upon  any  organ 
which  it  is  important  to  avoid.  2dly.  Those  which  lie  so  deep  that  their 
precise  seat  cannot  be  ascertained,  or  which  it  is  not  prudent  to  expose  at  a 
single  stroke.  There  is  no  objection  to  attacking  the  first  kind  by  puncture 
and  a  depression  of  the  handle,  using  the  straight  bistoury  held  in  the  third 
position  ;  for  example,  on  the  eminences  of  the  hand,  on  the  pahnar  surface 
of  the  fingers,  on  the  external  sides  of  the  limbs,  on  the  breech,  on  the  cranium, 
and  in  the  posterior  region  of  the  trunk. 

The  incision  by  puncture  is  not  applicable  to  the  second  class  of  abscesses. 
If  these  are  to  be  opened  with  the  straight  bistoury,  it  must  be  drawn  with 
the  edge  towards  the  abscess  in  the  first  or  third  position,  and  divide,  by 
successive  strokes,  the  parts  which  conceal  the  matter,  while  the  fore-fingei* 
of  the  left  hand  is,  from  time  to  time,  applied  to  the  bottom  of  the  wound  to 
ascertain  the  fluctuation  or  the  probable  depth  of  the  abscess.  This  is  the 
proper  mode  of  operating  for  abscesses  formed  under  aponeuroses,  between 
the  crural  muscles  and  the  thigh-bone,  in  the  hollow  of  the  ham,  about  the 
humerus,  in  the  thickness  of  the  abdominal  parietes,  or  of  the  muscular 
covering  of  the  chest,  or  on  the  forepart  of  the  neck. 

Unless  we  proceed  with  the  same  caution  in  the  neighborhood  of  the  joints, 
we  shall  run  the  risk  of  opening  the  subjacent  capsules  and  the  synovial 
membrane,  and  of  exposing  bony  surfaces  to  the  air,  whilst  these  incisions, 
made  through  successive  layers,  do  not  prevent  you  from  entering  the  capsule 
at  last,  where  this  is  deemed  indispensable.  If  the  abscess  is  extensive,  and 
its  external  wall  sufficiently  extenuated,  the  convex  bistoury  is  preferable, 
because  it  makes  a  cleaner  incision,  and  gives  less  pain.  When  its  seat  is 
less  clearly  indicated,  we  have  recourse  to  the  straight  bistoury,  which  is 
better  adapted  to  the  more  delicate  operations. 

The  same  principles  will  guide  us  in  cutting  about  an  artery,  an  aneurism,  or 
a  hernia,  near  the  pleura  or  the  peritoneum;  because  then  tlie  operator  is  sure 
that  he  shall  not  pass  the  interior  wall  of  the  sac  before  meetin«5  with  the  pus, 
and  that  he  may  interrupt  the  operation  when  he  chooses,  to  feel  the  pulsations 
of  arteries,  and  to  ascertain  with  the  finger  upon  what  tissue  he  is  working: 


OPERATIVE   SURGERY.  IS 

whereas  in  operation  by  puncture,  there  is  nothing  to  guarantee  the  safety 
of  the  concealed  organ  when  once  the  bistoury  has  begun  its  progress. 
How  many  times  has  the  instrument  been  plunged,  in  opening  an  abscess,  into 
an  aneurism,  or  a  large  healthy  artery,  or  a  hernia,  and  that  too  by  celebrated 
practitioners,  simply  for  want'^of  paying  proper  attention  to  these  indications  ! 

One  of  the  principal  faults  to  be  found  with  incisions  from  without  inwards 
is  that  of  pressing  upon  the  abscess  in  opening  it.  It  is  no  sooner  opened 
for  some  few  lines,  than  this  pressure  forces  out  the  pus,  lessens  the  tension 
of  the  partitions,  and  renders  it  almost  impossible  to  continue  the  incision  at 
the  same  stroke;  this,  however,  should  only  be  understood  of  slow  or 
gradual  incisions.  Those  which  can  be  made  briskly  with  the  whole  edge  of 
a  straight  bistoury,  or  what  is  better,  of  a  convex  bistoury  held  in  the  first  or 
sixth  position  (as"^in  collections  of  great  extent,  situated  immediately  beneath 
the  skin),  have  not  the  same  inconvenience,  and  are  in  fact  the  least  painful 
of  all. 

With  a  Director. — To  enlarge  the  opening  of  an  abscess,  the  finger  or  the 
grooved  director  serves  as  a  guide  to  the  instrument,  and  the  bistoury  or  the 
scissors  are  directed  in  the  manner  already  laid  down  in  speaking  generally 
of  incisions  from  within  outwards,  with  the  aid  of  a  director  and  a  previous 
opening. 

§  3.    Complex  Incisions. 

The  same  rules  will  govern  the  operator  if,  instead  of  a  simple  incision,  he 
wishes  to  open  an  abscess  by  an  incision  in  the  shape  of  a  V,  a  T,  or  a  cross. 
Modifications  like  these,  which  are  more  frequently  useful  than  the  greater 
part  of  practitioners  seem  to  admit,  are  of  very  great  advantage  in  cases  of 
subcutaneous  collections  with  alteration  of  the  skin.  The  first  opening  being 
made  upw^ards,  and  to  the  left  for  instance,  the  director  finds  itself  a  passage 
under  the  skin  to  the  right ;  a  second  incision  is  then  made  in  the  latter 
direction,  and  the  abscess,  laid  open,  presents  a  V  incision.  When  the  cul  de 
sac  is  on  one  side,  an  incision  in  T  is  made,  and  in  collections  where  it  is 
desirable  to  lay  the  bottom  entirely  open,  the  crucial  incision  finds  a  place. 
Thus  we  see  that,  except  elliptical  or  semicircular  incisions,  every  description 
of  division  can  be  called  in  in  the  treatment  of  purulent  collections,  but  yet 
that  the  simple  incision  is  almost  uniformly  the  only  one  required. 

Art,  4. — Incisions  applied  to  the  Dissection  of  Tumors  and  of  Subcutaneous 

Cysts* 

In  the  excision  of  cysts  and  tumors,  contrary  to  what  has  just  been  said  of 
the  treatment  of  abscess,  the  complex  excision  is  most  commonly  indicated. 
When  the  whole  of  the  skin  should  be  preserved  however,  a  simple  incision 
will  often  suffice.  Vascillating  or  very  movable  tumors  covered  with  sound 
and  flexible  skin,  do  not  always  require  a  complex  incision.  The  testicle, 
the  breast,  and  several  degenerate  ganglia,  are  often  extracted  by  a  simple 
straight  incision,  although  they  may  have  acquired  a  very  considerable  size. 

§  1.  Form  of  the  Incision. 

1st.  The  straight  incision  should  pass  from  a  half-inch  to  an  inch,  or  even 
more  than  that,  beyond  the  limits  of  the  tumor  at  either  end,  and  penetrate 


14  NEW    ELEMENTS    OF 

the  entire  thickness  of  the  adipose  layer.  There  are  then  several  methods 
of  continuing  the  operation.  One  of  those  most  frequently  adopted  is,  to 
seize  with  the  forceps  or  the  first  fingers  of  the  left  hand,  each  of  the  lips  of 
the  wound,  and  to  dissect  them,  one  after  the  other,  from  the  wound  outwards, 
with  tlie  rio-ht  hand,  whilst  an  assistant  draws  the  tumor  in  the  opposite 
direction,  with  his  fingers,  a  crotchet,  or  a  hook.  Others  prefer,  where  the  parts 
are  sufficiently  loose  and  flexible,  to  press  with  the  thumb  and  fingers  of 
one  hand  through  the  skin,  upon  the  sides  of  the  body  to  be  extirpated,  as 
deeply  as  possible,  as  if  to  expel  it  through  the  wound,  whilst  with  the  other 
hand,  the  adhesions  of  the  cellular  tissue  are  cut  perpendicularly,  in  proportion 
as  the  borders  of  the  incision  separate  or  withdraw  themselves  backwards.  If 
the  tumor  is  pendulous  you  attain  the  same  end  by  grasping  it  below  with  the 
whole  palm  or  the  hand.  By  this  method  the  pain  is  generally  less,  the  operation 
at  once  prompt,  easy,  and  sure,  but  unfortunately  is  not  in  every  case  appli- 
cable. Some  find  it  more  convenient  to  hold  the  tumor  themselves,  and  to 
cause  the  lips  of  the  incision  to  be  drawn  back  by  an  assistant,  whilst  they 
dissect  and  detach  it  from  its  bed.  Indeed  this  is  the  best  way  to  operate  in 
almost  every  case  as  soon  as  its  anterior  face  has  been  exposed.  In  adopting  any 
other  course  for  the  purpose  of  separating  it  from  the  deeper  tissues,  the  surgeon 
exposes  himself  to  the  danger  of  penetrating  too  far,  or  else  of  not  removing 
all  the  diseased  parts.  He  can  in  this  point  of  view  rely  only  upon  the 
testimony  of  the  fingers,  which  have  however  the  inestimable  adivantage  of 
being  able  to  feel  arterial  pulsations  if  they  present  themselves,  and  to  confine 
their  movements  without  difficulty  as  well  as  to  adapt  them  to  the  action  of 
the  other  hand. 

2d.  V  Incision. — It  is  an  erroneous  idea  that  the  elliptical  and  crescentic 
incisions  are  the  only  ones  which  permit  the  actual  abstraction  of  substance 
from  the  integumenti  The  V  incision  has  more  than  once  fulfilled  the  same 
indication.  By  cutting  several  Vs  or  triangular  flaps,  continuous  at  their 
bases  upon  the  surface  of  voluminous  tumors,  there  may  be  raised  with  the 
diseased  mass  a  star  of  integuments,  which  does  not  afterwards  hinder  the 
covering  of  all  the  bloody  surface  with  the  remaining  triangular  portions. 
M.  Delpech  and  M.  Clot,  have  had  recourse  to  a  similar  device  in  the  extirpation 
of  elephantiastic  tumors,  of  which  they  have  given  the  first  notices,  and  I  have 
seen  M.  Roux  operate  in  this  way  for  the  removal  of  a  fungous  hematodes  from 
before  the  knee. 

3d.  The  T  incision  or  a  crucial  incision,  is  only  used  where  the  skin,  of 
which  it  is  not  desirable  to  remove  any  part,  is  not  flexible  enough  to  allow  a 
straight  incision  properly  to  expose  the  tumor.  It  is  also  indicated  in  certain 
cases,  conjointly  with  the  elliptical  or  crescentic  incision  5  for  example,  when 
the  base  of  a  cyst  extends  so  far  beyond  the  flap  of  integuments  which  has 
just  been  circumscribed  that  it  appears  difficult  to  raise  alternately  the  lips 
of  the  wound,  or  where  it  is  desirable  that  the  flaps  should  not  be  very  large. 
In  this  case  all  that  is  to  be  done  is  to  divide  transversely  one  of  the  ed^es  of 
the  ellipse  or  crescent  for  the  T  incision,  or  both  of  them  successively  tor  the 
cross. 


§2.  Dissection  of  the  Flaps, 

Whatever  may  be  the  then  form  or  extent,  these  different  incisions  give 
rise  to  flaps  which  it  is  necessary  to  raise  from  the  apex  to  the  base.  This 
is  usually  the  most  delicate  part  of  the  operation,  and  is  not  executed  by 
precisely  the  same  rules  for  tne  exposure  of  all  kinds  of  tumors. 


OPERATIVE   SURGERY.  15 

1.  Concrete  Tumors. — Whenever  it  is  necessary  to  operate  for  the  removal 
of  adipose  tumor,  or  any  other  solid  mass  free  from  malignity,  the  edge  of  the 
bistoury  should  be  more  inclined  towards  the  tumor,  or  the  deep  parts,  than 
towards  the  skin,  since  the  thicker  the  flap  is  left  by  raising  with  it  the  cellular  or 
adipose  mass  which  lines  it  internally,  the  more  life  it  retains  and  the  more  it 
is  disposed  to  attach  itself  to  the  layers  beneath.  If  inclined  in  the  opposite 
direction,  the  instrument  would  leave  the  skin  entirely  naked,  might  even 
pierce  it,  and  render  its  preservation  or  restoration  impossible,  while  even, 
if  we  should  proceed  too  far  inwards,  I  cannot  see  what  evil  could  arise 
from  it. 

2.  Cancers. — Carcinomatous  tumors  deserve  a  little  more  attention.  Tlie 
skin  should  not,  indeed,  be  denuded,  but  it  is  necessary  at  the  same  time 
to  avoid  turning  over  with  it  the  least  trace  of  the  morbid  tissue. 

S.  Cysts. — The  removal  of  encysted  tumors,  of  sacs  filled  with  matter 
wholly  or  only  partially  liquid,  which  it  is  desirable  to  remove  without  opening 
them,  require  still  more  care ;  the  sides  of  the  cyst  are  sometimes  so  thin 
that  the  least  pressure  with  the  edge  of  the  bistoury  divides  them  ',  the  bag 
is  quickly  emptied,  and  the  tissues  can  no  longer  be  held  tense;  the  operation 
which,  without  this  accident,  would  have  been  one  of  the  most  easy  and 
simple,  becomes  immediately  most  laborious,  and  even  in  some  instances 
insusceptible  of  completion.  It  is  necessary  then,  although  we  endeavor  to 
preserve  the  cellular  tissue  in  exposing  a  cyst,  to  turn  the  edge  of  the  instru- 
ment a  little  more  towards  the  integuments  than  in  the  direction  of  tiie 
tumor,  whenever  the  parietes  of  the  cyst  are  superficial  enough,  or  appear 
thin  enough  to  be  easily  pierced. 

For  the  rest  it  is  well  to  remark,  that  certain  cysts  do  not  require  so 
much  caution,  and  that  the  operation  may  be  confined  to  cutting  through 
the  whole  anterior  wall  by  a  simple  incision,  by  a  T,  or  by  a  crucial  incision, 
as  in  the  case  of  abscess.  To  this  class  belong  deep  and  adherent  hydated 
tumors,  or  those  of  which  it  is  desirable  either  to  cauterise  the  interior  of  the 
cavity  or  to  expose  it  to  the  air,  in  order  to  occasion  suppuration.  We  shall 
see  hereafter  that  the  same  may  be  said  of  the  encysted  tumors  of  the  cranium 
and  some  others. 

4.  Abdominal  cysts,  and  collections  of  liquids  which  border  upon  the 
great  cavities  of  the  trunk,  and  the  adherence  of  which  to  the  serous  membrane 
of  the  walls  of  those  cavities  is  not  fully  ascertained,  often  justify  a  mode  of 
incision  mucli  boasted  of  by  some  practitioners  in  modern  tijnes.  It  is  a 
simple  incision,  straight  or  curved,  carried  through,  layer  after  layer,  by 
successive  strokes  with  a  straight  bistoury  held  in  the  first  or  second  posiiion 
with  the  edge  towards  the  cavity.  If  the  cyst  is  in  the  abdomen,  the  mcision 
is  carried  by  degrees  as  far  as  the  peritoneum,  which  is  opened  over  the  tumor 
if  it  is  found  not  to  be  adherent,  and  which  is  left  untouched  if  it  appears  to 
be  incorporated  with  the  parietes  of  the  morbid  sac,  and  these  very  much 
extenuated. 

The  operation  here  terminates  for  the  time,  the  seton-cord  is  placed  length- 
wise in  the  wound,  so  as  to  keep  the  lips  separate,  and  is  renewed  as  often  as 
may  be  necessary  for  a  certain  number  of  days.  Constrained  by  the  pressure 
of  the  divided  tissues,  the  cyst  inclines  to  slip  between  the  lips  of  the  incision, 
approaches  the  exterior,  and  often  finishes  by  bursting,  or  by  opening  spon- 
taneously, sometimes  the  next  day,  but  more  frequently  at  the  expiration  of 
several  days. 

If  it  was  unattached,  this  incision  would  occasion  an  adhesive  inflammation, 
which  would  immediately  unite  the  anterior  partition  to  the  laminae  which 


16  NEW    ELEMENTS   OF 

cover  it ;  puncture  or  incision  could  then  be  practised  without  the  least  danger 
of  an  eftusion  into  the  abdomen. 


Art»  5. — To  cause  the  least  possible  Pain, 


not  at 
surgery,  are 


To  avoid  giving  pain  in  making  incisions,  is  a  chimera  which  is 
this  time  pursued  by  any  one.  Cutting  and  pain,  in  operative  surge  ^ 
two  words  which  always  suggest  each  other  in  the  mind  of  the  invalid,  and  the 
association  of  which  it  is  always  necessary  and  proper  to  recognize.  The  efforts 
of  the  surgeon  should  then  be  confined  to  rendering  the  pain  of  the  incision 
as  light  as  possible,  without  endangering  in  any  degree  the  success  of  his 
operations. 

The  pretensions  of  several  foreign  writers,  German  surgeons  among  others, 
and  of  the  editors  of  the  work  of  Sabatier,  who  think  that  they  have  attained 
this  end  by  never  using  the  bistoury  without  having  first  dipped  it  in  oil,  seem 
to  me  entirely  without  foundation.  By  attaching  itself  to  the  pores  of  the 
bleeding  surface,  the  oil  would  even  have  the  ill  effect  of  impeding  the  circu- 
lation of  the  fluids,  the  exudation  of  the  plastic  lymph,  and  the  cohesion  of 
the  sides  of  the  wound,  if  it  is  intended  to  eftect  this  by  primary  inosculation; 
a  cerate  which  could  be  removed  by  washing  would  be  more  suitable  if  any  fatty 
substance  whatever  could  be  of  use.  It  cannot  be  denied,  that  after  being 
held  for  a  moment  in  warm  water,  as  is  advised  by  M.  Richerand,  or  in  any 
other  way  kept  at  the  temperature  of  the  body,  according  to  the  opinions  of  M. 
J.  Guyot,  the  operation  of  the  instrument  can  be  supported  with  less  pain  to  the 
patient,  but  upon  a  close  examination  the  difference  is  not  very  strongly  marked  ; 
the  precaution  would  cause  too  much  embarrassment  for  it  to  be  adopted  in 
practice,  or  to  be  accorded  any  great  degree  of  importance.  It  is  first  to  the 
hand  of  the  operator,  and  next  to  the  qualities  of  the  bistoury,  and  not  to  such 
accessory  circumstances,  that  we  are  to  look  for  the  remedy  desired. 

Have  a  light  and  sure  hand,  a  bistoury  with  a  fine  and  keen  edge,  give  your 
incision  at  the  first  stroke  all  the  length  and  depth  which  it  ought  to  have,  if 
you  can  do  so  without  danger ;  act  promptly  and  without  hesitation  ;  give  to 
the  wound  an  extent  rather  too  great  than  too  small,  yet  without  unnecessarily 
prolonging  it,  and  you  will  have  to  regret  or  to  apprehend  no  other  pain 
than  that  which  is  inherent  in  the  operation,  and  which  no  human  contrivance 
can  detach  from  it.  Any  further  details  on  this  subject  would  be  entirely 
superfluous. 


SECTION    III. 


Punctures. 

Whenever  the  surgeon  thrusts  the  point  of  the  instrument  through  any 
of  the  tissues,  he  makes  a  puncture.  Those  from  within  outwards  are  almost 
always  made  with  the  bistoury,  the  suture  needle,  or  with  spring  instruments. 
Those  which  pass  inwards  from  without  are  made  sometimes  with  the  straight 
bistoury  or  the  lancet,  as  we  have  seen  above,  sometimes  with  the  needle  or 
other  particular  instrument,  a  trocar,  &c.:  with  a  round  straight  needle,  in 
certain  sutures,  provided  with  an  eye  at  the  blunt  end  similar  to  ordinary 
sewing  needles:  with  a  needle  longer  than  the  other,  and  provided  with  a 
head,  a  handle,  or  a  ring,  such  as  that  used  for  acupuncture:  with  a  needle 
cutting  at  the  point  on  one  or  both  sides,  straight  or  curved,  for  the  purpose  of 
exploring  certain  tumors,  or  collections  of  a  doubtful  character,  as  has  been 
recommended  by  many  practitioners  after  Dr.  Hey :  with  a  needle  curved 


OPERATIVE    SURGERY.  17 

in  the  arc  of  a  circle,  edged,  andprovided  with  an  eye  to  carry  the  thread  used 
in  most  kinds  of  suture :  with  the  different  kinds  of  trocar,  when  a  canul^ 
is  to  be  introduced  into  tlie  bosom  of  some  reservoir  or  cyst,  in  order  to 
extract  the  fluid,  without  leaving  any  considerable  wound  to  cicatrize. 

1.  By  acupuncture  is  understood  a  puncture  which  traverses  the  tissues 
without  breaking  the  continuity  of  their  fibres.  The  needle  which  is  used 
for  this  operation  should  be  a  regular  cone.  The  surgeon  pushes  it  in,  rolling 
it  at  the  same  time  between  the  fingers  of  one  hand,  which  hold  it  like  a  pen 
and  press  it  gently  upon  the  skin,  which  is  stretched  by  the  other  hand  :  thus 
conducted,  its  point  removes  from  its  track,  but  does  not  divide  the  organic 
fibres ;  can  traverse  the  arteries,  the  heart  itself,  the  most  essential  organs, 
without  occasioning  the  effusion  of  any  liquid,  and  without  leaving  the  least 
trace  of  its  passage.  In  China  and  in  Egypt  where  acupuncturation  has  been 
known  and  practised  from  time  immemorial,  and  with  great  success,  thej 
frequently  strike  with  a  little  mallet  on  the  extremity  of  the  needle  as  it  is 
held  in  the  left  hand,  to  cause  it  to  enter,  instead  of  rolling  it  between  the 
fingers  of  the  right  hand.  Entering  it  more  rapidly  by  a  simple  effort  of 
pressure,  as  is  practised  by  some  persons  amongst  us,  generally  causes  some- 
what more  pain  than  is  necessary,  and  prudence  will  not  allow  us,  on  the 
principles  here  laid  down,  to  pass  it  through  any  great  vascular  canal. 

2.  The  needle  assigned  to  ordinary  punctures  is  more  easy  to  conduct,  and 
should  not  be  so  slender.  Although  the  round  needle  has  been  recommended 
for  opening  a  gaseous  collection  in  a  strangulated  portion  of  intestine,  the 
needle,  shaped  like  the  head  of  a  lance,  with  the  point  straight  or  curved,  is 
almost  always  used  for  the  purpose  of  exploring.  A  tumor  presents  itself  in 
a  complex  region  of  the  body  5  you  are  not  certain  that  it  contains  a  liquid,  or 
if  it  does,  whether  this  liquid  is  of  blood,  pus,  or  serum ;  whether  it  is  an 
abscess,  a  cyst  or  aneurism.  The  puncture  with  an  appropriate  needle  at 
once  dissipates  these  doubts.  If  there  is  any  fluid  at  the  bottom  of  the  mass, 
it  allows  some  drops  to  ooze  out  and  affords  an  opportunity  to  determine  its 
nature.  The  small  wound  which  is  produced  is  immediately  closed,  even  in 
the  case  of  arterial  cyst.  The  surgeon  then  takes  his  course  with  a  full- 
knowledge  of  the  case. 

3.  The  use  of  the  trocar  is  distinguished  principally  from  that  of  the 
needle,  by  the  canula  which  the  instrument  carries  with  it,  and  which 
becomes  the  conducting  tube  for  the  fluids  which  are  intended  to  escape.  Its 
point  should  be  flattened  like  that  of  a  lancet,  or  pyramidal  with  three  cutting 
edges,  and  as  it  is  generally  blunt  it  requires  some  force  to  make  it  penetrate; 
hence  the  necessity  of  grasping  the  trocar  with  the  whole  hand.  The 
handle  is  placed  between  the  thenar  and  hypothenar  eminences,  or  between  the 
hollow  of  the  palm  and  the  last  two  fingers  flexed.  The  thumb  and  the 
middle  finger  a  little  farther  advanced,  hold  it  near  the  root,  whilst  the  fore- 
finger extended  sustains  the  body  of  the  instrument  near  the  point,  in  order 
to  limit  the  depth  to  which  it  should  penetrate.  In  case  of  necessity,  we 
might  for  greater  safety  detach  the  middle  finger  from  the  instrument,  and 
rest  it  on  the  side  of  the  point  to  be  pierced.  When  it  is  entered,  the  fore- 
finger and  thumb  of  the  left  hand  hold  the  canula  with  the  point  of  the  cup 
downwards,  whilst  the  right  hand  pulls  by  the  handle  and  raises  the  perfo- 
rating shaft.  The  sac  is  emptied,  and  the  liquid  contents  received  in  a 
vessel.  In  order  to  withdraw  the  tube  it  is  only  necessary  to  draw  it  quickly 
by  the  head,  whilst  the  fingers  which,  until  then  had  sustained  it,  are  applied 
to  the  sides  of  the  puncture,  so  as  to  retain  in  its  position  the  skin  or  the  outer 
wall  of  the  cavity. 

3 


18  NEW  ELEMENTS  OF 


CHAPTER IL 


REUNION. 


The  reunion  of  the  divided  parts  is  effected  by  the  position  of  the  patient 
or  of  the  wound,  and  by  means  of  bandages,  of  plasters,  and  particularly  of 
suture. 

Art.  1. — Suture. 

The  bringing  together  the  lips  of  a  wound  with  the  assistance  of  threads 
or  of  metallic  wires,  is  the  only  one  amongst  the  various  means  used  in 
eflfectin^  reunion  which  deserves  the  title  of  a  bloody  operation,  and  the  only 
one  which  it  is  necessary  at  present  to  examine.-  The  suture,  which  is 
evidently  borrowed  from  the  art  of  the  tailor,  formerly  enjoyed  more  favor 
than  can  be  easily  conceived  at  the  present  day,  from  an  examination  of  the 
practice  of  the  greater  number  of  operators.  Since  the  time  of  Pibrac^  who 
80  heartily  condemned  the  practice,  and  who,  in  a  memoir,  at  best  by  no 
means  conclusive,  endeavored  almost  entirely  to  banish  it  from  the  domain  of 
surgery,  the  suture  has  continually  lost  ground  in  the  estimation  of  prac- 
titioners; so  that  now  it  is  no  longer  actually  recommended  in  classical 
works,  except  in  a  very  limited  number  of  cases.  On  both  sides,  as  usual, 
the  bounds  of  truth  have  been  transgressed.  If  the  suture  does  not  merit 
the  praises  formerly  lavished  upon  it,  as  little  does  it  deserve  the  neglect  into 
which  it  ,has  lately  fallen.  The  only  well-founded  reproaches  which  can  be 
advanced  against  it,  are,  that  it  prevents  the  due  escape  of  fluids,  increases 
the  pain  and  the  inflammation,  and  prolongs  the  operation.  But  the  first  of 
these  objections  lies  against  the  immediate  reunion,  rather  than  against  the 
suture;  and  it  needs  only  to  have  witnessed  what  occurs  in  cases  of  hare-lip, 
staphyloraphy,  rhynoplasm,  genoplasm,  cheiloplasm,  and  enter  or  aphy,  to  be 
convinced  that  tlie  second  and  third  objections  have  been  at  least  much 
exaggerated.  In  these  kinds  of  reunion,  it  is  not  the  pain  nor  the  inflammation 
which  occasion  failure ;  and  the  operator  would  be  fortunate  indeed,  if, 
in  a  like  case,  he  had  to  contend  with  no  other  difllculties  than  these.  As 
to  the  greater  duration  of  the  operation,  who  will  venture  to  lay  great  stress 
upon  tliis,  if  the  suture  really  possess  the  advantages  accorded  to  it  before 
the  time  of  Pibrac  and  Louis  ?  In  justice  it  must  be  said,  that  it  is  not 
actually  dangerous,  as  has  been  contended  by  the  old  academy  of  surgery, 
but  yet  that  it  is  most  frequently  useless,  and  at  most  but  seldom  indispen- 
sable. It  can  only  be  indicated  in  wounds  where  the  immediate  reunion  of 
the  parts  is  desired ;  and  even  in  this  kind  of  lesion  there  are  many  cases  in 
which  it  might  be  omitted  without  injury.  While  we  count  it  better  than  any 
kind  of  bandage  or  plaster  that  can  be  contrived,  where  it  is  necessary  to 
bring  into  apposition  the  edges  of  large  flaps  of  integuments,  movable  or  ill- 
supported,  or  of  membranous  or  very  thin  organs,  it  would  be  but  a  feeble 
resource  in  wounds  of  which  the  lips  are  firm  and  loaded  with  cellular  tissue, 
which  penetrate  to  the  great  muscles  of  the  limbs,  or  of  the  trunk,  and  of 
vhich  the  sides  are  perpetually  swayed  by  the  movements  of  the  parts  beneath. 


OPERATIVE    SURGERY.  19 

When  the  suture  is  used,  no  pressure  is  required ;  the  wound  can  be  gently 
dressed  without  any  dragging  of  the  surrounding  skin ;  and  the  apposition, 
which  incurs  no  risk  of  beinff  deranged,  extends  through  the  whole  thickness 
of  the  bleeding  edges.  In  the  use  of  strips  or  bandages,  the  skin  is  more  or 
less  irritated ;  the  contact  is  rarely  perfect,  and  if  the  skin  be  in  the  least 
degree  soft  or  loose,  the  lips  of  the  wound  continually  tend  to  roll  inwards, 
and  only  touch  by  the  part  of  their  thickness  next  the  epidermis.  The  least 
effort,  the  least  imprudence,  causes  a  separation.  Besides,  this  mode  of 
effecting  a  reunion  is  not  applicable  to  every  region  of  the  body;  we  do  not 
gee  that  it  is  much  more  difficult  to  relax  or  to  cut  a  stitch  than  an  emplastic 
strap  or  a  piece  of  linen,  if  strangulation  should  occur. 

Without  reposing  in  this  method  as  much  confidence  as  is  conceded  to  it  by 
Delpech,  Gensoul,  and  most  of  the  surgeons  of  Marseilles,  Brest,  and  Toulon, 
and  the  principal  cities  of  the  south,  an  abstract  of  whose  views  has  been 
given  by  M.  Serre,  of  Montpeliers,  in  his  treatise  on  '*  immediate  union," 
I  am  inclined  to  coincide  with  him,  as  also  with  MM.  Dupuytren,  Roux,  and 
Lisfranc,  in  the  opinion  that  it  is  worthy  of  resuming  a  more  prominent  place 
in  the  practice  of  surgery. 

Of  all  the  kinds  of  suture  which  have  been  devised,  the  science  has  only 
preserved,  and  in  fact,  only  should  preserve  the  interrupted  suture  (by  separate 
stitches),  the  "seamed,"  or  that  of  the  glover,  the  *' zig-zag  suture,"  the 
suture  of  Le  Dran,  the  "  twisted,"  and  the  "quilled"  suture. 

§  1.  Interrupted  Suture. 

To  eff*ect  a  suture  by  separate  stitches,  it  is  necessary  to  provide  as  many 
pieces  of  thread,  single,  double,  triple,  or  quadruple,  as  you  may  intend  to 
make  stitches ;  taking  care  that  they  are  well  waxed  ;  next,  a  sufficient  number 
of  needles.  The  needles  which  were  used  in  the  last  century,  curved  and 
flattened  only  in  the  anterior  half  of  their  length,  straight,  round,  or  slightly 
depressed  laterally,  and  pierced  in  the  same  direction,  with  an  extended  eye, 
are  now  entirely  abandoned.  The  needles  universally  preferred,  are  regularly 
curved  in  the  arc  of  a  circle  5  of  equal  width  and  thickness  from  one  end  to 
the  other,  except  within  a  few  lines  of  the  point;  provided  with  a  square 
opening  in  the  posterior  extremity  made  in  the  direction  of  the  thickness. 

It  is  only  necessary  to  place  a  needle  at  each  extremity  of  the  thread, 
when  the  stitch  is  to  be  made  by  piercing  first  one  and  then  the  other  of  the 
lips  of  the  wound  from  its  internal  or  cellular  side  towards  the  surface,  other- 
wise one  needle  suffices  for  each  ligature.  All  other  things  being  equal,  it  is 
best  to  pierce  one  of  the  edges  of  the  wound  from  without  inwards,  and  the  other 
from  within  outwards ;  the  operation  is  more  prompt  and  less  painful,  draws 
skin  less  from  the  exterior  to  the  interior  than  in  the  other  direction,  and  does 
not  involve  the  embarrassment  of  changing  the  needle  nor  the  hand,  in  passing 
from  one  edge  of  the  wound  to  the  other.  The  right  or  upper  lip  of  the  wound 
is  that  with  which  it  is  most  convenient  to  begin.  The  surgeon  pinches  it 
with  the  thumb  of  the  left  hand  on  the  internal  face,  and  the  fore -finger  prone 
upon  the  external  face,  raising  it  and  turning  it  a  little  outwards,  he  seizes 
the  needle  already  threaded  with  the  right  hand,  holding  it  like  a  pen,  the 
thumb  in  the  concavity,  the  fore  and  middle  finger,  sometimes,  if  the  needle 
be  large,  even  the  ring  finger,  upon  its  convex  part,  so  as  to  turn  it  into  a, 
lever  of  the  third  class,  applies  the  point  to  the  skin  at  three  or  four  lines 
distance  from  the  edge,  pushes  it  by  a  circular  movement  so  as  to  make  it 
come  out  by  the  wound  where  the  thumb  indicates  its  direction  and  passage, 
leaves  the  heel  as  soon  as  it  is  sufficiently  advanced,  seizes  the  point  with  the 


£0  NEW   ELEMENTS    OF 

thumb  on  its  convexity,  continues  itsprogress,  and  brings  it  out  by  turning  the 
hand  towards  a  supine  posture.  Taking  it  then,  as  at  first,  he  proceeds 
immediately  to  the  second  step  of  the  operation,  which  is  the  same  with  the 
first,  except  that  the  needle  ought  to  pierce  the  second  lip  of  the  wound  by 
commencing  on  its  inner  surface,  and  that  the  thumb  should  be  used  instead 
of  the  fore-finger  to  support  the  skin.  The  remaining  stitches  are  only  repe- 
titions of  the  first ;  and,  when  several  are  to  be  made,  the  operation  is  usually 
begun  at  the  right  or  inferior  extremity. 

If  any  reason  exist  for  following  the  old  method  of  placing  a  needle  at  each 
end  of  the  ligature,  the  right  or  upper  border  of  the  wound,  bold  as  above 
directed,  should  be  first  pierced  from  its  adherent  surface  outwards,  the  hand 
being  at  first  supine  with  the  thumb  on  the  concave  side  of  the  needle,  which 
is  pushed  in  with  a  movement  towards  pronation.  The  perforation  of  the 
other  edge  is  made  with  the  second  needle  just  as  in  the  former  method. 

To  close  the  operation  then,  the  surgeon  dries  the  part  or  causes  it  to  be 
dried,  seizes  successively  each  ligature  by  its  two  extremities,  adjusts  the 
co-aptation  of  the  parts,  and  ties  the  threads  one  after  the  other  at  the  lower  side 
of  the  wound.  The  practice  of  laying  lint  between  the  knot  and  the  wound 
so  that  the  ligature  shall  not  lie  immediately  upon  the  skin,  although  it  has 
been  recommended  by  many  persons,  can  only  be  justified  in  cases  where  it 
is  necessary  to  relax  the  suture  within  one  or  two  days  after  its  application. 
In  every  other  case  the  ligature  should  rest  upon  the  skin,  without  any  thing 
to  intervene.  A  pledget  of  lint,  or  charpie,  spread  with  simple  cerate,  then 
some  dry  lint,  and  one  or  two  turns  of  a  roller  applied  over  all,  will  serve  to 
support  them,  where  it  is  not  thought  sufficient  to  cover  the  parts  with  simple 
compresses  saturated  with  cold  water,  or  even  to  leave  them  exposed  to  the 
open  air. 

If  nothing  particular  occurs,  the  thread  is  not  to  be  withdrawn  until  about 
the  third,  fourth,  or  perhaps  the  fifth  day,  in  order  to  which  the  lower  extre- 
mity of  the  exposed  part  of  the  ligature  is  cut  with  the  scissors.  The  surgeon 
then  takes  hold  of  the  knot  or  superior  extremity  with  the  right  hand,  and 
removes  the  ligatures  gently  one  after  the  other,  whilst  with  the  fingers  of  the 
left  liand  he  keeps  in  place  the  skin  and  the  corresponding  lip  of  the  wound. 

§  2.  Suture  of  Le  Dran. 

Le  Dran  conceived  the  idea  that,  especially  in  enteroraphy,  after  having 
passed  the  threads  with  a  straight  needle,  as  in  the  interrupted  suture,  it 
would  be  advantageous  to  unite  the  extremities  of  all  the  ligatures  in  a  single 
cord,  and  to  retain  them,  thus  collected,  upon  the  exterior  without  a  knot. 
His  object  was,  to  be  enabled  to  leave  them  in  longer,  and  to  withdraw  them 
separately  witliout  the  necessity  of  cutting  any  thing.  The  fault  of  the  process 
of  Le  Dran  is,  that  a  wrinkling  or  plaiting  of  the  membranes  is  produced  by 
4U*awing  tlie  ligatures  together  on  each  side  into  a  single  cord.  The  suggestion, 
tlfccrefore,  is  not  available,  except  in  cases  where  a  single  ligature  will  suffice, 
or  when,  if  several  have  been  passed,  the  extremities  can  be  retained  on  the 
a;^terior  separately,  as  is  now  done  in  some  intestinal  sutures. 

*  Continuous  Suture  (seamed). 

The  suture,  properly  called  the  furrier's,  not  Pelletier's,*  as  it  has  been 

•  The  mistake  has  arisen  from  the  correspondence  of  the  above  eminent  name  with  the 
French  word  for  glover,  or  furrier. 


OPERATIVE    SURGERY.  21 

written  in  several  modern  books,  in  which  the  authors  have  taken,  not  the 
name  of  a  port,  like  the  ape  in  tlie  fable,  but  that  of  a  trade  for  the  name  of  a 
man,  is  that  which  is  usually  employed  after  the  opening  of  dead  bodies,  and 
in  veterinary  surgery.  Although  formerly  as  often  used  in  the  practice  of 
human  surgery,  it  is  now  almost  entirely  excluded,  but,  I  think,  very  impro- 
perly. Wounds  that  are  somewhat  long,  or  such  as  involve  hollow  organs, 
are  as  advantageously  treated  with  this  suture  in  the  living  body  as  in  the 
dead ;  and  the  strangulation,  which  it  is  charged  with  causing  so  easily,  is  • 
with  so  little  propriety  urged  as  a  motive  for  rejecting  it,  that  this  is,  in  fact, 
less  frequently  followed  by  that  accident  than  the  other  kinds  of  suture. 

The  seamed  suture  is  so  well  known  in  the  furrier's  and  tailor's  arts,  that 
its  very  name  is  equivalent  to  a  description.  It  is  commenced  like  the 
interrupted  suture,  except  that  a  straight  needle  is  more  convenient  than  one 
which  is  curved,  and  that  instead  of  piercing  the  lips  of  the  wound,  one  after 
the  other,  you  endeavor  to  bring  them  together,  and  take  them  up  in  the  same 
fold,  so  as  to  penetrate  them  both  at  the  same  stroke.  An  assistant  then 
draws  and  stretches  out  the  two  extremities  of  this  fold  ;  the  operator  pinches 
it  from  above  with  the  thumb  and  fore-finger  of  the  left  hand  in  a  prone  posi- 
tion, brings  the  needle  to  the  right  or  superior  lip  at  a  convenient  distance 
from  the  fissure,  transpierces  the  fold,  withdraws  the  thread,  the  extremity 
of  which  is  held  by  the  assistant,  or  which  he  stays  with  a  knot,  brings  back 
tlie  needle  obliquely  across  the  wound  to  the  same  side  of  the  skin,  three,  four, 
or  five  lines  from  the  first  puncture,  and  continues  in  this  way  until  the  last 
stitch  passes  a  little  beyond  the  other  extremity  of  the  fold,  so  that  the  entire 
suture  shall  present  a  certain  number  of  spiral  turns.  If  it  does  not  appear  to 
be  sufficiently  closed,  the  two  ends  are  drawn  before  being  fiistened  ;  in  the 
contrary  case,  the  lips  of  the  wound  are  somewhat  separated.  If  it  is  well 
done,  the  lips  of  the  wound,  without  being  tiglit,  should  touch  along  their 
whole  extent,  and  the  fold  should  be  wholly  eftaced.  The  suture  is  then 
definitively  finished,  by  passing  each  of  the  extremities  of  the  ligature,  like  a 
slip-knot,  around  the  adjacent  spiral.  Wiien  you  wish  to  remove  it,  each 
oblique  loop  is  to  be  cut  with  the  scissors,  and  then  withdrawn  singly ;  or 
you  may  merely  unfasten  the  upper  end,  and  then  disengage  successively  the 
different  spiral  turns,  and  draw  it  out  entire  by  its  lower  extremity. 

When  both  lips  of  the  opening  cannot  be  included  in  the  same  stroke  of  the 
needle,  each  turn  of  the  seamed  suture  is  practised  exactly  as  in  the  case  of 
suture  with  separate  stitches,  from  which,  in  fact,  as  we  have  seen,  it  very 
slightly  differs. 

§  4.  Zig-zag  Suture. 

This  suture,  the  idea  of  which  is  attributed  to  Bertrand,  is  made  with  a 
continued  thread,  the  same  as  the  one  just  described,  and  is  begun  and  finished 
in  the  same  way  ;  but  instead  of  crossing  spirally  in  front  of  the  wound,  the 
thread  passes  through  the  fold  alternately  from  right  to  left  and  from  left  to 
right,  forming  a  complete  zig-zag,  which  leaves  the  anterior  aspect  of  the 
bleeding  surface  entirely  free  and  uncovered.  In  performing  this  suture  the 
needle  traverses  the  tissue,  beginning  with  the  right  border;  being  drawn  out 
by  the  left  border,  it  again  passes  through,  but  in  an  opposite  direction,  a  little 
above,  coming  out  by  the  right  border;  it  is  then  returned  on  this  side 
some  lines  higher,  and  being  again  drawn  out  on  the  other,  it  is  carried,  as  in 
the  first  case,  somewhat  further,  so  that  it  proceeds  in  a  serpentine,  and  not 
in  a  spiral  course,  as  in  the  case  of  the  furrier's  suture.     Some  surgeons 


22  NEW   ELEMENTS   OF 

ascribe  to  it  the  advantage  of  not  tearing,  or  cutting  the  tissue  so  easily,  in 
consequence  of  the  lateral  loops  which  it  forms  between  every  two  punctures, 
and  that  it  does  not  strangulate  the  parts  like  the  other,  by  passing  over  them. 
Admitting  this  to  be  the  case,  it  must  be  allowed  on  the  other  hand  that  it 
has  the  fault  of  drawing  unequally  the  two  halves  of  the  wound,  and  of  giving 
no  support  to  the  anterior  surface.  Although  slightly  improved  by  Beclardy 
the  zig-zag  suture  is  scarcely  ever  used,  and  can  always,  in  fact,  without 
danger  or  inconvenience,  give  place  to  the  interrupted,  or  to  the  seamed 
suture. 

§  5.  The  Twisted  Suture. 

One  of  the  sutures  most  in  vogue,  is  that  which  is  practised  by  means  of 
threads  passed  in  different  ways  around  metallic  pins,  which  are  allowed  to 
remain  in  the  thickness  of  the  flesh.  Needles  of  iron,  steel,  gold,  silver,  lead, 
copper,  brass,  &c.,  straight,  curved,  thick,  thin,  long,  short,  round,  and  flat, 
have  been  employed  in  this  operation;  but  at  last  this  great  variety  has  given 
wav  to  the  almost  universal  employment  of  ordinary  pins,  which  are  every 
where  at  hand,  and  which  are  found  in  actual  practice  to  answer  every 
purpose  as  well  as  needles  of  the  most  precious  metals  and  most  ingeniously 
contrived.  They  are  prepared  by  sliarpening  and  flattening  the  point  upon  a 
stone,  and  covering  them  with  cerate.  If  the  wound  is  seated  in  a  movable 
part,  such  as  the  lips,  or  the  eye-lids,  the  pin  nearest  to  the  free  border  of  the 
organ  is  the  first  applied,  the  others  are  afterwards  successively  inserted. 
As  this  species  of  suture  is  to  be  minutely  described  in  treating  of  hare-lip^ 
it  would  occasion  useless  repetition  to  detail  here  the  particulars  of  the 
operation.  When  the  two  extremities  of  the  woUnd  are  closed,  or  it  is 
required  to  connect  cutaneous  flaps,  the  placing  of  the  needles  is  not  subject 
to  the  same  rules.  The  operator  then  commences  at  the  centre,  the 
extremities,  the  point,  the  sides,  or  the  base  of  the  parts  which  he  wishes  to 
bring  in  apposition,  according  to  the  difliculties  which  he  thinks  he  has  to 
surmount.  In  this  respect  he  must  rely  upon  his  own  particular  intelligence. 
The  right  lip  of  the  wound  being  seized  with  the  fingers  of  the  left  hand,  as 
in  the  case  of  the  interrupted  suture,  or  with  the  forceps,  the  hook,  or  any 
other  operative  means,  according  to  the  case,  he  plunges  tlie  prepared  pin 
from  without  inwards,  and  causes  it  to  appear  in  the  interior  of  the  wound, 
continuinjj  to  push  against  the  other  lip,  which  he  seizes  in  turn  and  pierces 
from  withm  outwards,  so  that  the  needle  will  come  out  at  the  same  distance 
up)n  the  skin.  He  embraces  the  needle  immediately  with  a  turn  of  thread 
which  he  passes  under  the  head  and  point,  at  the  same  time  that  it  crosses  the 
front  of  the  wound,  and  tends  to  press  the  two  sides  against  each  other.  An 
assistant  takes  the  ends  of  this  looped  thread  and  holds  them  a  little  extended, 
while  the  surgeon  proceeds  to  the  application  of  the  other  pins. 

As  soon  as  they  are  all  placed,  the  surgeon  proceeds  to  secure  them  by 
casting  the  thread  around  them.  The  middle  of  a  long  ligature  put  above 
the  last,  is  passed  and  crossed  many  times  around  its  extremities  in  the  form 
of  a  figure  8,  then  conducted  in  the  form  of  a  X  to  the  next  needle,  and  turned 
in  the  same  manner  around  its  head  and  point  before  it  proceeds  to  the  third, 
from  which  it  is  returned  to  the  second  and  the  first  by  renewed  crossings. 
He  then  concludes  by  knotting  or  twisting  the  two  ends  together,  and  turning 
them  under  the  body  of  the  needle.  To  prevent  these  needles  from  wounding 
the  integuments,  a  small  strip  of  plaster  or  roll  of  charpie  is  placed  under 
each  of  their  extremities.  Notiiing  further  is  required,  than  some  suitable 
covering  if  such  a  thing  is  deemed  requisite. 


OPERATIVE   SURGERY.  23 

These  are  to  be  removed  at  the  same  time  as  all  other  sutures.  We  com- 
mence bj  the  needle  which  supports  the  parts  the  least,  so  as  to  leave  the 
removal  of  the  others  until  the  next  day,  if  we  do  not  find  a  reunion  suffi- 
ciently solid.  If  there  be  any  fear  on  this  head  it  is  proper  only  to  remove 
the  needles  and  leave  the  thread  a  day  or  two  longer,  which,  being  attached 
to  the  parts,  and  having  become  more  or  less  consolidated,  perform  the  office 
of  adhesive  strips.  This  fear  further  requires  that  the  surgeon  should  care- 
fully support  the  right  lip  of  the  wound  with  the  fingers  of  the  left  hand,  while 
with  the  other  he  draws  out  the  needle  by  the  head  in  a  straight  line,  or  by 
giving  it  small  rotatory  motions. 

The  punctures  which  the  needles  leave  suppurate  a  day  or  two,  and 
cicatrize  like  all  other  wounds  of  the  same  class. 

§  6.  Quilled  Suture, 

The  practice  of  infibulation,  which  is  still  in  use  among  some  of  the  oriental 
nations,  but  which  has  for  many  years  ceased  to  be  used  in  Europe,  except 
to  prevent  the  approaches  of  the  male  of  certain  animals  to  the  female  at 
improper  times,  is  a  sort  of  quilled  suture ;  but  instead  of  the  metallic  rods 
used  in  operating  upon  the  mare,  this  suture  is  effected  upon  a  human  subject 
with  threads  and  two  small  rolls  of  something  more  solid.  The  quilled  suture 
is  performed  in  the  same  manner  as  the  interrupted  suture,  but  with  double 
threads,  preserving  a  loop  at  one  extremity.  When  they  are  all  placed,  a  slip 
of  wood,  the  barrel  of  a  quill,  a  bougie  of  elastic  gum,  or  even  a  rouleau  of 
waxed  cloth,  or  a  small  metallic  rod,  in  short,  any  cylindrical  body  of  a  con- 
venient length  and  thickness,  is  slipped  along  parallel  with  the  wound  into  each 
of  the  loops.  The  other  extremity  is  then  also  undoubled  for  the  purpose  of 
receiving  a  similar  slip  of  wood  or  other  body,  upon  which  the  threads  are 
successively  tied,  having  previously  secured  an  accurate  apposition  of  the 
edges.  Care  must  be  taken  not  to  exercise  too  forcible  a  constriction,  nor 
yet  to  allow  any  gaping  of  the  sides  of  the  wound. 

Altliough  rarely  indispensable,  the  quilled  suture  has  always  the  advantage 
of  exercising  a  pressure  perfectly  equable  upon  all  the  points  which  the  thread 
is  intended  to  bring  together,  of  being  more  firm  than  any  of  the  others,  of 
being  less  apt  to  lacerate  the  parts,  and  of  being  particularly  adapted  to 
straight,  long,  and  deep  wounds  of  the  walls  of  the  abdomen  and  of  the  limbs. 
The  only  objection  to  this  suture  is,  that  it  requires  a  little  more  time  and 
care  than  the  continued  suture. 

In  using  any  species  of  suture,  we  must  avoid  needlessly  multiplying  the 
stitches  or  leaving  them  too  far  apart.  The  intervals  must  vary  according  as 
the  strain  to  be  opposed  is  more  or  less  considerable — the  incision  more  or 
less  extended — the  parietes  to  be  repaired  more  or  less  flaccid — more  or  less 
difficult  to  be  kept  in  apposition.  A  stitch  for  every  half  inch  is  generally 
sufficient;  while  there  are  cases  which  require  one  in  every  three  lines,  and 
others  in  which  the  stitches  may  be  an  inch  apart.  What  has  been  here  said 
however,  cannot  be  fully  understood  without  the  aid  of  particular  examples, 
which  would  here  be  out  of  place. 


d4  ^.  NEW    ELEMENTS   OF 


COMPLEX    OPERATIONS. 


OPERATIONS  UPON  THE  BLOOD-VESSELS. 


CHAPTER  I. 


OPERATION  FOR  ANEURISM. 


The  true  aneurism  or  a  dilatation  of  all  the  arterial  coats  (•*  the  circum- 
scribed arteriectasis"),  so  lonff  admitted  as  the  most  common,  but  the  existence 
of  which  has  been  contested  by  Scarpa  and  Delpech,  although  really  very 
rare,  has  yet  been  sometimes  obseiTed.  Hodgson  cites  several  examples : 
M.  Floret  declares  that  he  has  seen  a  number  situated  at  intervals  on  the  first 
four  intercostal  arteries,  and  M.  Berard,  sen.,  has  deposited  in  the  museum 
of  the  faculty  a  preparation,  which  leaves  no  doubt  upon  the  subject.  It 
will  be  perceived  in  the  preparation,  that  on  its  passage  between  the  pillars 
of  the  diaphragm  the  aorta  presents  a  fusiform  swelling  as  large  as  the  fist,  in 
which  three  arterial  coats  are  still  distinguishable  ;  the  root  of  the  cceliac 
trunk,  which  corresponds  with  the  middle  of  the  tumor,  is  itself  much  dilated 
and  spread  out  like  a  funnel,  and  the  same  appearance  is  presented  by  the 
superior  mesenteric. 

Another  species  of  true  aneurism  can  now  be  established,  which  also  some- 
times claims  the  assistance  of  Operative  Surgery.  It  is  the  diffused  Arteri- 
ectasis, which  only  affects  the  arteries  of  the  fourth  or  fifth  order,  which  are 
then  thickened,  dilated,  and  contorted,  as  if  aff'ected  with  hypertrophy,  and 
somewhat  similar  to  varicose  veins.  It,  however,  occupied  the  femoral  as 
well  as  all  the  other  arteries  of  the  leg,  in  a  case  which  was  treated  last  year 
by  M.  Dupuytren,  at  the  Hotel  Dieu.  Park  has  seen  the  posterior  tibial 
artery  in  tnis  state,  and  Pelletan  the  occipital,  temporal,  and  frontal,  in  the 
same  subject.  All  the  arteries  of  the  hand  and  of  the  fore-arm  are  some- 
times thus  aflfected,  as  I  once  had  an  opportunity  of  observing  at  the  lectures 
of  Beclard. 

Perhaps  it  would  be  well  to  give  the  name  of  true  aneurism  of  the  capillary 
system  to  those  erectile  tumors  which  have  already  received  so  many  appella- 
tions, and  which  appear  to  have  been  encountered  even  in  the  thickness  of 
the  bones. 

False  Aneurism,  which  is  characterized  by  a  rupture  of  some  of  the  coats, 
or  of  the  whole  tliickness  of  the  arteries,  ought,  in  theory  at  least,  to  bear 
another  denomination,  but  practical  utility  rules,  and  this  custom,  though  by 
all  acknowledged  to  be  vicious,  is  yet  by  all  observed. 


OPERATIVE    SURGERY.  25 

Tlie  primitive  or  diffused  false  Aneurism  arises  from  the  opening  of  an  artery, 
and  consists  of  an  effusion  of  blood,  more  or  less  considerable,  in  the 
neighborhood  of  the  lesion,  and  in  that  particular  diflfers  essentially  from  all 
other  kinds  of  aneurism. 

In  the  circumscribed  false  Aneurism  some  foreign  body  has  perforated  the 
artery,  but  the  blood,  escaping  by  degrees  through  this  opening,  forms  for 
itself  a  sac  at  the  expense  of  the  surrounding  cellular  substance,  and  of  the 
external  coat  of  the  wounded  vessel. 

If  the  blood  pass  directly  from  an  artery  into  a  vein,  by  an  opening  in  the 
adjacent  coats  of  these  two  vessels,  an  aneurismal  varix  is  the  result. 

If  a  sac  is  formed  in  which  blood  may  accumulate  between  the  opening  in 
the  artery  and  that  in  the  vein,  there  is  a  false  circumscribed  aneurism 
complicated  with  an  aneurismal  varix^  or  as  some  would  style  it  a  varicose 
aneurism. 

Mixed  Aneurism,  or  that  which  is  formed  by  the  spontaneous  solution  of 
the  continuity  of  a  part  of  the  coats  of  an  artery,  and  by  the  mechanical 
dilatation  of  those  which  are  sound,  presents  itself,  according  to  authors, 
under  two  forms.  Sometimes  the  internal  coat  distends  itself  and  bulges  out 
so  as  to  form  a  cyst  through  an  opening  in  the  other  two,  and  which  constitutes 
internal  mixed  aneurism,  or  aneurismal  hernia;  at  other  times,  on  the  contrary, 
it  is  the  external  or  cellular  coat  alone  which  dilates  and  receives  the  blood 
through  a  perforation  of  the  internal  and  middle  coats :  this  is  an  external 
mixed  aneurism,  or  mixed  aneurism,  properly  so  called. 

But  there  is  no  proof  that  the  first  of  these  two  varieties  is  really  possible, 
or  that  it  has  ever  been  positively  observed  :  tlie  fact  which  is  attributed  in  all 
the  books  to  Messrs.  Dubois  and  Dupuytren,  and  which  is  brought  fonvard 
in  demonstration  of  its  existence,  is  not  conclusive.  The  experiments  of 
M.  Casamayor  on  dogs,  and  the  new  observation  which  M.  Dupuytren  has 
just  communicated,  do  not  appear  to  be  mu«h  more  so.  Those  of  Haller, 
who  has  seen,  in  operating  upon  frogs,  the  internal  coat  of  the  mesenteric 
artery  form  a  hernia  through  the  lesser  and  external  coats,  can  have  no 
weight  here,  as  it  will  be  more  easy  to  explain,  together  with  all  that  relates 
to  aneurism,  after  having  briefly  sketched  the  surgical  anatomy  of  the  arterial 
system. 

SECTION   I. 

Anatomical  Remarks, 

Every  artery  of  any  considerable  size  is  composed  of  three  coats,  three 
concentric  cylinders,  very  distinct  in  the  great  trunks,  but  which  mix  insen- 
sibly with  each  other  as  the  vessel  diminishes  and  can  no  longer  be  separated 
when  it  approaches  its  capillary  extremity. 

1st.  The  Middle  Coat,  also  designated  as  the  muscular  coat,  the  yellow 
coat,  the  tunica  albuginea,is  composed  of  incomplete  fibrous  circles,  and  not 
of  longitudinal  fibres,  united  to  one  another  by  lamellas  and  filaments  of  the 
same  nature  ;  no  vessels,  either  lymphatic  or  carrying  red  blood,  are  to  be 
traced  in  it,  although  certain  observers  have  pretended  the  contrary ;  it  is 
almost  inert,  and  breaks  like  glass ;  if  it  is  tightly  encircled  with  a  thread  it 
tears,  instead  of  being  distended  when  it  is  subjected  to  a  pressure  superior 
to  its  natural  power  of  resistance.  Although  it  is  elastic  like  the  yellow 
tissue  of  tlie  trachea  and  the  ligaments  of  the  vertebrae,  which  it  to  a  certain 
4 


Xb  NEW    ELEMENTS   OF 

point  resembles,  it  is  almost  impossible  to  draw  this  coat  in  a  direction 
•parallel  to  its  axis  without  breaking  it.  By  its  outer  surface  it  is  united  to 
the  external  coat,  through  the  intervention  of  an  irregular  layer  of  laminar 
tissue,  imperfectly  organized ;  on  the  inside,  the  internal  membrane  is  connected 
-with  it  by  a  simdar  medium.  As  this  tunic  is  devoid  of  sensibility,  and  of 
almost  all  the  properties  of  animated  matter,  it  is  not  astonishing  that  the 
diseases  of  which  it  is  the  subject  should  be  in  great  measure  independent 
of  the  vital  phenomena,  and  should  seem  to  develop  themselves  under  the 
influence  of  the  laws  which  govern  inanimate  matter.  It  is  this  coat  which 
distinguishes  the  arteries  from  the  veins,  keeps  them  patulous  after  they  have 
been  cut  across,  determines  their  form  and  color,  renders  inflammation  of  these 
vessels  so  difficult  and  rare,  prevents  wounds  or  incomplete  divisions  of  them 
from  cicatrizing  by  aggktination,  and  enables  them  better  to  resist  the  lateral 
pressure  of  the  blood.  As  the  arterial  trunk  approaches  the  heart  and  is 
enlarged,  or  when  it  is  destined  to  sustain  a  greater  pressure,  the  middle  coat 
is  increased  in  thickness,  and  that  rather  more  on  the  convex  side  of  the  curve 
than  on  the  other.  When  it  has  reached  the  branches  of  the  fourth  or  fifth 
order,  and  is  approaching  the  final  ramifications  of  the  arterial  system,  it  is 
observed  gradually  to  become  thinner  and  less  distinct,  until,  at  last,  it  is 
confounded  in  a  common  tissue  with  the  other  coats  of  the  vessel.  From 
this  it  follows  that,  all  other  things  equal,  the  arteries  are  more  flexible,  more 
extensible,  and  less  easy  to  rupture,  in  proportion  as  they  are  smaller  and 
farther  removed  from  the  centre  of  the  vascular  system. 

2d.  The  Internal  Tunic,  which  has  been  compared  by  some  to  a  mucous, 
and  by  others  to  a  serous  membrane,  is  smooth  and  generally  unctuous  on  its 
free  surface :  on  the  other  it  adheres  to  the  preceding  coat  only  by  a  thin  layer 
of  laminar  tissue,  in  which  there  exist  no  vessels,  nor  indeed  any  other 
eleuientary  organ.  This  coat  contains  no  fibres  or  vascular  canals  of  any 
description,  and  is  in  fact  nothing  more  than  a  lamella  of  a  homogenous  sub- 
stance something  like  the  cornea,  the  substance  of  the  nails  and  tlie  corneous 
tissue  in  general,  facilitating  the  passage  of  the  blood  through  all  the  ramifi- 
cations of  the  arterial  tree.  In  the  small  and  capillary  branches,  this  layer 
is  no  longer  separated  from  the  cellular  tunic  by  the  middle  membrane,  but 
approaches  more  nearly  the  character  of  a  really  organized  substance, 
admitting  the  fluids  on  its  external  surface  by  direct  circulation ;  besides,  it 
is  thicker  and  more  distinct,  but  extremely  fragile.  It  is  separated  from  all  the 
rest  of  the  vascular  system  by  the  yellow  tunic,  and  is  an  almost  inorganic 
layer  like  the  cartilages,  endued  with  very  little  elasticity,  and  very  easily 
destroyed.  From  these  characters,  it  results  that  the  inner  membrane  of 
the  arteries  cannot  be  primarily  inflamed  ;  that  it  can  only  become  the  seat  of 
this  pathological  phenomenon  by  transmission  from  the  surrounding  tissues; 
in  short,  that  it  is  subject  only  to  mechanical  derangements,  unless  it  receive, 
by  contact  from  the  other  tunics,  the  diseases  with  which  they  may  be  affected. 

Sd.  IJie  External  or  Cellular  Tunic  is  the  only  one  which  presents  all  the 
elements  of  an  actual  tissue ;  it  is  formed  of  small  fibres  and  lamellae  variously 
interlaced,  like  all  the  other  cellular  sheaths ;  fine  arterial  and  venous 
branches,  run  through  it  in  every  direction.  These  vessels,  known  by  the 
appellation  of  «*  vasa  vasorum,^^  supply  the  entire  thickness  of  the  artery, 
yet  do  not  penetrate  into  the  middle  tunic,  nor,  of  course,  into  the  internal; 
80  that  the  cellular  membrane  is  the  only  one  in  which  there  is  a  real  circu- 
lation, and  the  others,  either  are  not  nourished  at  all,  or  only  keep  themselves 
in  their  natural  state  by  imbibition,  or  by  simple  deposit  of  molecules.     Thi« 


OPERATIVE   SURGERY.  SUt 

texture  of  the  external  tunic  of  the  arteries  allows  it  great  extensibility, 
permits  it  to  yield  without  rupture  to  all  impressions  made  upon  it,  to  inflame, 
to  cicatrize,  to  contract  adhesions  with  the  tissues  about,  and  to  transmit  to 
the  other  coats  its  peculiar  diseases  ;  whence  it  follows,  that  in  the  capillary 
system,  where  it  forms  nearly  all  the  thickness  of  the  vascular  walls,  life  is 
more  active,  and  diseases  infinitely  more  frequent. 

4.  Besides  the  cellular  coat,  the  arteries  are  again  covered  throughout  by  a 
sheath  of  similar  structure,  but  much  less  firm;  this  sheath,  which,  is 
denominated  the  "  common  skeathP  analogous  to  that  which  envelopes  all  the 
cords,  and  all  the  fascicles  or  assemblages  of  fibres  in  the  system,  increases 
and  preserves  the  inflexibility  of  the  former,  connects  it  to  the  neighboring 
tissues,  and  principally  to  the  collateral  veins. 

5.  Further,  the  arteries  are  every  where  connected  with  parts  more  or  less 
solid  and  fixed.  In  the  breast  and  the  abdomen  the  aorta  receives  no  solid 
support,  except  from  the  vertebral  column  against  which  it  is  applied,  so  that 
the  aneurisms  which  occur  in  it,  even  if  they  originate  on  its  posterior  side, 
generally  project  in  a  lateral  direction,  or  even  in  front.  The  branches  which 
it  gives  m  the  visceral  cavities  resting  upon  no  solid  bed,  would  seem  from 
this  circumstance  more  subject  than  any  others  to  dilatation  or  to  rupture. 
But  the  support  which  they  receive  from  the  pressure  of  the  viscera,  the  great 
freedom  of  motion  which  they  enjoy,  and  the  slightness  of  the  impulse  made 
upon  them  by  external  agents,  explain  their  great  exemption  from  these 
affections.  In  the  limbs,  where  they  are  surrounded  by  muscles,  and  sup- 
ported and  protected  by  bones,  the  arteries  appear  at  the  first  view  to  have 
less  to  fear  from  the  causes  of  aneurism  ;  but  since  they  are  there  obliged  to 
follow  all  the  great  movements  of  the  frame  without  possessing  the  same 
freedom  of  motion,  as  in  the  abdomen  for  example,  and  since  the  elongations 
and  stretchings  of  every  kind  to  which  they  are  there  subjected  expose  them 
to  frequent  rupture,  we  have  no  difliculty  in  conceiving  how  they  should 
become  on  the  contrary  so  frequently  diseased — how  the  ham,  the  groin,  the 
bend  of  the  elbow,  and  the  armpit,  should  present  so  many  instances  of  spon- 
taneous aneurism,  while  they  so  rarely  occur  in  the  leg,  the  thigh,  the  arm  or 
the  fore-arm. 

6.  The  arteries  receive  their  nerves  only  from  the  plexus  of  the  great 
sympathetic,  and  these,  like  the  vessels,  are  never  traced  except  in  the  cellular 
tunic.  On  the  outside  however,  they  are  generally  accompanied  by  nerves 
of  the  cerebro-spinal  system.  While  we  are  on  this  subject,  it  may  be  well 
to  mention  the  law  imagined  by  M.  Foulhoux :  that  with  arteries  of  any 
considerable  size  in  the  superior  division  of  the  body,  the  collateral  nerve 
is  always  placed  on  the  outside,  that  is,  on  the  side  most  remote  from  the  axis 
of  the  part,  while  on  the  inferior  limbs  the  reverse  generally  obtains. 


SECTION   II. 

Spent aneotis  Cure, 

Aneurism  is  always  a  dangerous  disease.  Left  to  itself,  it  seldom  stops 
short  of  the  destruction  of  its  subject.  The  parieties  of  the  cyst  become 
more  thin  as  it  expands,  or  gangrene  by  degrees;  the  blood  and  clots 
contained  in  the  tumor  escape,  and  a  profuse  hemorrhage  ensues,  which  ceases 
only  with  life.  It  is  yet  true,  that  with  some  persons  such  a  termination 
may  be  a  long  time  deferred ;  that  patients  have  carried  for  many  years,  even 


S8  KEW   ELEMENTS  OF 

for  twenty  years,  as  in  one  case  reported  by  Saviard,  one,  or  even  several 
aneurisms,  without  beinc  seriously  incommoded. 

But  it  must  not  be  understood  that  nature  never  succeeds  in  overcoming 
aneurism ;  on  the  contrary,  authors  relate  a  considerable  number  of  spon- 
taneous cures  of  this  disease. 

M.  A.  Scverin  has  seen  gangrene  attack  the  whole  of  an  inguinal  aneu- 
rism, and  the  patient  recover.  Lancissi  cites  an  observation  of  an 
aneurism  of  the  thigh,  which,  after  having  acquired  a  considerable  volume, 
gradually  diminished,  and  at  last  entirely  disappeared.  Reinig  published, 
in  1741,  an  observation  of  a  traumatic  aneurism  of  the  femoral,  which  healed 
without  operation  or  gangrene.  Guattani,  Paoli,  Moinichen,  Clarck,  and 
Albert,  each  report  an  example  of  aaemism  terminating  in  gangrene,  and 
spontaneously  cured.  In  the  dead  body  of  a  young  woman,  Mr.  Freer,  of 
Birmingham,  discovered  a  tumor  about  the  size  of  a  small  apple,  entirely 
filled  with  solid  layers,  and  which  had  formerly  communicated  with  the 
interior  of  the  aorta.  Mr.  Marjolin  speaks  of  an  aneurism  of  the  femoral 
artery,  which  resulted  in  a  large  abscess,  and  afterwards  healed.  But 
observations  of  this  kind  are  so  familiar  at  the  present  day,  that  it  will  suffice 
to  refer  to  them  when  treating  upon  each  particular  artery. 

In  order  to  attain  this  happy  result,  nature  employs  different  processes.  1st. 
The  entire  aneurismal  bag  may  be  attacked  with  gangrene ;  the  fluid  which  it 
contains  is  decomposed,  the  blood  coagulates  above  and  below  the  perforation 
in  the  artery,  and  sometimes  becomes  solid  enough  to  completely  interrupt 
the  circulation  in  this  point,  and  to  permit  the  tumor  to  open  and  empty  itself 
without  danger.  The  wound  whick  results  is  cleansed,  suppuration  is 
established,  and  a  cicatrix  is  formed  without  the  occurrence  of  the  slightest 
hemorrhage. 

2.  Chronic  inflammation  may  affect  the  partitions  of  the  cyst,  and  the 
surrounding  laminae  may  extend  itself  to  the  arterial  trunk,  form  an  actual 
abscess,  occasion  an  effusion  of  coagulable  lymph  above  and  below  the  point 
of  the  artery  which  communicates  with  the  aneurism,  and  produce  there 
adhesions  sufficiently  firm  to  resist  the  impulse  of  the  blood,  so  that  the 
purulent  collection  will  be  enabled  to  open  and  to  discharge  itself  without 
involving  greater  danger  than  any  other  abscess. 

3.  The  tumor,  when  it  is  supported  by  muscles,  by  aponeurotic  expansions, 
or  by  dense  laminae  of  cellular  tissue,  is  sometimes  filled  up  with  successive 
and  concentric  layers  of  fibrin,  and  acquires  sufficient  size  ana  firmness  to  react 
by  its  superior  part  against  the  arterial  trunk  from  which  it  arose,  so  as  to 
obliterate  it,  if  it  bears  it  against  any  solid  point,  and  thus  to  suspend  the 
circulation  through  this  part  of  the  artery.  Then  all  the  blood  contained  in 
theaneurismal  cyst,  coagulates ;  its  more  fluid  part  is  absorbed  ;  the  molecular 
action  diminishes  by  degrees  the  mass  of  the  more  solid  elements,  and  the  cure 
of  the  aneurism  is  eff'ected. 

4th.  In  other  cases  of  much  less  frequent  occurrence,  the  different  concrete 
layers  which  successively  line  the  interior  of  the  cyst  at  last  entirely  fill  it 
up,  and  even  form  in  the  opening  in  the  side  of  the  artery,  and  acquire  such 
a  consistence  that  the  blood  cannot  displace  them.  They  then  increase  in 
thickness,  approachingby  degrees  the  axis  of  the  vessel,  until  at  last  they  close  it 
entirely,  and  thus  put  an  end  to  the  circulation  through  that  part. 

5th.  Finally,  in  the  other  cases  still  more  rare,  these  concretions,  after 
having  completely  filled  the  sac,  dispose  themselves  in  such  a  manner  as  to 
close  exactly  the  lateral  opening  of  the  artery,  which  preserves  its  calibre 
without  preventing  the  resolution  of  the  aneurism.    It  was  so  in  the  case 


OPERATIVE   SURGERY.  29 

spoken  of  by  Mr.  Freer.  Sir  A.  Cooper  has  met  with  a  disposition  still  more 
remarkable.  The  femoral  artery,  says  he,  had  been  the  seat  of  a  true  aneurism, 
the  interior  of  which,  lined  with  very  firm  fibrinous  layers,  preserved  in  its 
centre  a  cylindrical  canal  having  the  same  dimensions  as  the  remainder  of 
the  artery.  This  is  however,  a  disposition  which  appears  to  have  been  observed 
by  Guattani,  and  of  which  Roe,  surgeon  in  the  navy,  also  thinks  he  had  seen 
an  instance  on  the  iliac  artery  ;  but  is  it  certain  that  a  true  aneurism  existed 
there  ? 

While  aneurism  was  thought  to  be  most  commonly  formed  by  the  simulta- 
neous dilatation  of  all  the  tunics  of  the  artery,  a  hope  had  been  indulged  of 
curing  it  by  maintaining  the  calibre  of  the  vessel  in  its  natural  state.  It  was 
thought  that  by  skillful  management  the  aneurismal  sac  might  be  forced  to  con- 
tract upon  itself  to  resume  by  degrees  the  place  which  it  had  occupied  before,  and 
to  restore  to  the  artery  its  primitive  calibre,  and  all  the  attributes  of  the  normal 
state.  Scarpa  has  endeavored,  on  the  contrary,  to  establish  it  as  an  axiom,  that 
the  radical  cure  of  aneurism  cannot  take  place,  whatever  may  be  its  situation, 
unless  the  corroded,  lacerated,  or  wounded  artery,  be  to  a  certain  extent  above 
and  below  the  place  of  its  morbid  change  converted  into  a  solid  and  ligament- 
ous substance,  whether  this  process  be  effected  by  nature  or  by  art.  Although 
such  a  proposition  may  be  generally  true,  it  is  yet  liable  to  some  exceptions, 
even  if  there  were  only  the  observations  of  Messrs.  Cooper  and  Freer,  which  have 
just  been  quoted,  and  some  others  which  may  be  found  in  the  works  of  M.  Hodg- 
son, to  oppose  its  universal  acceptation.  Scarpa  himself  relates  a  fact  which 
contradicts  his  own  assertion.  A  patient  attended  by  Monteggia,  died  twenty 
months  after  having  had  the  humeral  artery  pierced  by  the  point  of  a  lancet. 
The  aneurism  had  been  for  a  long  time  healed ;  the  artery  had  preserved  its 
calibre,whileinthe  interior  of  this  vessel  a  cicatrix  was  discovered,  supported 
on  the  outside  by  a  small  clot,  blackish  and  very  hard,  corresponding  to  the 
original  wound.  Observations  more  or  less  analogous  have  been  recorded  by 
Saviard,  Petit,  Foubert,  and  others.  Yet  it  would  be  very  wrong  to  count 
upon  a  termination  like  this  ;  it  is  too  rare  to  permit  us  to  endeavor  of  choice 
to  obtain  it.  It  is  but  an  exception  which  does  not  impair  the  correctness  of 
tlie  principle  of  Scarpa. 


SECTION  ni. 

Curative  Methods. 

The  aim  of  surgery,  in  the  treatment  of  aneurism,  should  be  to  effect  the 
most  surely,  the  most  promptly,  and  with  the  least  pain  possible,  tlie  obliteration 
of  the  affected  artery. 

In  order  to  attain  this  end,  different  methods  have  been  tried. 

1st.  Internal  means,  and  regimen. 

2d.  Topical  applications. 

Sd.  Mediate  compression. 

4th.  Cautery  ;  absorbents  and  immediate  compression. 

5th.  The  ligature,  suture,  fraying,  acupuncture,  and  torsion. 

Art,  1. — Method  of  Valsalva, 

Valsalva  and  Albertini,  while  yet  students  of  medicine,  resolved  to  treat  tht 
first  subject  that  they  might  encounter  afiiicted  with  aneurism,  by  biteding 


so  NEW    ELEMENTS   OF 

and  a  weakening  regimen.  This  is  their  manner  of  proceeding.  The  patient, 
after  being  bled  once  or  twice,  is  confined  to  his  bed  for  forty  days,  and  allowed 
during  that  time  barely  sufficient  aliment  for  the  support  of  life.  His  allow- 
ance of  nourishment  is  to  be  gradually  increased,  after  the  weakness  induced 
hj  this  treatment  has  almost  disabled  him  from  raising  his  arms  or  turning 
himself  in  bed,  Hippocrates  had  before  said,  that  in  case  of  hemorrhage  of  the 
lungs  the  best  method  of  treatment  is  to  bleed  the  patient  freely  and  frequently, 
until  he  is  almost  drained  of  blood,  and  to  reduce  him  by  diet  to  a  state  of  ex- 
treme leanness.  Lancisi,  Guattani,  Corvisart,  Pelletan,  Hodgson,  Sabatier, 
Boyer,  Yatmann  and  others,  have  obtained  from  this  treatment,  some  advan- 
tageous results,  and  have  even  effected  cures,  if  the  annals  of  Hecker,  for  1828, 
are  to  be  believed.  Yet  it  must  be  confessed  that  there  is  a  difficulty  in  believing 
in  its  efficacy.  There  is  no  doubt  that,  by  repealed  and  frequent  bleedings  and 
a  low  diet,  the  impulsive  force  of  the  heart  and  the  throbbings  of  the  aneurismal 
tumor  may  be  reduced,  and  the  volume  of  this  tumor  may  be,  in  the  greater 
number  ot  cases,  diminished  ;  but  is  it  not  to  be  feared,  that  in  weakening  the 
patient,  we  majr  increase  the  fluidity  of  the  blood,  and  that,  so  far  from  favor- 
ing the  concretion  and  solidification  of  the  aneurism,  and  the  obliteration  of 
the  artery,  we  may  render  these  results  more  difficult  to  obtain.  When  it  is 
recollected  with  what  facility  the  least  emotion,  the  slightest  movement  produces 
tumultuous  palpitations  of  the  heart,  and  that,  by  thus  reducing  the  patient  to 
anemia  we  render  him  incapable  of  supporting  the  most  trifling  operation, 
and  that  the  slightest  indispositon  may  then  be  fatal;  when  it  is  further 
remarked,  that  up  to  the  present  time  the  cures  obtained  through  the  method 
of  Valsalva  are  but  very  limited  in  number,  if  those  alone  are  counted  which 
belong  to  it  exclusively,  may  we  not  be  permitted  to  contest  its  importance  ? 
The  opinion  which  I  have  here  advanced,  is  also  very  much  in  accordance 
with  that  of  M.  Dupuytren,  and  may  be  found  in  several  theses  defended 
before  the  faculty  of  Paris  within  a  few  years  past. 

Nevertheless,  blood-letting  and  an  enfeebling  regimen  should  not  be 
rejected  in  the  cure  of  aneurism.  When  the  disease  is  seated  in  the  aorta 
beyond  the  reach  of  operation,  it  is  then  prudent  to  have  recourse  to  them, 
and  to  join  with  them  the  preparations  of  digitalis,  so  much  extolled  by 
Yatmann,  Brooke,  and  other  English  surgeons.  Some  facts  reported  by 
Pelletan,  Sabatier,  Roux,  and  others,  induce  us  to  believe  that  this  compound 
treatment  is  not  entirely  without  efficacy,  and  should  not  be  rejected  when 
nothing  better  can  be  attempted.  The  reduction  of  the  force  and  frequency 
of  the  circulation,  which  is  usually  effected  by  the  preparations  of  digitalis, 
together  with  a  sensible  but  moderate  diminution  of  the  volume  of  the  blood, 
"Will,  it  is  to  be  hoped,  permit  the  fluid  contents  of  the  aneurism  to  coagulate 
and  the  whole  tumor  to  become  hard,  particularly  if  the  orifice  by  which  it 
communicates  with  the  artery  be  irregular  and  small.  We  may  conceive 
also  how  such  a  tumor,  resting  upon  an  artery,  might  cause  its  obliteration; 
because  the  pressure  which  it  exerts,  although  insufficient  in  the  natural  state, 
had  then  become  strong  enough  to  resist  the  diminished  impulse  of  the  heart. 

Art.  2. — Refrigerants  and  Styptics* 

Almost  all  the  older  authors  profess  to  have  cured  aneurisms  by  the  use 
of  compresses  steeped  in  astringent  liquids,  or  formed  of  astringent  substances, 
of  various  plasters,  of  little  bags  filled  with  tan,  of  decoctions  of  bistort,  oak, 
and  willow  bark,  walnut  leaves,  of  camphorated  spirits,  vinegar,  or  hot  wine. 
They  thought  in  operating  in  this  manner  to  force  the  artery  to  contract  upon 


OPEKATIVE   SURGERY.  3f 

itself.  Others  employed  cold  applications.  T.  Bartholin,  for  example,  is  said 
to  have  cured  an  aneurism  of  the  arm  by  the  lepeated  application  of  snow. 
But  we  are  indebted  to  Mr.  Guerin  of  Bordeaux,  for  the  knowledge  of  the 
importance  of  topical  refrigerants  in  such  cases.  In  1790,  a  carman  was 
admitted  into  the  hospital  of  St.  Andre,  afflicted  with  an  aneurismal  tumor, 
which  finally  occupied  all  the  supra-clavicular  region,  and  a  part  of  the  neck. 
Several  blood-lettings,  a  ptisan  with  the  eoAi  de  Rabel,  and  the  use  of  com- 
presses steeped  in  oxycrate,  placed  over  the  tumor,  succeeded  in  the  space  of 
a  few  months  in  effecting  a  cure.  In  1795,  M.  Treyran  treated  an  enormous 
aneurism  of  the  femoral  artery  by  the  same  means  and  with  the  same  success. 
M.  Guerin,  jun.has  since  reported  several  similar  examples.  In  1799,  Sabatier 
put  an  invalid,  affected  with  aneurism  of  the  ham,  upon  soup  and  boillou  for 
his  whole  nourishment,  prescribed  an  acidulated  ptisan,  applied  ice  to  the 
tumor,  and  cured  his  patient  in  the  space  of  four  months.  Pelletan  also  had 
recourse  to  cold  applications,  at  the  same  time  that  he  was  trying  the  method 
of  Valsalva.  Since  then  Mr.  Hodgson,  M.  Larry,  and  others,  have  reported 
fiicts,  which  tell  in  favor  of  the  method  of  Guerin.  It  is  then  a  means  to 
which  we  may  resort,  when  the  more  certain  methods  we  possess  are  not 
applicable,  or  when  the  patients  are  not  willing  to  submit  to  them.  It  may 
be  employed  singly,  or  combined  with  that  ol  Valsalva,  with  the  mediate 
compression,  or  with  the  due  application  of  a  certain  number  of  moxas,  as  it 
appears  to  have  been  practised  many  times  by  M.  Larry  with  advantage. 
There  is  nothing  about  the  action  of  this  remedy  but  what  it  is  very  easy  to 
comprehend.  Under  the  influence  of  such  topical  applications,  the  heat  of 
the  part  is  very  much  diminished  ;  the  circulation  there  becomes  less  active, 
the  blood  which  has  been  effused  loses  its  fluidity,  and  has  a  strong  tendency 
to  coagulate ;  and  if  the  disposition  of  the  parts  and  the  state  of  the  system 
are  favorable  to  such  a  termination,  the  artery  is  closed  and  obliterated,  and 
the  cure  is  complete. 


ARTICLE    KI, 
Compression. 

§  1.  Mediate  Compression, 

Aneurism  of  the  carotid,  and  of  the  subclavian,  have  been  cured  by  Acrel, 
by  means  of  a  gradual  compression  exerted  upon  the  tumor.  Those  of  the 
ham,  the^  thigh,  the  groin,  the  hand,  and  the  elbow,  have  been  treated  with 
success  in  the  same  manner,  by  F.  de  Hilden,  Saviard,  Tnlpin,  Weltin, 
Dehaen,  Leber,  Plenk,  Petit,  Theden,  Guattint,  and  many  others,  so  that  it 
is  not  possible  to  doubt  the  efficacy  of  this  method.  But  it  has  been  used  in 
a  great  variety  of  ways:  sometimes  the  compression  is  only  applied  upon  the 
aneurism,  at  other  times  upon  the  aneurism  and  the  other  parts  of  the  member 
at  the  same  time,  and  again  it  is  applied  either  above  or  below  the  tumor. 

1.  On  the  Tumor,  or  the  affected  point. — Galen  is  one  of  the  first  who  made 
use  of  compression  in  the  treatment  of  aneurisms  ;  by  means  of  plasters  and 
pieces  of  sponge,  confined  by  bandages,  he  perfectly  succeeded  in  a  case  where 
the  artery  had  been  opened  in  the  act  of  blood-letting.  From  the  days  of 
Dionis,  it  has  been  a  common  practice  to  apply  pledgets  of  chewed  paper,  of 
agaric,  or  of  tinder,  confined  by  a  piece  of  money,  and  over  these,  other  masses 
of  the  softer  material  still  larger,  so  as  to  form  a  pyramid,  of  which  the  point 
should  correspond  to  the  opening  of  the  artery,  and  to  confine  the  whole  by 


92  NEW   ELEMENTS  OP 

means  of  appropriate  bandages.  The  Abbe  Boudelot  records,  that  he  was 
himself  cured  of  a  false  consecutive  aneurism,  bj  carrying  for  the  space  of 
one  year  a  little  cushion  firmly  pressed  upon  the  tumor. 

Since  that  period,  and  especially  in  the  first  half  of  the  last  century,  the 
improvement  of  this  species  of  compression  has  been  an  object  of  much 
attention.  Arnaud,  Heister,  Ravaton,  Leber,  and  others,  have  proposed 
different  bandages,  with  the  intention  of  rendering  it  more  easy  and  more 
secure.  Each  endeavored  to  modify  the  compressor  of  Scultet,  or  the  tourni- 
quet of  J.  L.  Petit,  and  each  imagined  that  he  had  found  the  means  of  curing 
aneurisms  without  an  operation.  Foubert  constructed  a  steel  ring  of  an  oval 
form,  having  on  one  of  its  longer  curves  a  metallic  plate  furnished  with  a 
cushion,  and  pierced  on  the  opposite  side  by  a  screw  bearing  upon  its  extre- 
mity a  second  cushion  like  the  first.  This  ring,  when  applied,  was  intended 
to  press  only  upon  the  diseased  point  and  the  part  of  the  limb  diametrically 
opposite.  This  machine,  although  more  ingenious  than  many  others,  and  far 
superior  to  those  plates  of  lead,  of  silver,  or  of  iron,  with  or  without  cushions, 
or  sponges,  to  be  confined  upon  the  aneurisms  by  the  aid  of  ribbons,  straps, 
or  bandages,  has  yet  the  serious  inconvenience  of  being  easily  deranged,  of 
not  establishing  the  compression  except  upon  a  diseased  part  of  the  artery  and 
that  of  slight  extent,  of  producing  engorgement  in  the  parts  below,  and  of 
being  insupportable  except  by  a  small  proportion  of  subjects. 

2d.  Compression  on  the  whole  extent  of  the  limb. — The  compression  of  the 
whole  length  of  the  aftected  part  should  then  be  deemed  preferable  to  local 
compression.  Gengha  practised  it  in  the  following  manner: — I  apply,  says 
he,  to  each  finger  a  little  strip  in  the  form  of  an  expulsive  bandage,  then  I 
envelope  in  the  same  way  the  hand  and  the  forearm  almost  to  the  wound  ;  I 
then  place  on  this  latter  a  large  compress  of  fine  linen  soaked  in  a  mixture  of 
terra  sigillata,  bol  ammoniac,  dragons'  blood,  hematite,  white  of  egg,  and 
plantain  ;  I  apply  over  this  a  thick  plate  of  lead,  some  compresses,  and  three 
or  four  turns  with  a  bandage  passing  above  the  elbow ;  then  I  fix  with  the 
same  bandage  over  the  passage  of  the  artery,  on  the  internal  face  of  the  arm, 
a  wooden  cylinder  enveloped  in  linen,  after  the  manner  of  a  splint ;  I  then 
return  my  bandage  over  the  wound  so  as  to  confine  it  by  several  turns,  after 
which  I  moisten  the  bandage  with  some  astringent  liquid,  and  put  my  patient 
on  a  very  spare  and  cooling  regimen. 

This  is  what  is  generally  called  the  bandage  of  Theden,  who  previously 
applied  to  the  tumor  compresses  steeped  in  eau  vulneraire.  In  using  this 
method  the  infiltration  of  the  part  is  not  so  much  to  be  apprehended  ;  the 
pain  is  less  lively,  and  the  compression  is  more  easily  to  be  supported ;  but, 
on  the  other  hand,  the  circulation  by  the  collateral  or  supplementary  arteries 
is  by  the  same  means  rendered  much  more  difficult  than  by  the  other  method ; 
the  more  so  in  proportion  as  it  is  necessary  to  compress  with  greater  force. 

3d.  Compression  below  the  Tumor. — According  to  M.  Caillot,  who  said  that 
be  received  it  from  M.Boyer,  a  military  surgeon,  M.  Vernet,  conceived  the 
idea  of  curing  aneurism  upon  the  limbs  by  a  compression  applied  upon  the 
course  of  the  artery  at  a  point  situated  below  the  tumor.  He  tried  this 
method  on  a  patient  affected  with  inguinal  aneurism,  but  the  pulsation  increased 
with  such  force  in  the  cyst,  that  he  was  soon  forced  to  relinquish  his  design. 
This  method  has  been  generally  blamed,  even  by  those  who  have  adopted  the 
idea  of  Brasdor  on  the  subject  of  ligature ;  but  yet  it  does  not  seem  worthy 
of  entire  rejection.  If,  for  example,  it  were  necessary  to  treat  an  aneurism, 
above  which  it  would  be  impossible,  or  at  least,  highly  dangerous  to  apply 
compression  or  ligature ;  if  on  the  other  hand,  no  important  branch  were 


OPERATIVE    SURGERY.  33 

furnished  between  the  cardiac  extremity  and  the  free  part  of  the  tumor,  it  is 
by  no  means  certain  that,  by  compressing  the  artery  on  tins  latter  point,  you 
will  not  succeed  in  suspending  the  circulation  in  the  aneurism,  in  occasioning 
the  formation  of  a  solid  coagulura  in  its  cavity,  and,  in  short,  of  producing  the 
obliteration  of  the  arterial  canal,  and  a  perfect  cure  of  the  disease. 

Compression  above  the  Tumor. — Finding  that  the  bandage  of  Theden  and 
that  ol  Guattani,  and  all  other  instruments  for  effecting  partial  compression 
tend  to  impede  the  circulation  in  the  limb,  or  else  to  cause  the  rupture  of  the 
aneurism   if  it  do  not  yield   to   their   application,  surgeons  have  happily 
thought  to  compress  the  diseased  artery  at  the  point  where  it  is  most  super- 
ficially situated,  between  the  tumor  and  the  heart.     Mr.  Freer  has  strongly 
recommended  for  this  purpose  the  bandage  of  Sennefio.     That  practitioner 
first   encompassed  the  whole  extent   of  the  limb  with  a  rolled  bandage, 
moderately  tight,  and  placed  a  pad  some  inches  above  the  tumor.     A  plate 
was  then  applied  to  the  opposite  surface  of  the  part,  which  he  encircled  with 
the  tourniquet  so  as  to  compress  the  artery  upon  a  single  point  with  a  few 
turns  of  the  screw^     After  some  hours,  says  Mr.  Freer,  the  limb  becomes 
oedematous  and  swells :  at  that  time  the  tourniquet  may  be  removed,  and  a 
pad  with  a  bandage  tolerably  tight  is  all  that  is  further  necessary.     This 
bandage,  which  is  a  combination  of  those  of  Theden  and  of  Foubert,  appears 
to  me  to  afford  some  probability  of  success.     M.  Dubois  effected  the  cure  of 
an  aneurism  of  the  thigh,  by  making  use  of  it  as  a  species  of  spring,  con- 
structed on  the  principles  of  the  tourniquet  of  Petit,  and  acting  only  on  two 
very  circumscribed  points  of  the  limb.     M.  Albert,  of  Bremen,  has  derived 
the  same  advantage  from  a  bandage,  which  he  denominates  the  '' inguinal 
compressors'^  which  is  composed  of  a  little  cushion  designed  to  be  applied 
against  the  pubis,  over  the  passage  of  the  femoral  artery,  and  of  two  straps 
which  embrace  the  whole  circumference  of  the  pelvis  and  the  root  of  one  of 
the  thighs.     M.  Verdier  has  arrived  at   the  same   result,   by  means   of  a 
bandage  which  has  some  analogy  to  the  herniary  bandage  of  Camper.     M. 
Dupuytren  has  constructed  another,  composed  of  a  semicircle  of  solid  steel, 
which  is  surmounted  at  one  end  by  a  large,  thick,  and  concave  cushion,  to  be 
applied  to  the  surface  of  the  limb  opposite  the  artery  ;  on  the  other  extremity 
is  a  plate  of  iron  which  supports,  with  the  aid  of  two  stanchions  and  a  screw, 
a  rounded  pad,  which  may  be  brought  nearer  to  the  first  cushion,  or  removed 
farther  from  it,  and  which  is  to  be  applied  over  the  artery.     It  appears  that 
with  a  species  of  dog-collar,  M.Viricel,  in  the  hospitals  at  Lyons,  met  with 
the  most  decided  success  by  compressing  the  artery  above  the  tumor.     M. 
Morel,  who  relates  these  cases  in  his  thesis,  advances  the  idea  that  success 
would  be  rendered  more  certain  if  the  compression  were  exerted  at  the  same 
time  on  several  points  of  the  limb.     Lastly,  Mr.  Blizard  and  Sir  A.  Cooper 
have  described  another  instrument,  not  less  ingenious  than  those  which  have 
been  mentioned.     A  long  piece  of  steel  is  first  fixed  upon  the  outer  face  of 
the  knee,  and  of  the  great  trochanter ;  from  the  centre  of  this  piece,  another 
piece  advance's  in  a  semicircle  towards  the  femoral  artery,  and  carries  on  its 
extremity  a  plate  provided  with  a  cushion  capable  of  being  moved  by  a  screw, 
and  of  compressing  the  artery  to  the  interruption  of  the  throbbings  of  the 
aneurism,  without  impeding  the  circulation  in  the  smaller  vessels.     Com- 
pression employed  in  this  manner,  may,  no  doubt,  succeed,  and  ought  even 
to  be  practised  in  some  cases ;  such  as  aneurisms  in  the  neck  of  the  subcla- 
vian artery,  or  of  the  superior  part  of  the  femoral,  if  any  circumstance  should 
occur  to  prevent  the  use  of  the  ligature ;  in  other  cases  it  would  rarely  be 
found  beneficial.    The  patient  spoken  of  by  Sir  A.  Cooper,  was  only  able  to 
5 


S4  NEW   ELEMENTS   OF 

bear  it  for  a  few  hours.  With  one  of  those  under  the  care  of  M.  Dupuytren 
it  was  necessary  to  apply  the  bandage  successively  upon  several  dift'erent 
parts  of  the  artery,  ana  very  shortly  to  relinquish  entirely  the  employment  of 
this  mode  of  compression.  M.  Roux  relates  a  similar  case ;  and  it  required 
all  the  fortitude  and  resignation  of  the  patient  mentioned  by  M.  Verdier  to 
prevent  him  from  throwing  off  the  apparatus  several  days  after  the  experi- 
ment had  been  begun.  It  may,  however,  without  hesitation  be  affirmed,  that 
compression  will  cure  a  certain  number  of  aneurisms  in  whatever  way  it  may 
be  applied,  although  the  method  of  Guattani,  or  that  of  Theden,  appears 
preferable  to  all  the  others. 

To  draw  from  compression  all  the  advantage  possible,  it  is  necessary  to 
associate  with  it  a  regimen  somewhat  severe,  uninterrupted  repose,  and  the 
employment  of  refrigerants  or  astringents ;  not  forgetting,  however,  that  it 
has  succeeded  without  these  adjuncts,  even  with  patients  who  have  not 
refrained  from  the  most  fatiguing  exertions,  as  we  see  in  the  man  whose  case 
is  recorded  by  Lassus,  who  after  having  applied  a  bag  filled  with  cinders, 
and  fixed  by  tour  long  linen  bandages  upon  an  aneurism  of  the  thigh,  thought 
that  he  should  facilitate  his  cure  by  taking  every  day  a  hard  walk,  and  using 
other  active  exercise  to  which  he  had  been  unaccustomed,  and  who  yet  suc- 
ceeded, at  the  end  of  eight  months,  in  getting  rid  of  his  disease.  If  compression 
had  not  been  superseded  of  late  years  by  the  ligature ;  if  it  did  not  act  at 
tlie  same  time  upon  the  veins,  and  sometimes  also  upon  the  nerves ;  if  it 
were  true  that  it  had  at  least  the  effect  of  preparing  the  way  for  the  successful 
use  of  the  ligature,  by  forcing  the  collateral  arteries  to  dilate,  and  that  it  was 
never  dangerous ;  it  certainly  would  be  wrong  to  neglect  it,  or  not  to  have 
recourse  to  it  in  particular  cases.  But  the  use  of  the  ligature  has  now  become 
so  easy  and  simple,  that  it  is  really  almost  impossible  to  accord  to  other 
methods  any  considerable  degree  of  estimation. 

Down  to  the  time  of  Scarpa  compression  was  recommended  with  ardor, 
because  it  seemed  capable  of  causing  the  disappearance  of  the  aneurism 
without  obliterating  the  artery.  J.  L.  Petit  ventured  to  set  himself  up  in  the 
academy  of  sciences  the  champion  of  this  hypothesis.  According  to  him, 
when  an  artery  is  laterally  opened,  if  it  is  compressed  the  blood  diffused 
among  the  surrounding  tissues  coagulates  and  hardens ;  a  portion  of  the  clot 
stops  in  the  wound  of  the  artery,  and  there  contracts  such  adhesions  that  it  is 
impossible  afterwards  to  dislodge  it,  although  the  artery  itself  preserve  its 
calibre  and  the  other  characteristics  of  its  natural  state.  '*  When  the  blood 
is  stopped,"  says  Foubert,  "  the  wound  upon  which  a  sufficient  compression 
has  been  made,  closes;  the  skin,  the  fat,  and  the  aponeurosis,  cicatrize; 
while  the  incision  of  the  artery  does  not  reunite  immediately,  but  leaves  a  round 
opening  in  which  rests  a  small  clot  of  blood.  The  compression,  continued 
long  enough  to  secure  the  induration  of  the  clot,  radically  cures  the  disease ; 
but  if  the  arm  is  permitted  to  be  moved  before  the  clot  has  acquired  a  proper 
degree  of  solidity  to  cement  the  adhesion  of  the  tissues,  it  escapes  from  the  open- 
ing, the  blood  insinuates  itself  around  it,  and  removes  it  from  the  place  which  it 
has  occupied."  Examples  have  been  given  in  support  of  this  theory  by  Petit, 
Morand,  Foubert,  and  some  others.  It  has  since,  however,  been  established 
as  a  general  truth,  that  the  cures  thus  obtained  were  not  radical ;  that  the 
clot  of  blood,  the  cork  or  nail,  as  it  was  called  by  Petit,  which  fills  up  the 
opening  in  the  arterj,  never  identifies  itself  with  the  tissue  of  the  vessel,  but 
that  sooner  or  later  it  is  expelled,  and  a  new  aneurism  makes  its  appearance. 
So  in  the  experience  of  Saviard,  a  patient  who  had  apparently  been  cured  of 
an  aneurism  in  the  arm,  saw  the  tumor  reappear  after  a  lapse  of  fifteen  years, 


OPERATIVE   SURGERY. 


in  consequence  of  an  effort:  it  is  useless,  then,  to  attempt  the  cure  of 
aneurism  by  compression,  otherwise  than  by  the  obliteration  of  the  artery. 

This  point  established,  it  only  remains  to  determine  which  among  the 
methods  that  have  been  invented  is  the  most  likely  to  produce  the  desired 
effect.  Scarpa  thinks  it  absolutely  necessary  that  the  two  opposite  sides  of 
the  canal  should  be  placed  and  maintained  in  contact  for  a  certain  time,  and 
that  compression  upon  the  tumor  produces  this  effect  with  difficulty  ;  conse- 
quently, he  recommends  that  the  artery  should  be  acted  upon  above  the 
tumor,  excepting  however  recent  traumatic  aneurisms.  Experience  is  not 
in  accordance  with  the  opinion  of  Scarpa.  Guattani  cured  four  aneurisms 
out  of  fifteen,  which  he  treated  by  applying  the  bandage  upon  the  tumor 
itself.  Flajani  obtained  the  same  proportion  of  success  under  the  same 
circumstances,  and  every  day  announces  similar  cures. 

The  aneurismal  varix,  first  observed  by  Sennert,  and  afterwards  so  well 
described  by  Guattani  and  W.  Hunter,  is  better  suited  than  any  other 
species  of  aneurism  to  the  compressive  bandage,  and  frequently  yields  to  its 
application.  The  two  Brambilla,  Guattani,  and  Monteggia,  relate  each  an 
instance.  It  is  a  palliative  at  least,  even  if  it  do  not  produce  a  radical  cure. 
An  elastic  sleeve,  even  a  simple  laced  stocking,  will  arrest  the  progress  of  the 
disease,  and  enable  the  limb  to  perform  its  usual  functions  without  causing 
the  sliglitest  danger  to  the  patient.  A  lady  who  had  been  thus  treated  by 
Scarpa,  wrote  to  him  at  the  expiration  of  fourteen  years  that  she  did  not 
experience  the  least  inconvenience  in  the  affected  arm,  except  a  slight  occa- 
sional numbness. 

If  Cleghorn,  instead  of  directing  his  patient  to  change  his  profession  of 
shoemaker  for  that  of  hair  dresser,  in  order  that  he  might  hold  his  arms  in 
elevated  position,  had  employed  compression,  he  most  assuredly  would  have 
derived  results  equally  advantageous.  For  the  rest,  since  after  the  expiration 
of  thirty -five  years  the  patient  spoken  of  by  Hunter  had  not  become  worse, 
since  in  three  different  cases  Pott  did  not  feel  obliged  to  operate,  and 
B.  Bell,  as  well  as  Bertrandi  and  many  others  have  made  a  similar  observ- 
ation, prudence  and  humanity  require,  where  there  is  no  special  counter 
indication,  that  before  resorting  to  the  ligature  we  should  make  trial  of  simple 
compression  in  cases  of  aneurismal  varix. 

If  it  is  intended  only  to  confine  the  parts  within  their  natural  limits,  the  laced 
stocking,  or  the  simple  rolled  bandage  of  Theden  will  be  found  sufficient; 
but  if  a  radical  cure  is  to  be  attempted,  this  treatment  demands  additional 
precautions,  the  same  in  fact  as  for  the  other  sorts  of  aneurism,  that  is  to 
say,  that  besides  the  rolled  bandage,  exactly  applied  from  the  free  extremity 
to  the  root  of  the  member,  where  it  is  finisned  with  one  or  two  turns  spica- 
wise  round  the  trunk,  it  is  necessary  previously  to  place  upon  the  tumor,  if 
there  be  one,  pieces  of  lint,  sponge,  or  graduated  compresses,  steeped  in  cold 
and  discutient  liquids;  to  fix  a  pad  upon  the  passage  of  the  artery  between 
the  wound  and  the  heart,  and  to  add  above,  like  Sennefio,  a  compressor  like 
that  of  Foubert,  or  of  M.  Dupujtren. 

Whenever  the  affected  arteries  rest  upon  bones,  or  other  solid  parts  capable 
of  affording  a  sufficient  counter-resistance,  and  where  they  are  only  removed 
from  the  surface  of  the  body  by  the  common  integuments,  the  aponeurosis,  or 
<:ellular  tissue,  compression  offers  every  possible  advantage,  and  ought  to  be 
frequently  employed. 


S6  NEW    ELEMENTS    OF 

§  2.  Immediate  Compression, 

Surgeons  have  frequently  found  themselves  unable  to  tie  an  artery  which 
they  have  opened  either  by  accident  or  design  ;  they  have  then  been  obliged, 
in  order  to  preserve  the  life  of  the  patient,  to  fill  up  the  wound  and  compress 
the  vessel,  applying  directly  to  it  the  substances  so  much  extolled  by  Trew, 
Teichmeyer,  &c.  This  sort  of  compression,  which  is  much  less  frequently 
used  than  mediate  compression,  is  also  in  lact  much  less  advantageous,  and 
ought  to  be  completely  excluded  from  the  practice  of  the  present  day.  Guat- 
tani  having  occasion  to  treat  a  very  voluminous  aneurism  of  the  groin,  caused 
it  to  be  opened  by  Maximini,  with  the  intention  of  applying  im?,.odiately  upon 
the  artery,  at  the  bottom  of  the  sac,  and  against  the  pubis,  graduated 
compresses  firmly  confined  by  a  bandage.  Every  thing  succeeded  according 
to  the  wish  of  the  surgeon  ;  the  dressings  were  removed  at  the  expiration  of 
thirteen  days,  and  the  health  of  the  patient  was  perfectly  re-established. 

A  patient  under  the  care  of  Mayer  was  afflicted  with  an  aneurismal  tumor 
in  the  groin,  as  large  as  the  head  of  an  infant.  That  surgeon,  at  first  believing 
it  to  be  a  hernia,  resolved  upon  exposing  it  for  the  purpose  of  effecting  its 
reduction,  and  did  not  discover  his  error  until  after  he  had  divided  the 
common  integuments  and  the  aponeurosis.  A  great  quantity  of  bloody  matter 
which  had  accumulated  between  the  cyst  and  the  adjacent  parts  was  removed. 
Instead  of  opening  the  tumor,  the  pulsations  of  which  sufliciently  indicated  its 
nature,  Mayer  contented  himself  with  establishing  upon  it  an  exact  pressure 
which  he  afterward  renewed  with  the  greatest  possible  care.  The  patient 
recovered. 

Desault,  in  a  case  nearly  similar,  embraced  the  upper  portion  of  the  artery 
with  two  flat  pieces  of  wood,  connected  by  a  piece  of  thread,  in  the  form  of 
pincers,  and  was  thus  enabled  to  pass  the  ligature;  but  this  conduct,  although 
pardonable  at  that  time,  would  be  justly  censured  at  the  present  day.  If  the 
aneurism  is  so  much  elevated  as  not  to  permit  the  exposure  or  compression  of 
the  femoral  artery  between  the  tumor  and  Poupart's  ligament,  a  ligature  is 
applied  to  the  iliac  artery,  without  exposure  to  those  dangerous  consequences 
which  Guattani  and  Desault  escaped  only  by  a  sort  of  miracle.  Sabatier  him- 
self thought  it  necessary  to  use  immediate  compression  for  an  aneurism  in  the 
superior  third  of  the  thigh.  The  patient  was  a  young  man  of  twenty-five. 
Two  tourniquets  were  applied,  the  one  upon  the  hollow  of  the  groin,  and  the 
other  a  little  below.  When  the  tumor  was  opened  and  cleared  of  the  clots  of 
blood,  the  opening  in  the  artery  was  seen  perfectly  round.  Sabatier  passed 
under  this  vessel,  above  and  below  the  aperture,  a  needle  armed  with  thread, 
with  the  intention  of  making  a  ligature  should  it  become  necessary.  A  cushion 
was  placed  upon  the  posterior  part  of  the  tliigh,  opposite  to  the  wound, ^which 
was  filled  with  a  pyramid  formed  of  pieces  of  agaric  and  compresses ;  lint, 
well  sprinkled  with  colophony  was  also  disposed  round  the  pyramid  in  such  a 
manner  as  to  support  it,  and  it  was  kept  in  place  by  compresses  and  an  ordinary 
bandage.  A  few  trifling  hemorrhages  occurred,  but  the  patient  eventually 
recovered,  and  was  able  to  walk  at  the  expiration  of  two  months. 

Notwithstanding  these  happy  results,  obtained  by  surgeons  of  the  highest 
rank,  the  above  mode  of  treatment  ought  to  be  proscribed  from  sound  practice. 
The  only  occasion  to  which  its  use  is  applicable  is,  when  after  having  opened 
an  aneurismal  sac  it  is  impossible  to  discover  the  artery,  a  difficulty  of  which 
Ave  can  scarcely  conceive  the  possibility,  and  which,  besides,  could  now 
occasion  embarrassment  only  in  cases  where  the  malady  approaches  too  near 
to  the  splanchnic  cavities. 


OPERATIVE    SURGERY.  37 

Another  species  of  immediate  compression,  originating  doubtless  from  the 
observation  of  Desault,  consists  in  pressing  the  artery,  whether  previously 
open  or  not,  with  any  appropriate  instrument,  and  holding  it  flat  until  its  sides 
have  become  firmly  united.  Percy  recommended  for  this  purpose,  in  1792, 
a  leaden  plate;  and  afterwards,  in  1810,  a  steel  forceps,  terminating  in  two 
small  plates,  and  furnished  with  a  longitudinal  slit,  to  enable  the  operator,  by 
meams  of  a  button,  to  graduate  at  will  the  pressure  exerted  upon  the  artery. 

In  the  same  year,  M.  Duret,  of  Brest,  constructed  an  instrument  upon  the 
same  principles.  According  to  M.  Roux,  an  instrument  very  nearly  the  same 
as  the  above,  was  invented,  in  1808  or  1809,  by  M.  Levesque,  who  described 
it  in  his  Thesis. 

A  third  compressive  instrument,  invented  by  Assaline,  of  Milan,  formed 
of  two  silver  branches,  joined  like  those  of  the  dressing  forceps,  with  a  spring 
between  the  handles,  resembles  very  much  the  invention  of  M.  Duret. 
Assalini  affirms  that  he  has  cured  several  aneurisms  of  the  ham  and  thigh,  by 
leaving  his  instrument  applied  for  only  three  or  four  days,  or  even  24  hours. 
Other  forceps  and  metallic  instruments  of  diflferent  kinds,  have  been  since 
invented  to  attain  the  same  object,  and  will  receive  due  attention  hereafter. 

Art.  4. — Cautery. 

Two  methods  of  cauterization  have  been  practised  for  the  cure  of  aneurism. 
Some  practitioners,  indeed,  before  the  discovery  of  the  circulation  of  the  blood, 
had  the  temerity  to  apply  caustics  more  or  less  powerful  to  the  aneurismal 
tumors,  and  to  the  skin  which  covered  them.  Others  begun  by  opening  and 
emptying  the  cyst,  and  then  cauterized  the  lacerated  part  of  the  artery  with 
a  red  hot  iron,  or  with  concentrated  acids,  or  by  introducing  into  the  orifice 
troches,  or  plup  of  alum,  or  vitriol.  At  that  time  also,  and  even  since, 
surgeons  have  in  some  cases  contented  themselves  with  filling  up  the  whole 
wound  with  lint  or  oakum,  previously  steeped  in  caustic  liquids.  Such  means 
might  be  tolerated  at  a  time  when  surgery  had  made  but  little  progress,  when 
the  nature  of  aneurisms  was  unknown,  and  when  scarcely  any  one  possessed 
sufficient  anatomical  knowledge  to  dare  to  make  use  of  the  bistoury  ;  now, 
however,  it  is  not  permitted  to  speak  of  such  methods,  excepting  to  proscribe 
them,  and  to  show  at  what  a  distance  modern  surgery  is  from  the  ancient.  . 

It  has  been  recently  recommended  to  thrust  a  needle  into  the  sac  in  such  a 
manner  that  it  should  pass  almost  through  its  cavity,  and  to  attach  to  the 
needle  a  metallic  chain  or  rod,  capable  of  transmitting  to  it  an  electric 
discharge.  I  am  not  acquainted  with  any  case  that  can  be  adduced  in  support 
of  this  recommendation.  I  only  know  that  M.  Pravaz  has  attempted  some- 
thing like  this  by  means  of  cautery,  and  that  it  is  not  unreasonable  to  suppose, 
that  by  means,  of  such  a  contrivance  as  this  we  may  in  some  cases  occasion 
the  coagulation  of  the  blood,  and  possibly  even  a  resolution  of  the  aneurism 

Art.  5. — Ligature. 

As  the  obliteration  of  the  artery  is  indispensable,  or  nearly  indispensable, 
to  the  cure  of  aneurism,  so  the  ligature  is  the  surest  and  best  means  of 
accomplishing  that  object.  This  is  a  truth  which  is  not,  nor  ever  has  been, 
contested.  But  to  apply  a  ligature  upon  an  arterv  is  a  painful  and  sanguinary 
operation  ;  it  is  necessary  to  divide  susceptible  tissues  with  a  cutting  instru- 
ment ;  hence  the  frequent  attempts  to  discover  other  and  milder  means. 


38  ^  NEW    ELEMENTS   OF 

§  1.  Nature  and  Form  of  the  Ligature. 

Until  of  late  surgeons  had  used  ligatures  composed  of  threads  of  linen  or 
hemp.  A  single  thread  was  preferred  for  the  small  arteries,  while  for  the 
large  trunks  several  threads  were  put  together,  and  formed  into  a  sort  of 
cord  by  means  of  wax.  It  appears,  however,  that  the  ancients  made  use  of 
silk.  Guy  de  Chauliac  says  so  positively.  This  was  still  the  custom  when 
Scarpa  and  Jones  subjected  to  the  test  of  reason  and  experiment,  what  had 
before  been  practised  only  by  routine. 

The  first  of  these  authors  established  the  point,  that  in  order  to  obliterate 
the  cavity  of  an  artery  it  is  necessary  to  bring  its  parieties  into  contact 
without  lacerating  them,  and  to  occasion  adhesive  inflammation.  In  accord- 
ance with  these  views,  Scarpa  recommended  the  use  of  two  fiat  ligatures, 
composed  of  six  strands  of  thread  ;  and  further,  that  there  should  be  placed 
between  the  ligature  and  the  artery  a  small  roll  of  cloth,  six  lines  in  length 
and  three  in  thickness  ;  this  roll  is  spoken  of  by  Pare,  Platner  and  Heister,  and 
was  used  by  almost  all  the  Italian  surgeons  of  the  last  century:  also  by  Funchall 
and  Forster.  The  last  substituted  a  small  wooden  cylinder,  a  quarter  of  an 
inch  thick  and  three-quarters  of  an  inch  long,  which  Saviard  mentions  as  being 
in  general  use  in  his  time,  but  which  Mr.  Cline  has  since  replaced  by  a  bit  of 
coi-K.  By  these  means  the  inner  and  middle  tunics  of  the  vessel  are  neither 
bruised  nor  lacerated ;  their  contact  is  perfect  5  they  unite  firmly,  even 
before  the  separation  of  the  two  portions  ot  the  artery  has  been  effected  by 
ulceration  under  the  cord. 

According  to  Dr.  Jones,  the  opinion  of  Scarpa  is  completely^  erroneous ;  it 
is  not  by  the  inflammation  of  their  internal  surface  that  the  arteries  are  closed, 
but  rather  by  the  effusion  of  coagulable  fluid  which  follows  the  rupture  of 
their  inner  coats;  consequently,  instead  of  large  and  flat  ligatures,  with 
rolls  of  linen  or  cylinders  of  any  description,  which  more  or  less  oppose  this 
rupture,  Jones  recommends  the  selection  of  such  ligatures  as  shall  effect  it 
the  most  easily  and  the  most  completely.  Numerous  experiments  were  made 
by  him  upon  dogs  and  horses,  and  all  had  results  conformable  to  his  theory, 
which  speedily  assumed  the  form  of  a  law  with  the  generality  of  English 
surgeons.  To  Mr,  Hodgson  the  justice  of  the  hypothesis  of  Jones  seems  so 
evident,  that  he  cannot  comprehend  how  any  practitioners  dare  still  to  make 
use  of  the  large  ligatures  and  the  little  rolls  of  Scarpa.  And  it  is  not  without 
some  degree  of  bitterness  that  Mr.  Samuel  Cooper  reproaches  the  French 
surgeons  for  being  so  slow  to  adopt  the  practice  recommended  by  Jones,  a 
practice  which  has  induced  several  of  his  countrymen  to  prefer  the  finest 
possible  threads ;  threads  of  silk,  of  that  gummed  silk  which  dentists  and 
anglers  use  ;  in  short,  threads  so  fine  that  when  they  are  cut  near  the  knot,, 
as  was  done  by  Mr.  Lawrence,  there  does  not  remain  the  20th,  or  even  the 
46th  part  of  a  grain  in  the  wound. 

Without  denying  the  importance  of  the  labors  of  Dr.  Jones,  M.  Roux 
continued  and  still  continues  to  use  flat  ligatures,  which  he  generally  ties 
over  a  small  roll  of  gummed  diachylum.  In  support  of  this  practice  may  be 
quoted  that  of  M.  Boyer,  of  Scarpa,  and  even  of  the  older  surgeons  ;  for 
Saviard  speaks  of  the  little  roll  in  his  treatise  on  surgery  as  a  thing  already 
in  common  use.  Mr.  Crampton,  in  Ireland,  has  never  done  otherwise,  and 
has  had  no  occasion  for  regret.  He  has  even  combated  the  doctrines  of 
Jones  with  such  ability  as  to  hinder  them  from  being  universally  received  in 
the  three  kingdoms.  M.  Richreand  endeavored  to  reconcile  these  conflicting 
opinions,  by  remarking  that  a  flat  ligature  becomes  round  in  tying,  and  that 


OPERATIVE    SURGERY.  39 

its  application  really  resulted,  like  that  of  (he  cylindrical  ligature,  in  the 
rupture  of  the  middle  and  internal  coats  of  the  artery,  which  tends  to 
substantiate  the  doctrine  of  the  practitioners  of  Great  Britain.  But  in  the 
meantime  comes  Dr.  Jameson,  of  Baltimore,  in  America,  who  by  new  experi- 
ments, discredits  the  principal  assertions  of  Jones.  It  is  not  true,  says  he, 
that  the  rupture  of  the  fragile  tunics  of  the  artery  is  advantageous  ;  on  the 
contrary,  every  exertion  should  be  made  to  avoid  it.  Fine  threads  and  round 
ligatures  are  dangerous,  because  they  cut  the  internal  and  middle  membranes, 
but  above  all,  because  they  strangulate  the  vasa  vasorum  of  the  cellular  tunic. 
Yet  he  rejects  every  kind  of  foreign  body,  which  some  would  place  between 
the  vessel  and  the  bandage,  as  well  as  all  ligatures  of  thread  of  whatever  form 
or  volume :  strips  of  untanned  deer  skin  appear  to  him  to  be  infinitely  prefer- 
able in  every  case,  since  these  ligatures  possess  an  elasticity  and  flexibility 
which  will  permit  them  gently  to  close  and  indent  the  artery  without  breaking 
any  of  its  coats,  or  lacerating  the  vasa  vasorum,  and  which  may  be  safely  left 
in  the  wound. 

Another  question  naturally  connects  itself  with  this  discussion.  It  has 
been  asked,  if  it  would  not  be  possible  to  substitute  for  threads  of  vegetable 
substance  cords  formed  of  animal  matter,  likely  to  soften,  to  dissolve,  and 
be  removed  by  interstitial  absorption  into  the  living  tissues,  without  hindering 
in  any  degree  the  immediate  reunion  of  the  divided  parts.  A  series  of 
experiments  of  this  description  was  made  in  London,  in  1815,  with  silk. 
One  trial  in  the  hands  of  Mr.  Lawrence,  and  another  in  those  of  Mr.  Carwar- 
dine,  met  with  all  the  success  they  could  have  anticipated.  The  incision 
was  enabled  to  cicatrize  in  the  space  of  four,  five,  or  six  days,  and  the  little 
knot  left  on  the  artery  occasioned  no  accident.  But  other  experimenters 
have  been  less  fortunate  ;  either  the  immediate  reunion  has  not  taken  place, 
or  there  have  been  formed  small  purulent  sacs,  little  abscesses  which  have 
not  been  dried  up  until  after  the  expulsion,  or  removal  of  portions  of  the  silk 
left  in  the  wound.  A  patient  on  whom  Mr.  Lawrence  himself  operated  on 
the  29th  of  March,  1829,  was  not  completely  cured  until  the  end  of  May. 
Mr.  Watson,  after  he  had  practised  upon  a  patient  this  manner  of  tying  the 
humeral  artery,  saw  the  knot  of  silk  tear  open  the  cicatrix,  and  escape,  at 
the  expiration  of  two  months.  The  same  thing  occurred  under  the  observ- 
ation of  Mr.  Hodgson,  at  the  end  of  six  months ;  and  M.  Cumin  speaks  of 
a  patient  who  retained  this  ligature  for  the  space  of  two  or  three  years.  So 
that,  to  sum  up  the  whole  matter,  silk  does  not  appear  to  be  susceptible  of 
removal  by  absorption. 

Sir  A.  Cooper  has  completely  succeeded  with  a  ligature  of  catgut.  This 
substance  is  much  more  easily  dissolved  than  silk,  and  would  be  preferable 
in  every  respect,  if  it  were  not  necessary,  in  consequence  of  its  slight  power 
of  resistance,  to  allow  it  a  considerable  volume.  On  the  first  patient  the 
cure  was  completed  on  the  twentieth  day  ;  on  the  second,  who  was  eighty 
years  of  age,  the  incision  required  only  four  days  to  cicatrize,  and  in  neither 
case  has  the  ligature  ever  reappeared.  The  same  success  however  has 
not  crowned  the  efforts  of  Mr.  Norman ;  this  physician  twice  tried  the 
method  of  Sir  A.  Cooper,  and  both  times  the  cure  was  a  long  time  de- 
ferred. Mr.  Wardrop,  in  some  of  his  operations  according  to  the  method  of 
Brasdor,  has  made  use  of  the  intestines  of  the  silk- worm,  in  the  shape  of 
thread. 

According  to  Drs.  Jameson  and  Dorsey,  Dr.Physick,  of  Philadelphia,  was 
the  first  to  use  ligatures  of  animal  matter,  in  1814;  those  which  he  prefers 
are  round,  and  made  of  deer  skin  or  of  catgut ;  but,  like  Messrs.  Lawrence 


40  NEW  ELEMENTS  OF 

and  Cooper,  he  intended  to  cut  or  break  the  arterial  coats,  while  Dr.  Jameson 
desires  by  all  means  to  preserve  them. 

The  surgeon  of  Baltimore  allows  to  his  deer  skin  ligatures  the  thickness 
of  two  lines,  and  increases  their  strength  and  firmness  more  or  less,  by- 
drawing  them  between  the  nails.  When  applied  to  the  artery,  these  strips 
need  not  be  tightly  drawn  in  order  to  efface  its  calibre,  so  that  in  spite  of  the 
absence  of  a  mreign  intermediate  body  they  produce  the  same  effect  as  the 
ligatures  of  Scarpa,  without  arresting  like  them  the  circulation  in  the  vessels 
of  the  cellular  tunic.  Dr.  Jameson  assures  us,  that  after  having  been  pulled 
between  the  nails,  these  ligatures  if  tightly  drawn  can  cut  the  arterial  tunics 
in  the  same  manner  as  the  flat  ligatures  of  thread  or  silk,  whilst  in  their 
naturally  soft  and  flexible  state  they  are  incapable  of  producing  this  eff*ect. 
Dr.  H.  Levert,  of  Alabama,  in  America,  has  lately  published  results  of  a 
different  description.  Having  remarked  that  lead,  gold,  silver,  and  platina 
but  slightly  irritate  the  parts  with  which  they  come  in  contact.  Dr.  Physick 
first  conceived  the  idea  of  fabricating  ligatures  of  these  metals.  Dr.  Levert 
seized  upon  this  proposition  of  Dr.  Physick,  and  subjected  it  to  several 
experiments.  He  made  five  upon  the  carotid  artery  of  a  dog  with  leaden 
threads  strongly  fastened,  then  cut  very  close  to  the  knot,  and  left  at  the 
bottom  of  the  wound.  Immediate  reunion  has  been  obtained  at  the  expiration 
of  the  17th,  18th,  19th,  28th  and  42d  day;  the  vessel  has  constantly  been 
found  to  be  obliterated,  and  the  little  circle  of  lead  enclosed  in  a  cellular  cyst 
more  or  less  dense.  Three  experiments  on  the  carotid,  and  two-  on  the 
femoral  artery,  with  gold  wire,  three  others  on  the  femoral,  and  the  two 
carotids  with  silver,  and  three  on  the  carotid  with  platina,  have  produced 
exactly  the  same  effects  as  the  ligatures  of  lead.  Dr.  Levert  has  arrived  at 
similar  results  by  the  use  of  ligatures  of  waxed  silk,  of  gum  elastic,  and 
even  with  blades  of  grass. 

From  these  inquiries  it  results,  as  I  conceive,  that  the  nature  and  the  form 
of  the  ligatures  in  the  treatment  of  aneurisms,  are  not  so  important  as  they 
have  been  generally  thought  for  the  last  thirty  years,  and  that  the  French 
suro;eons  were  right  in  this  pomt  of  view,  in  not  adopting  precipitately,  and 
without  reserve,  the  consequences  deduced  in  England  from  the  experiments 
of  Jones.  The  large  ligatures  of  Scarpa  cause  too  much  irritation  in  the 
wound,  produce  a  too  extensive  suppuration,  and  require  too  long  a  time  to 
elapse  before  they  can  be  withdrawn,  to  merit  an  exclusive  preference.  Thi» 
I  think  cannot  be  denied;  but  it  is  equally  true  that,  by  flattening  the  artery 
without  bending  it,  they  hold  the  parietes  in  perfect  contact,  without  neces- 
sarily cutting  the  vasa  vasorum.  The  cellular  tunic  becoming  inflamed  under 
such  pressure,  soon  transmits  its  or2;anization  to  the  two  other  arterial  mem- 
branes, and  the  whole,  being  speedily  blended,  form  one  impermeable  cord. 
The  reproaches  of  Mr.  Hodgson,  then,  are  far  from  being  perfectly  well 
founded.  When  a  fine  ligature  is  used  in  order  to  break  more  surely  the 
internal  and  middle  tunics,  you  compress,  at  the  same  time,  as  is  contended 
by  Dr.  Jameson,  the  small  vessels  of  the  external  membrane,  and  it  is  not, 
as  advanced  by  Jones,  by  the  interior  infusion  of  organizable  lymph  that  the 
obliteration  of  the  artery  is  principally  effected.  On  the  contrary,  the  liga- 
ture is  itself  promptly  enveloped  with  a  coagulable  fluid,  the  continuity  of 
the  small  vessels  which  had  been  broken  is  quickly  re-established  on  its 
external  surface,  and  it  finds  itself  at  last  in  the  centre  of  an  organized 
ring,  analogous  to  that  which  has  been  imagined  by  Duhamel,  in  the 
formation  of  callus  for  the  union  of  fractured  bones.  This  albuminous 
ring,  the  mechanism  of  which  has  been  followed  up  by  Dr.  Pecot,  with  great 


OPERATIVE    SURGERTJI  4T 

care,  in  observations  on  dogs,  hardens  by  degrees,  contracts  upon  itself,  and 
is  gradually  confounded  with  the  two  occluded  ends  of  the  artery,  after  the 
removal  of  the  ligature.  Messrs.  Scarpa,  Crampton,  and  Jameson,  were  then 
wrong  in  attributing  to  fine  ligatures  a  greater  tendency  to  produce  secondary 
hemorrhages  than  to  the  flat  or  large  ligatures. 

As  to  ligatures  composed  of  animal  substances,  it  is  incontestable  that  in 
permitting  the  incision  to  close  immediately  they  may  be  of  very  great  service 
in  practice.  It  remains  to  be  seen  what  should  be  their  exact  form  or  nature. 
If  it  is  desired  that  thev  should  be  very  fine,  silk  alone  should  be  employed, 
but  unfortunately  we  have  seen  that  this  substance  will  not  yield  to  the 
interstitial  action  of  the  organs — catgut  has  not  the  same  solidity,  nor  is  it 
very  easily  absorbed.  Straps  of  deer  skin,  which  are  easily  dissolved  and 
possess  great  elasticity,  promise  greater  advantages,  but  before  adopting 
them,  surgery  demands  new  experiments,  and  that  the  results  mentioned  by  Dr. 
Jameson  shall  be  confirmed  by  other  practitioners.  Admitting  that  when 
left  about  the  artery  these  cords  do  not  act  as  foreign  bodies,  that  the  system 
may  be  able  to  appropriate  them  and  will  not  be  obliged,  sooner  or  later  to 
remove  them,  there  is  no  person  who  cannot  comprehend  at  a  glance  the 
services  which  they  may  render  to  invalids.  With  them  the  plastic  ring, 
indicated  M.  Pecot,  would  be  complete ;  free  from  all  perforation  or  inter- 
ruption, it  would  be  sustained  by  the  exact  apposition  and  immediate  reunion 
of  the  parts,  and  would  incur  no  risk  of  being  destroyed  by  suppuration,  or 
lacerated  by  the  removal  of  the  thread.  For  the  rest,  whether  the  ligature 
be  a  little  larger  or  a  little  smaller  j  whether  the  internal  and  middle  tunics  be 
or  be  not  broken  ;  whether  the  vasa  vasorum  be  more  or  be  less  completely 
strangulated,  I  believe  that  the  definitive  results  will  nevertheless  be  very 
much  the  same. 

§  2.  Permanent  Ligature. 

A  ligature  formed  of  vegetable  materials,  tied  tightly  enough  to  intercept 
the  passao-e  of  the  blood  in  an  artery,  is  a  foreign  body  which  will  not  retire 
from  the  incision  until  it  have  cut  the  cord  which  it  encircles.  It  is  neces- 
sary, then,  in  order  that  hemorrhage  may  not  follow  its  removal,  that  the 
vessel  should  have  had  time  to  close  itself  firmly,  both  above  and  below,, 
otherwise  the  albuminous  virole  which  surrounds  it  not  being  of  sufficient 
consistence  to  resist  the  blood,  and  being  already  open  towards  the  skin,, 
would  be  immediately  swept  away.  If  the  ligature,  as  has  been  generally 
believed,  produce  only  adhesive  inflammation  in  the  circle  of  the  vessel  whicli 
it  immediately  embraces,  there  would  be  nothing  to  fear  from  the  separation, 
for  before  it  can  divide  the  artery  must  of  necessity  be  inflamed.  But  the 
experiments  and  reasoning  of  M.  Pecot  tend  to  prove  that  this  is  not  the  case ; 
that  the  portion  of  the  vessel  inclosed  by  the  loop  of  the  ligature  almost  neces- 
sarily mortifies,  whatever  may  be  the  degree  of  constriction  which  it  sustains, 
and  that  it  is  only  by  an  eliminating  process,  analagous  to  that  which  takes  place 
in  other  instances  of  gangrene,  that  it  is  detached  from  the  surrounding  tissues. 

When  this  process  is  not  deranged,  and  when  the  organic  elements  upon 
which  it  is  effected  are  in  the  normal  state,  and  where  nothing  intervenes  to 
prevent  the  establishment  of  adhesive  inflammation,  the  ligature  is  not  removed 
until  from  the  eleventh  to  the  twentieth  day ;  and  since  by  the  fourth  or  fifth 
day  the  superior  extremity  of  the  arterial  canal  has  become  impermeable, 
there  is  on  this  point  no  occasion  for  anxiety.  But  if  unhappily  the  parietes 
of  the  vessel  are  soft,  steotamatous,  yellow,  or  inflamed,  the  ligature  will 
6 


42  NEW   ELEMENTS  QF 

have  mechanically  divided  them ;  if  the  channel  is  not  completely  closed, 
they  will  ulcerate  without  interrupting  the  current  of  the  blood :  and  again, 
if  they  are  hard,  and  incrusted  with  calcareous  concretions,  as  they  frequently 
are  in  aged  persons,  it  is  easy  to  see  that  the  inflammation  which  can  be 
excited  in  them  will  be  most  frequently  of  too  low  a  grade,  and  too  irregular 
to  occasion  the  necessary  effusion  of  concrescible  material,  either  on  the 
exterior  or  the  interior,  and  that  however  long  deferred,  the  coming  away  of 
ligature  may  produce  a  serious  hemorrhage. 

§  3.  Precautionary  Ligature ^ 

In  order  to  obviate  such  unfortunate  results,  have  been  invented  precau- 
tionary ligatures  :  that  is  to  say,  cords  which  only  become  useful  in  case  that 
which  has  been  first  applied  has  effected  the  division  of  the  artery  before  it 
has  been  perfectly  obliterated.  One  of  these  ligatures  was  carried  round  the 
vessel  without  being  tightened,  a  few  lines  below  the  principal  ligature;  a 
second,  composed  of  two  separate  strands,  was  placed  a  little  above  the 
inferior  portion,  to  be  tied  in  such  a  manner  as  not  to  close  up  the  arteries, 
but  only  to  deaden  the  impulse  of  the  column  of  blood  against  the  point 
which  it  is  intended  to  obliterate  ;  a  third,  also  double,  was  placed  still  higher, 
and  this  latter,  the  same  as  the  superior  strand  of  the  preceding,  was  left 
loose.  In  case  the  fixed  ligature  should  fail,  the  first  pair  of  the  uppef 
precautionary  ligatures  would  be  tied,  and  subsequently,  in  case  of  need,  all 
tlie  others,  in  order  to  stop  the  hemorrhage. 

The  same  was  done  with  the  two  portions  of  the  inferior  ligature,  which 
has  no  other  object  than  to  oppose  the  reflux  of  the  blood  through  the  incision. 
This  was  the  reasoning  and  the  practice  of  A.  Monroe,  Guattani,  Hunter, 
Desault,  Deschamps,  Pelletan,  and  even  for  some  time  of  Mr.  Boyer.  At 
this  time,  precautionary  ligatures  have  almost  entirely  disappeared.  So  far 
are  they  from  being  considered  useful,  that  they  are  denounced  as  being  very 
dangerous;  they  were  at  first  reproached,  and  justly,  with  irritating  the 
incision  too  highly,  with  continuing  suppuration,  and  with  opposing  an  in- 
surmountable obstacle  to  immediate  reunion.  Besides,  Messrs.  Dupuytren 
and  Beclard  have  demonstrated,  that  during  the  inflammation,  the  pofnt  of 
the  vessel  near  which  they  lie  assumes  a  fatty  consistence,  is  extremely 
easy  to  cut,  and  entirely  incapable  of  supporting  the  action  of  any  ligature 
whatever  ;  whence  it  follows,  that  their  mere  presence  is  enough  to  occasion 
the  ulceration  of  the  artery,  which  they  divide  with  the  same  facility  as  lard 
or  cheese,  as  soon  as  it  is  necessary  to  exert  the  slightest  farce  in  the  way  of 
constriction. 

§  4.   Temporary  Ligature, 

Not  only  have  the  precautionary  ligatures  been  rejected,  but  it  has  been 
inquired  whether  it  would  not  be  possible,  without  affecting  the  success  of  the 
operation,  to  remove  the  only  ligature  which  may  be  employed  before  it  has 
had  time  to  cut  the  vessel.  It  is  near  thirty  years  since  the  examination  of  this 
question  was  began  in  England.  Jones  is  said  to  have  found,  that  in  breaking 
at  three  or  four  points  at  some  distance  from  each  other  the  internal  and 
lesser  coats  of  an  artery,  with  as  many  fine  threads,  a  lymphatic  effusion 
was  produced  which  was  sufficient  to  determine  the  obliteration  sought  for, 
and  permitted  the  removal  of  the  ligatures  in  a  few  minutes.  The  results 
obtained  by  Mr.  Hutchinson  fully  confirm  those  of  Jones ;  but  Dalrymple, 
Hodgson,  and  Travers,  have  been  less  successful.    Their  experiments  have  been 


OPERATIVE   SURGERY.  43 

tried  upon  horses  and  sheep,  and  the  artery  has  never  been  found  obliterated. 
It  was  only  slightly  contracted  when  the  animal  was  killed,  after  the  lapse  of 
IS,  15,  or  18  days.  Mr.  Travers,  however,  thought  that  this  suggestion, 
might  be  rendered  available  by  a  slight  modification.  Instead  of  removing 
the  ligature  immediately  after  having  closed  up  the  artery,  he  resolved  to  leave 
it  tied  until  sufficient  time  should  nave  elapsed  to  permit  the  clotted  blood 
and  the  lymphatic  effusion  to  acquire  a  certain  degree  of  firmness  and  consist- 
ence, which  would  render  it  capable  of  resisting  the  force  of  the  blood.  His 
experiments  upon  horses  have  led  him  to  the  conclusion,  that  a  ligature  continued 
for  six  hours,  two  hours,  or  even  one  hour,  upon  the  carotid,  will  commonly  result 
in  a  permanent  obliteration  of  the  arterial  canal.  In  1817,  he  applied  a  ligature 
upon  the  brachial  artery  of  a  man,  and  withdrew  it  fifty  hours  afterwards 
without  the  pulsation  being  restored  in  the  tumor.  Mr.  Roberts  has  gone  still 
farther  ;  a  ligature  which  he  left  only  twenty-four  hours  on  the  femoral  artery 
of  a  sailor  affected  with  popliteal  aneurism^  was  sufficient  to  effect  a  complete 
cure  in  twelve  days. 

In  repeating  these  experiments,  unfortunately  the  same  successful  results 
have  not  always  been  obtained.  Mr.  Hutchinson  has  seen  the  circulation 
immediately  re-established  in  the  femoral  artery,  although  it  had  been  firmly 
tied  with  a  ligature  for  the  space  of  six  hours.  The  same  thing  has  occurred 
to  Sir  A.  Cooper,  after  thirty-two  and  forty  hours.  Mr.  Travers  himself, 
upon  withdrawing  the  thread  which  he  had  left  upon  the  artery  of  the  thigh  for 
twenty-five  hours,  has  seen  the  pulsation  reappear  by  degrees  in  the  aneurism, 
refuse  to  yield  to  a  long-continued  mediate  compression,  and  occasion  the 
necessity  of  at  last  applying  a  ligature  in  the  ordinary  way,  so  that  he  finally 
relinquished  this  practice,  which  the  experiments  of  Beclard  had  prevented 
from  being  adopted  in  France. 

At  the  very  time  when  the  temporary  ligature  lost  its  warmest  partisans  in 
London,  the  surgeons  of  Italy  took  it  up.  Scarpa  subjected  it  to  new  trials,  and 
endeavored  to  establish  it  in  general  practice.  Flat  ligatures  tied  over  a  small 
cylinder  of  waxed  cloth  upon  the  carotid  arteries  of  several  sheep,  and 
withdrawn  on  the  third,  fourth,  or  fifth  day,  always  produced  the  complete 
obliteration  of  the  cavity  of  the  vessel.  These  experiments  being  repeated 
on  horses  by  M.  Mislei,  veterinary  surgeon  at  the  school  of  Milan,  produced 
exactly  the  same  results.  Upon  the  human  body  the  success  of  this  practice 
has  not  been  less  happy.  Paletta  communicated  to  Scarpa  two  remarkable 
examples.  The  first  subject  was  a  man  of  forty,  who  had  been  affected  for 
two  or  three  months  with  an  aneurism  in  the  ham.  The  ligature  was  applied 
upon  the  femoral  artery  on  the  8th  of  January,  1817,  and  removed  on  the  12th. 
The  second  instance  relates  to  an  invalid,  sixty  years  old,  with  an  aneurism  in 
the  bend  of  the  arm ;  a  ligature  placed  on  the  humeral  artery  was  withdrawn  on 
the  fourth  day,  and,  as  in  the  case  of  the  first  individual,  the  operation  resulted 
in  success.  A  popliteal  aneurism,  treated  in  the  same  way  by  M.  Biraghi, 
had  the  same  termination.  The  same  is  true  of  a  fourth  individual,  on  whom 
the  humeral  artery  had  been  opened,  and  who  had  applied  for  assistance  at 
the  hospital  of  Pavia.  Messrs.  Molina,  Fenini,  Maunoir,  Wattmann,  Fitz, 
Medoro,  Solera,  Roberts,  Falcieri,Uccelli,  Giuntini,  and  Malago,  have  also  used 
the  temporary  ligature  with  success  in  the  treatment  of  aneurisms  of  the  carotid 
and  femoral  arteries.  Vacca  objected,  that  after  the  removal  of  the  ligature, 
the  artery  is,  notwithstanding,  sooner  or  later  divided.  The  experiments  of 
M.  Pecot,  opposed  to  those  of  Mr.  Seller,  tend  to  confirm  this  opinion,  whicli 
nevertheless,  takes  nothing  from  the  weight  of  the  facts  and  reasonings  of 
Scarpa. 


44  NEW   ELEMENTS    OF 


Operative  Processes. 


The  difficulty,  as  is  shown  in  a  case  related  by  Mazzoni,  consists  in 
removing  the  ligature,  without  drawing  upon  the  artery  or  disuniting  the  lips 
of  the  incision.  Viewed  in  this  light,  all  the  means  employed  in  England 
appear  faulty.  The  two  single  threads  previously  laid  by  Messrs.  Paletta 
and  Roberts  between  the  vessel,  or  the  little  roll  and  the  tape  which  serves 
as  a  ligature  for  the  purpose  of  untying  the  latter  in  drawing  them  out,  eff'ect 
the  object  but  very  imperfectly.  The  same  may  be  said  of  the  bit  of  a 
grooved  director  which  M.  Uccelli  tied  in  the  same  tape  with  the  roll  of  cloth, 
and  upon  which  he  proposed  afterwards  to  cut  the  knot.  M.  Giuntini  con- 
tents nimself  with  attaching  to  the  end  of  the  cylinder,  or  roll,  before  it  is 
fixed  upon  the  artery,  a  waxed  thread,  by  which  it  may  afterwards  be  with- 
drawn so  as  to  render  the  cutting  of  the  ligature  more  easy.  For  all  these 
modes  Scarpa  substituted  the  following  : — 

1.  Process  of  Scarpa. — A  grooved  probe,  notched  at  its  extremity,  and 
furnished  with  two  small  flat  rings  on  one  edge,  the  oneabouthalf  a  line  from 
the  point,  the  other  about  an  inch  from  the  handle,  serves  to  conduct  a  very 
small  knife  down  to  the  ligature  where  it  surrounds  the  artery ;  the  mode  of 
using  this  little  apparatus  is  very  simple.  The  end  of  the  ligature  which  has 
been  kept  outside,  is  successively  passed  through  the  two  rings  which  are 
intended  to  receive  it.  The  beak  of  the  director  is  then  carefully  directed 
to  the  little  roll  of  linen  which  arrests  its  progress ;  the  knife  then  penetrates 
as  far  as  the  ligature,  which  it  cuts  across,  and  which  can  then  be  withdrawn 
without  the  least  danger  to  the  vessel.  For  further  details  of  this  ingenious 
process,  consult  the  article  inserted  by  M.  Ollivier  in  the  second  volume  of 
the  Archives  Generates, 

2.  Process  of  Deschamps. — In  France  also,  some  attempts  have  been  made 
with  the  temporary  ligature,  but  after  a  different  manner ;  that  is,  in  combi- 
nation with  immediate  compression.  In  1793,  Deschamps  invented  his  presse- 
artere,  that  is  to  say,  an  instrument  composed  of  a  flattened  metallic  wire, 
about  three  inches  in  length,  notched  at  its  free  extremity,  and  terminated  at 
the  other  by  a  horizontal  plate  resembling  the  head  of  a  nail,  flat,  rather  long 
than  wide,  and  pierced  with  two  slits  near  the  edges.  The  operation  is 
commenced  by  passing  the  ends  of  the  ligature,  which  has  been  placed  under 
the  vessel,  through  the  two  holes  in  the  instrument.  The  surgeon  then  draws 
upon  these,  and  at  the  same  time  presses  down  the  head.  Thus  the  trunk  of 
the  vessel  is  held  flat,  between  the  tape  and  the  flat  extremity  of  the  presse- 
artere ;  the  one  drawing  it  forwards,  and  the  other  pressing  it  backwards. 
Lastly,  the  ends  of  the  ligature  are  fastened  upon  the  notch  of  the  instrument. 

The  small  canuli  used  by  Assalini,  the  compresses  tried  or  recommended 
by  Forney,  Flajani,  Buzani,  Garnery,  Ayzer,  Crampton,  Ristelhueber,  Deaze, 
and  others,  although  differing  in  some  respects  from  that  of  Deschamps,  have 
yet  been  all  constructed  after  the  same  idea  ;  that  is  to  say,  with  the  intention 
of  flattening  instead  of  pursing  up  the  vessel,  and  of  withdrawing  the  ligature 
at  a  given  time.  Like  it  also  they  are  attended  with  the  inconvenience  of 
irritating  tlie  wound,  and  of  promoting  the  ulceration  of  the  artery,  which  they 
too  often  but  incompletely  close. 

3.  New  Process. — If  any  just  conclusions  may  be  deduced  from  experi- 
ments made  upon  dogs,  the  following  process  will  prove  to  be  means  as  easy 
of  employment  as  certain  of  success,  for  obtaining  by  means  of  temporary 
ligatures  the  obliteration  of  arterial  canals.  A  common  pin  is  passed  under 
the  artery,  the  two  extremities  of  which  are  then  encircled  by  a  loop  of  thread. 


I 


OPERATIVE    SURGERY.  '^^   45 

as  in  the  twisted  suture,  which  is  made  sufficiently  tight  to  prevent  the  passage 
of  the  blood.  A  second  thread  attached  to  its  head,  allows  the  removal  of 
the  pin  whenever  it  is  thought  expedient.  The  ligature  thus  released,  no 
lono-er  oifers  the  slightest  resistance,  but  drops  out  almost  of  itself.  The 
process  employed  by  M.  Malago,  and  which  consists  in  twisting  the  two  heads 
of  the  ligature  instead  of  tying  them,  would  be  more  simple,  it  is  true,  but 
it  would  not  possess  the  same  degree  of  certainty. 

4.  Process  of  M,  Dubois. — The  idea  which  suggested  to  Deschamps  the 
construction  of  his  presse-artere,  that  is,  of  obliterating  the  vessel  only  by 
degrees,  was  adopted  by  M.  Dubois,  who  endeavored  to  found  upon  it  a  new 
method  of  treating  aneurism.  In  1810,  after  having  placed  the  ligature  around 
the  artery,  this  practitioner  then  passed  the  extremities  through  the  serre-ncBud 
of  Desauit,  in  such  a  manner  as  to  gradually  intercept  the  course  of  the  blood, 
and  only  to  effect  the  complete  obliteration  of  the  arterial  calibre  after  six  or 
eight  days.  His  intention  in  following  this  plan  was  to  permit  the  supple- 
mentary branches  to  dilate  gradually,  and  to  prevent  the  gangrene,  which  at 
that  period  was  thought  to  be  a  necessary  consequence  of  suddenly  tying  a 
large  artery.  The  two  instances  of  success  mentioned  by  M.  Richerand,  and 
which  were  obtained  by  this  process  at  La  Clinique  de  la  Faculte,  at  first 
forcibly  attracted  public  attention  ;  but  a  third  attempt  being  followed  on  the 
fifteenth  day  by  a  hemorrhage,  which  required  the  amjifutation  of  the  limb, 
and  finallv  caused  the  death  of  the  patient  (although  the  pulsations  had 
ceased  to  be  discoverable  in  the  tumor  by  the  tenth  day),  soon  put  an  end  to 
these  gratifying  expectations.  Since  then  (the  close  of  1810),  I  have  no 
knowledge  that  recourse  has  been  again  had  to  this  mode  of  procedure, 
notwithstanding  the  two  successful  cases  of  MM.  Viricel  and  Larrey.  Now 
that  we  are  able  to  set  a  just  estimate  upon  the  dangers  of  suddenly 
suspending  the  circulation  in  the  principal  artery  of  a  limb,  a  process  of  that 
nature  has  deservedly  lost  all  value,  and  what  I  have  said  concerning  the 
precautionary  ligatures,  is  enough  to  shov/  that  they  are  the  most  dangerous 
contrivances  which  can  be  proposed. 

§  5.  Two  Ligatures  with  intennediate  division  of  the  Artery. 

Galen,  Aetius,  Celsus,  Guy  de  Chauliac,  Rufus,  Rhazes,  Gouey,  Severin, 
and  others,  were  in  the  habit  of  applying  two  ligatures  at  some  distance  from 
each  other,  and  then  dividing  the  artery  between  them.  Pelletan,  following 
the  suggestion  of  Tenon,  was  upon  the  point  of  imitating  this  practice,  which 
had  been  completely  forgotten  about  the  close  of  the  last  century,  and  which 
Heister,  Callisen,  and  Richter,  have  strongly  reprobated.  Abernethy  adopted 
it  for  his  first  ligatures  on  the  external  iliac  artery,  not  knowing  that  his  coun- 
trymen Bell  had  already  spoken  of  it,  but  believing  himself  to  be  the  inventor. 
\Vith  this  .precaution,  says  he,  the  two  ends  of  the  artery  are  retracted  into 
tlie  flesh,  without  being  subjected  to  any  dragging,  and  are  in  the  same  condition 
as  in  the  case  of  amputation.  M.  Maunoir,  who  published  in  1802  a  treatise 
on  this  modification,  w^hich  he  also  regarded  as  his  own,  has  declared  himself 
its  defender.  With  Morand,  he  concedes  to  the  arteries  a  great  retractile 
power ;  believes  that  in  pursing  them  up  the  circular  ligature  shortens  them, 
disposes  them  to  be  violently  pulled  by  the  impulse  of  the  heart  at  the  throb 
of  every  pulsation,  and  that  the  best  means  of  preventing  secondary  hemor- 
rhage, is  to  permit  the  artery  which  has  just  been  tied  to  retire  into  the  soft 
parts  as  far  as  its  natural  retractility  requires.  Some  facts  cited  by  Messrs., 
Abernethy,  Black,  A.  Cooper,  Maunoir,  Dairy mple,  Post,  Guthrie,  and  others. 


46  NEW   ELEMENTS  Ot 

seemed  at  first  to  confirm  the  elij^ibility  of  this  method,  which  Messrs.  Roux, 
Larrev,  Lisfranc,  and  Taxil,  in  France,  were  very  much  disposed  to  adopt,  at 
least  for  tlie  great  arteries.  But  on  being  tried  in  1807,  by  Mr.  Norman,  of 
Batli,  it  gave  rise  to  a  very  troublesome  hemorrhage,  and  Scarpa,  who,  con- 
demning it,  advances  the  observations  of  Monteggia,  Assalini,  and  others,  when 
it  was  attended  with  fatal  hemorrhage. 

It  is  certain  that  the  reasonings  on  which  they  rely  in  dividing  the  arteries 
between  the  two  ligatures,  are  ill  grounded.  The  retractility  imagined  by 
Morand  and  M.  Maunoir,  and  upon  which  Messrs.  Beaufils,  Taxil,  Saint 
Vincent,  and  more  recently  Mr.  Guthrie,  have  so  earnestly  insisted,  scarcely 
exists,  as  has  been  proved  by  the  experiments  of  Beclard,  and  as  I  have  several 
times  been  able  personally  to  convince  myself.  If  after  the  amputation  of 
limbs  the  arteries  retire  sometimes  very  far,  it  is  because  they  are  drawn  away 
by  the  muscles  and  not  by  any  contractility  inherent  in  themselves.  Then 
even  supposing  that  being  indented  by  a  ligature  they  undergo  some  stretch- 
ing, nothing  is  more  simple  than  to  pick  an  end  to  this  without  breaking  the 
continuity  of  any  tissue.  It  is  sufficient  for  that  purpose  to  follow  the  advice 
given  by  Lyng,  that  is,  to  place  the  member  in  a  semiflexed  position,  and  all 
the  muscles  in  a  state  of  relaxation.  Not  only  is  there  no  appreciable  advantage 
to  be  gained  from  this  division  of  the  artery,  but  it  also  exposes  you  to  the 
greatest  danger.  If  the  ligature  of  th€  superior  extremity  of  the  artery  for 
example,  should  get  loose,  or  should  become  relaxed,  as  has  happened  in  the 
practice  of  Messrs.  A.  Cooper  and  Cline,  an  alarming  hemorrhage  will  of 
necessity  result,  capable  of  becoming  quickly  mortal  if  the  patient  is  not 
instantly  relieved.  Should  a  similar  accident  happen  after  ligature  of  the 
carotid  artery  in  the  inferior  region  of  the  neck  of  the  subclavian,  or  of 
either  of  the  iliac  arteries,  death  will  be  the  almost  inevitable  consequence. 
We  must  then  conclude  that  the  advice  given  by  Abernethy  and  Maunoir,  to 
place  two  ligatures  on  the  great  arteries  and  then  to  cut  the  vessel  in  the 
interval,  is  a  method  dangerous  in  its  consequences  and  of  no  avail  in  regard 
to  the  end  proposed. 

§  6.  Ligature  through  the  Artery* 

For  some  time  past  there  has  been  an  endeavor  to  bring  forward  a  process 
mentioned  by  Dionis,  and  described  by  Richter  in  the  following  terms : — "  The 
artery,"  says  he,  ♦*  after  having  been  drawn  to  the  outer  side,  should  be  encir- 
cled twice  with  an  ordinary  ligature,  which  should  be  fastened  by  a  knot,  and 
when  the  artery  is  of  any  considerable  size,  one  of  the  ends  of  the  ligature  should 
be  passed  through  it  by  means  of  a  needle.  It  is  this  manner  of  operating  which 
Cline  thought  proper  to  recommend,  in  order  to  prevent  the  ligatures  used 
after  the  manner  of  Maunoir  from  relaxing  and  slipping  from  the  ends  of  the 
artery.  Sir  A.  Cooper  made  trial  of  it  upon  a  subject  twenty -nine  years  of  age, 
in  operating  for  an  aneurism  in  the  popliteal  region.  The  two  ligatures  were 
first  tied  at  the  bottom  of  the  inguinal  region  ;  the  needles  were  then  passed 
through  the  coats  of  the  vessel  between  the  two  ligatures,  and  the  ends  of  both 
the  threads  were  then  attached  to  the  knots  of  the  first  ligatures,  with  the 
intention  of  preventing  the  possibility  of  slipping.  Mr.  S.  Cooper,  and  all 
other  surgeons,  have  condemned  this  procedure,  and  I  think  with  reason,  for 
it  has  neither  analogy  nor  experience  in  its  favor,  nor  couldany  thing  justify 
its  employment.  Yet  it  may  have  given  birth  to  that  operation  which  Dr. 
Jameson  appears  to  have  practised  several  times  with  success.  This  phy- 
sician thougnt  that  to  transfix  a  large  artery  or  vein  with  a  seton,  two  or  tnree 


OPERATIVE    SURGERY.  47 

lines  in  size,  would  be  sufficient  to  determine  its  obliteration ;  the  experiments 
made  by  him  on  the  carotid,  and  jugular  veins  of  horses,  have  always  produced 
an  effusion  of  plastic  lymph  in  the  interior  of  the  vessel,  a  thickening  of  the 
divided  parietes,  and  soon  after  a  complete  interruption  of  the  course  of  the 
blood.  I  learn  from  Dr.  Chumet,  of  Bordeaux,  that  these  experiments  having 
been  repeated  at  Val-de- Grace,  gave  the  same  results.  From  a  communica- 
tion of  M.  Carron  du  Villards,  it  appears  that  he  too  has  made  experiments 
on  animals,  which  demonstrate  that  the  same  end  is  obtained  by  piercing  the 
artery  with  a  linen  thread  or  with  a  wire  of  iron,  steel,  or  silver,  &c.  so  that 
a  new  question  here  presents  itself,  which  in  my  view  merits  the  attention  of 
practitioners.  A  strip  of  skin,  or  a  conical  wire,  or  shank  of  some  metallic 
substance,  being  left  at  the  extremity  of  the  wound,  would  not  in  any  degree 
hinder  its  immediate  reunion,  and  would  render  the  operation  for  aneurism 
exceedingly  simple,  if  the  cure  would  as  surely  follow  this  method  as  it  does 
tlie  application  of  the  ligature, 

§  7.  Mediate  Ligature, 

The  ancients,  not  possessing  the  necessary  anatomical  knowledge,  did  not 
give  themselves  the  trouble  ot  finding  the  artery,  but  contented  themselves 
in  some  cases  with  piercing  the  whole  thickness  of  the  limb  between  the 
vessel  and  the  bone,  and  then  tying  up  the  two  ends  of  the  cord  over  a 
compress  placed  between  the  ligature  and  the  skin.  This  is  the  process 
recommended  by  Thevenin,  and  the  process  which  Le  Dran  and  Garengeot 
did  not  disdain  to  follow  in  the  beginning  of  the  last  century,  in  order  to 
suspend  the  circulation  of  the  brachial  artery  whilst  they  amputated  the 
shoulder.  Although  surgeons  may  sometimes  have  succeeded  by  this  absurd 
method  in  the  cure  of  aneurism,  I  do  not  think  it  necessary  in  our  day  to 
discuss  it  at  greater  length  to  point  out  its  disadvantages  and  its  dangers. 

§  8.  Immediate  Ligature. 

On  proceeding  to  search  for  the  artery  at  the  bottom  of  the  aneurismal  sac 
or  bag,  it  was  sometimes  so  difficult  to  isolate  it  from  the  surrounding  tissues, 
that  the  question  arose  whether  it  would  not  be  right  at  the  same  time  to 
comprehend  within  the  ligature  the  accompanying  veins,  or  nerves. — 
Molinelli  sustains  that  it  is  useless  to  take  so  many  precautions,  and  that 
the  inclusion  of  the  great  nervous  cords  rarely  effects  the  success  of  the 
operation.  Thierry  has  arrived  at  the  same  conclusions,  after  having  made 
sundry  experiments  on  dogs,  sometimes  tying  up  the  axillary  and  femoral 
artery  without  touching  the  nervous  plexus,  and  sometimes  including  it  with 
the  thread,  and  no  case  whatever  resulted  in  either  gangrene  or  permanent 
paralysis.  The  moderns,  nevertheless,  have  rejected  this  practice,  and 
consider  that,  except  in  cases  of  insurmountable  difficulty,  the  artery  alone 
should  be  confined  by  means  of  the  ligature.  An  observation  is  extracted  by 
!Pelletan  from  a  letter  of  Testa,  in  which  it  is  seen  that  a  patient,  treated  by 
Falconnet,  who  had  included  in  the  same  ligature  the  nerves,  the  vein,  and 
the  popliteal  artery,  was  immediately  seized  with  horrible  pains  in  the  limb, 
which  mortified  in  the  evening  of  the  same  day.  Even  if  this  case  will  not 
compel  us  to  conform  to  the  practice  of  modern  surgeons,  reason  itself,  unas- 
sisted by  such  dreadful  experience,  should  suffice  to  bring  us  to  the  same 
result.    It  may  indeed  be  conceived  that  the  division  of  one  or  more  of  the 


-48  ■*  NEW  ELEMENTS  OF 

nerves  of  a  part  will  not  necessarily  produce  paralysis:  and  it  may  be 
conceived,  too  (notwithstanding  the  opinions  of  Mr.  Guthrie),  that  the  liga- 
ture of  a  great  vein  need  not  of  course  be  attended  with  gangrene,  but  if  both 
these  kinds  of  organs  be  included  in  a  ligature  at  the  same  time  with  the 
principal  artery  of  the  same  limb,  it  cannot  be  doubted  that  mortification  and 
loss  01  feeling  must  take  place,  if  not  always,  at  least  in  the  greater  number 
of  cases.  It  is  evident  besides,  that  in  advising  us  to  pay  no  attention  to 
organs  of  smch  importance,  tlie  surgeons  have  desired  to  justify  their  want 
of  care  in  isolating  the  artery.  At  the  present  day  it  is  customary  to  exclude 
from  the  ligature  every  vein,  and  every  the  smallest  nervous  cord,  and  every 
particle  of  the  surrounding  tissues  ;  and  this  practice  is,  without  doubt,  one 
of  the  reasons  why  the  operation  for  aneurism,  heretofore  so  formidable,  is 
now  so  simple  and  so  easy. 

Since  precautionary  ligatures  have  been  rejected,  some  persons  have 
tliought,  that  for  greater  security  it  would  be  well  to  apply  upon  the  great 
arteries  two  ligatures  at  some  distance  from  each  other.  Vacca  observes  that 
nothing  is  gained  by  this  procedure,  inasmuch  as  the  portion  of  the  vessel 
between  the  two  ligatures  necessarily  gangrenes.  But  this  reason  of  the 
Professor  of  Pisa  cannot  now  have  weight ;  for  Mr.Briquet  reports,  upon  tlie 
authority  of  Beclard,  that  a  segment  of  artery  may  very  well  continue  to  live, 
although  it  have  no  longer  any  communication  with  the  trunk  from  which  it 
has  been  separated.  It  should  then  be  for  other  reasons  that  we  proscribe 
the  double  ligature. 

Art,  6. — Methods  of  Operation, 

A.  Aetius  says,  that  in  order  to  cure  aneurism  you  must  expose  the  artery 
above  the  affected  part,  tie  it  in  two  places,  then  cut  across,  open,  and  empty 
the  aneurismal  cyst;  raise  the  vessel,  tie  it  above  and  then  below  the  opening, 
and  cut  it  a  second  time  across. 

B.  Paulus  ^gineta  speaks  of  a  process  which  consists  in  passing,  by  means 
of  a  needle,  a  double  ligature  behind  the  centre  of  the  aneurism,  to  bring  back 
one  of  these  ligatures  to  the  upper,  and  the  other  to  the  lower  part  of  the 
tumor,  which  is  thus  strangulated  above  and  below.  It  is  then  opened  and 
almost  completely  removed.  Thevenin  also  mentions  this  process,  which  is 
evidently  nearly  the  same  with  that  formerly  employed  for  the  removal  of 
wens,  and  several  other  tumors.  It  is  to  him,  no  doubt,  that  Guy  de  Chau- 
liac  refers,  when  he  asserts  that  aneurism  can  be  cured  by  employing  the 
ligature,  a  mode  de  rompure. 

C  The  last-mentioned  author  describes  another  method,  which  although  it 
approaches  that  of  Paul  of  Egina,  would  yet  seem  to  differ  from  it  in  some 
respects,  and  in  reality  to  be  more  rational.  *' It  is  necessary,"  says  he, 
**  tliat  the  artery  should  be  exposed  in  both  directions,  and  tied  with  the  thread  ; 
the  f)art  remaining  between  the  two  bands  should  be  cut,  and  then  treated  in 
the  same  manner  as  ordinary  incisions."  The  process  so  elaborately  described 
by  Bertrandi,  about  the  middle  of  the  last  century,  being  nothing  more  than 
a  repetition  of  that  of  Guy  de  Chauliac,  does  not  deserve  further  notice  in 
this  place.  It  is,  besides,  so  far  from  being  new,  that  even  Philagrius  had 
had  recourse  to  it. 

D.  Guillemeau,the  competitor  and  disciple  of  Pare,  simplified  the  method  of 
the  ancients.  He  contented  himself  with  tying  the  artery  above  the  tumor, 
opening  the  latter,  removing  the  coagula,  and  then  dressm^  it  as  a  common 
wound.    This  formed  the  basis  of  the  old  method  of  treating  aneurisms ;  a 


\ 


OPERATIVE    SURGERY.  49 

method  which,  until  the  last  century,  was  never  applied  except  in  cases  of 
aneurism  of  the  bend  of  the  arm. 

E.  Keisleyre,  a  surgeon  of  Lorraine,  in  the  Austrian  service,  is  the  only 
one  who,  about  the  year  1644,  had  ventured  to  practice  it  several  times  for 
popliteal  aneurism.  Instead  of  beginning  with  the  exposure  of  the  artery 
above  the  tumor,  Keisleyre,  after  having  suspended  the  course  of  the  blood 
in  the  member,  by  the  assistance  of  the  garot  or  of  the  tourniquet,  opened 
the  whole  length  of  the  aneurismal  bag,  cleansed  it  carefully,  sought  out 
the  opening  in  the  artery,  introduced  by  it  the  end  of  a  sound,  so  as  to 
raise  the  trunk,  tied  its  superior  portion,  compressed  the  inferior,  and  then 
treated  the  wound  by  the  customary  means.  A  century  after  the  time  of 
Keisleyre,  Guattani,  Molinelli,  Flajani,  and  almost  all  the  surgeons  of  Italy, 
employed  the  same  method,  which  was  not  long  of  being  generally  adopted  in 
France,  Germany,  and  England,  after  having  undergone  at  difterent  times 
some  slight  modifications. 

F.  Instead  of  merely  compressing  the  inferior  extremity  of  the  artery, 
Molinelli,  Guattani,  and  others,  found  it  most  prudent  to  encircle  this  too 
with  a  ligature.  The  two  Monros,  Hunter,  Desault,  Pelletan,  Deschamps, 
and  Boyer,  believed  that  it  would  also  be  useful  to  leave  some  threads  above 
and  below  the  former,  to  be  used  in  case  of  necessity  to  arrest  consecutive 
hemorrhages.  Hence  arose  the  use  of  the  precautionary  ligature,  which  has 
been  already  discussed. 

G.  A  method  diiferent  from  this  last,  and  of  which  the  elements  are  found 
in  Aetius  and  Guillemeau,  was  introduced  into  practice  in  tke  beginning  of 
the  last  century  by  Anel.  Having  to  treat  an  aneurism  on  a  missionary  of 
the  Levant,  on  the  30th  of  January,  1710,  Anel  applied,  in  the  presence  of 
Lancisi,  a  simple  ligature  to  the  humeral  artery  immediately  above  the  tumor, 
without  touching  the  cyst.  On  the  5th  of  March  following  the  patient  was 
cured.  Nevertheless,  this  result,  however  remarkable,  did  not  at  first  attract 
attention,  and  was  not  rescued  from  oblivion  until  somewhere  between  1780 
and  1786,  when  Desault  endeavored  to  bring  it  again  into  notice  in  the 
month  of  June,  1785.  He  tied  the  popliteal  artery  without  opening  the 
aneurismal  sac.  On  the  19th  day  a  large  quantity  of  matter  mixed  with  blood 
escaped  from  the  wound,  and  in  a  short  time  after,  the  cure  appeared  to  be 
complete  ;  but  the  patient  sunk  about  the  seventh  or  eighth  month. 

According  to  M.  Martin,  of  Marseilles,  Professor  Spezani  had  conceived, 
early  in  the  year  1781,  the  project  of  tying  the  femoral  artery  without 
touching  the  sac,  in  cases  of  popliteal  aneurism.  In  the  month  of  December, 
1785,  Hunter  carried  this  project  into  execution.  His  operation,  being 
completely  successful,  caused  a  great  sensation  in  the  surgical  world,  and  was 
really  the  signal  of  an  entire  revolution  in  the  theory  of  the  treatment  of 
aneurisms. 

After  this  period  the  method  of  Anel  has  been  described  as  the  "  new 
method,"  the  "  modern  method,"  the  *'  method  of  Desault,"  or  of  **  Hunter," 
neither  of  which  denominations  is  justly  applicable,  and  all  of  which  should 
yield  to  the  name  of  "  the  method  of  Anel,"  its  actual  inventor. 

H.  A  last  method  has  just  been  introduced  into  the  science.  Arrested  by 
the  difficulty  or  the  impossibility  of  applying  a  ligature  betwixt  the  aneu- 
rism and  the  heart,  and  by  the  dangers  of  opening  the  sac  when  the  disease 
is  situated  too  near  the  trunk,  yet  unwilling  to  resort  to  the  method  of 
Valsalva,  or  to  topical  refrigerants,  some  surgeons  have  thought  it  feasible  to 
tie  the  vessel  between  the  tumor  and  the  capillary  termination  of  the  artery. 
According  to  M.  Boyer,  it  is  to  Vernet,  a  military  surgeon,  that  we  should 
7 


50  NEW    ELEMENTS    OF 

ascribe  the  suggestion  of  this  idea,  since  he  first  tried  the  compression  of  the 
femoral  artery  below  an  inguinal  aneurism.  Brasdor  is  not  the  less  the  first 
who  formally  proposed  to  place  the  ligature  in  that  situation.  Desault  after- 
wards advised  the  same  method,  and  Deschamps  put  it  in  practice  in  the 
case  of  a  very  voluminous  aneurism  in  the  bend  of  the  arm,  which  threatened 
to  burst.  The  palpitations  soon  became  much  stronger  in  the  tumor,  which 
it  was  found  necessary  in  a  few  days  to  open  very  freely,  and  the  patient 
died  in  consequence  of  this  operation,  after  having  lost  a  considerable  quantity 
of  blood.  From  that  time  the  proposition  of  Brasdor  seemed  to  have  been 
definitively  condemned,  was  pronounced  to  be  absurd,  and  was  generally 
rejected  as  dangerous.  The  experiment  of  Deschamps  seemed  to  confirm 
fullvthe  fears  which  had  been  suggested  by  reasoning  a  priori.  It  had  been 
saicf  that  upon  tying  the  artery  on  that  side  of  the  cyst,  the  blood  being 
arrested  at  this  point  by  an  insurmountable  obstacle,  would  distend  the 
aneurismal  tumor  with  more  violence  than  ever,  render  the  parietes  thinner, 
and  finish  by  bursting  a  passage  through  them.  But  Sir  Astley  Cooper, 
convinced,  like  Brasdor,  that  the  circulation  when  suspended  in  the  artery 
below  the  tumor,  would  turn  aside  by  the  collateral  branches,  to  return 
through  the  inferior  portion  of  the  limb,  but  would  stagnate  and  occasion 
coagula  in  the  tumor  itself,  and  all  that  part  of  the  vessel  which  lay  between 
the  ligature  and  the  first  considerable  branch  given  oft*  in  the  direction  of  the 
iieart,  thought  it  not  right  to  yield  to  the  above  reasoning.  With  these  views 
he  ventured  in  1818  to  repeat  the  experiment  of  Deschamps  on  an  aneurism 
which  pushed  upwards  Poupart's  ligament,  and  appeared  to  occupy  a  great 
part  of  the  iliac  fossa.  The  pulsation  in  the  tumor  continued,  but  the  progress 
of  the  disease  was  arrested.  At  the  expiration  of  some  time,  the  tumefaction 
of  the  neighboring  parts  disappeared ;  the  coming  away  of  the  ligatures  was 
not  followed  by  any  accident;  the  wound  cicatrized,  and  about  the  sixth 
week  he  sent  the  patient  to  pass  the  period  of  convalescence  in  the  country. 
They  learned  afterwards  that  the  tumor  had  broken,  and  that  the  man  had 
expired  about  two  months  after  the  operation  :  the  body  was  not  opened. 
Notwithstanding  this  unfortunate  result.  Sir  A.  Cooper's  operation  was  still 
capable  of  exciting  some  hope,  and  of  giving  rise  to  new  experiments.  M. 
Marjolin,  in  1821,  says,  that  before  this  method  should  be  entirely  abandoned, 
new  experiments  ought  to  be  made,  particularly  on  the  primitive  trunk  of  the 
carotid.  M.  Pecot  has  positively  advised  its  adoption  (since  1822),  in 
certain  cases  of  aneurism  of  the  primitive  and  external  iliac  arteries,  and  even 
of  the  subclavian,  when  the  volume  or  the  disposition  of  the  tumor  prevents 
the  exposure  of  the  artery,  by  the  method  of  Anel ;  the  collateral  branches 
which  may  exist  between  the  principal  ligature  and  the  sac,  should  be  at  the 
same  time  secured.  M.  Casamayor  also  says,  in  his  thesis  (in  1825),  after 
having  reviewed  the  facts  and  arguments  cited  for  and  against  the  method  of 
Brasdor,  that  it  may  be  employed  with  success  in  cases  of  aneurism,  where  it 
is  possible,  by  this  means,  to  suspend  the  current  of  the  blood,  or  to  reduce 
its  column  to  a  size  insufficient  to  prevent  the  contraction  of  the  tumor.  M. 
Dupuytren  has  long  said,  in  his  lectures  at  the  Hotel  Dieu,  that  the  partial 
success  obtained  by  Sir  A.  Cooper  should  incite  rather  than  repress  the  zeal 
of  surgeons,  and  that  by  restricting  the  patient  to  a  close  regimen,  and  dimi- 
nishing the  mass  of  the  fluids  by  frequent  blood-lettings,  either  before  or  after 
operation,  its  success  would,  in  all  probability,  be  favored.  Things  were  in 
this  state,  when,  in  spite  of  the  reasonings  of  A.  Burns,  Hodgson,  and  many 
other  English  authors,  Mr.  Wardrop,  in  1825,  resorted  to  the  method  of 
Brasdor  in  a  case  of  aneurism  of  the  primitive  carotid.     This  operation  was 


OPERATIVE    SURGERY.  51 

performed  on  a  woman  seventy-five  jears  old,  on  whom  the  tumor,  being 
situated  close  to  the  sternum,  would  not  permit  the  passage  of  a  ligature 
between  itself  and  the  heart.  On  the  fourteenth  daj^  the  aneurism  was 
diminished  one  half;  pulsation  in  it  ceased,  and  it  at  last  broke  and  emptied 
itself  like  an  abscess.  The  ulcer  was  promptly  cicatrized,  and  the  patient 
recovered.*  In  the  course  of  the  same  year,  Mr.  Wardrop  had  occasion  to 
treat  another  woman,  aged  fifty-seven  years,  for  an  aneurism  situated  exactly 
under  the  sterno-mastoidean  muscle  of  the  right  side.  On  the  10th  of  December, 
in  the  presence  of  Mr.  Lawrence,  the  carotid  artery  was  tied  with  a  ligature 
formed  of  the  intestines  of  the  silk-worm;  on  the  13th  the  wound  was  found 
to  be  entirely  closed,  and  on  the  21st  the  patient  was  believed  to  be  entirely 
cured.  She  sunk  on  the  23d  of  March  following,  but  with  all  the  symptoms 
of  hypertrophy  of  the  heart,  and  of  accidents  which  could  not  be  said  to  have 
any  connection  with  the  operation  itself.  On  the  1st  of  March,  1827,  Mr.  J. 
Lambert,  of  Walworth,  took  occasion  to  imitate  Mr.  Wardrop,  in  a  case  of 
aneurism  of  the  right  carotid,  on  a  woman  of  forty-nine  years  of  age.  On 
the  third  day  the  tumor  had  greatly  decreased  in  size,  and  presented  only 
slight  pulsations.  On  the  tenth  day  came  on  a  hemorrhage,  which,  how'- 
ever,  did  not  prevent  the  wound  from  closing.  The  tumor  soon  after 
disappeared.  On  the  17th  of  April  the  cicatrix  opened,  and  a  fleshy  lump 
was  found  to  occupy  the  centre.  On  the  18th  a  new  hemorrhage  occurred  ; 
was  several  times  repeated  between  that  day  and  the  30th,  and  on  the  1st  of 
May  became  so  abundant  that  the  patient  expired. 

On  examination  of  the  body,  it  was  perceived  that  the  carotid  artery  was 
ulcerated  above  the  ligature  ;  that  the  aneurism  was  entirely  obliterated,  and 
that  the  hemorrhage  was  attributable  to  the  reflux  of  the  blood  from  one 
carotid  artery  through  the  other.  Mr.  Bushe,  of  New  York,  performed,  on  the 
11th  of  September,  1827,  a  similar  operation  on  a  woman,  thirty-six  years  of 
age,  with  complete  success.  Mr.  Wardrop  practised  it  for  the  third  time,  on 
the  6th  of  July  of  the  same  year,  on  a  lady  of  forty-five  years  of  age.  On  this 
occasion,  he  tied  the  subclavian  artery  instead  of  the  carotid,  which  was  not  the 
seat  of  any  pulsation,  and  which  appeared  to  be  obliterated.  One  month  after 
the  patient  left  London,  in  order  to  recruit  her  strengtli  in  the  country,  and 
towards  the  end  of  August  was  completely  restored.  Various  symptoms  of 
disease  in  the  chest  afterwards  occasioned  some  uneasiness:  on  the  9th  of 
September,  1828,  her  health  was  as  good  as  it  ever  had  been  ;  yet  she  died  on 
the  13th  of  the  same  month,  in  1829.  On  the  2d  of  July,  1828,  Mr.  Evans, 
of  Belper,  in  his  turn,  operated,  upon  the  plan  of  Brasdor,  upon  a  patient  aged 
thirty  years,  for  an  aneurism  of  the  trunk  of  the  carotid  artery,  and  on  the  28th 
of  October  the  patient  returned  to  his  usual  avocations.  The  disease  after- 
wards reappeared,  and  it  became  necessary  to  perform  a  new  operation  ;  to  tie 
two  tumors  and  excise  them.  The  patient  was  finally  cured.  (Letter  of  Mr. 
Evans  to  M.Villardebo,  May,  1831.)  A  negro,  treated  in  the  same  manner,  on 
the  10th  of  March,  1829,  by  Mr.  Montgomery,  of  the  island  of  Mauritius, 
appeared  to  have  been  cured,  but  died  on  the  llth  of  July  following.  Dr.V. 
Mott  lost  a  patient  on  the  22d  of  April,  1830,  upon  whom  he  had  operated  on 
the  20th  September,  1829,  and  whom  he  had  believed  to  be  cured.  A  woman 
operated  upon  by  Mr.  Key,  expired  during  the  course  of  the  same  day. 
Lastly,  an  attempt  of  the  same  kind  was  made  on  the  12th  June,  1829,  at  the 
Hotel  Dieu,  by  M.  Dupuytren,  in  case  of  an  aneurism  at  the  origin  of  the 
right  subclavian  artery:  the  patient  died  on  the  ninth  day  after  the  operation, 

*  Was  it  really  an  aneurism  ? 


52  NEW   ELEMENTS    OF 

rather,  perhaps,  in  "consequence  of  profuse  hemorrhages  than  immediatelj 
from  the  operation  itself.  Messrs.  White  and  James,  who  have  imitated  Sir 
A.Cooper,  have  not  been  more  successful.  There  are  then,  these  three 
methods  of  treating  aneurism  by  ligature;  and  it  only  remains  to  be  de- 
termined which  should  be  generally  preferred,  and  in  what  cases  it  will  be 
advisable  to  have  recourse  to  the  other  two. 


Relative  value  of  the  three  principal  methods. 

By  the  old  method,  or  that  of  Keisleyre,  it  is  necessary  tliat  tl;e  situation  of 
the  tumor  should  permit  the  introduction,  between  it  and  tl.e  heart,  of  a 
sufficient  compression  to  suspend  for  a  time  all  circulation  in  the  limb.  The 
opening  of  the  sac  requires  very  extensive  incision  ;  involves  a  large  suppu- 
ration ;  renders  the  isolation  and  the  ligature  of  the  artery  sometimes  very 
difficult ;  frequently  requires  the  thread  to  be  placed  on  a  part  of  the  artery 
more  or  less  diseased  ;  especially  exposes  the  patient  to  the  dangers  of  con- 
secutive hemorrhage,  and  of  gangrene  by  default  of  circulation ;  and  is  ex- 
tremely slow  of  cicatrization. 

By  the  method  of  Anel,  on  the  contrary,  we  deal  with  tissues  which  are  in 
their  normal  state,  and  of  which  the  relations  have  not  been  disturbed.  It  is 
easy  to  exclude  every  thing  but  the  arterial  trunk  from  the  loop  of  the  ligature, 
leaving  untouched  the  nerves  and  veins,  and  all  other  tissues,  the  inclusion  of 
which  mi^ht  endanger  more  or  less  the  success  of  the  operation.  The  previous 
compression  of  the  vessel  is  not  indispensable  :  the  incision  is  clean,  of  slight 
extent,  and  quickly  and  easily  cicatrized.  The  operation  is  simple,  easy  of 
execution,  much  less  painful,  and  less  protracted  than  the  other  method ;  and 
the  artery  not  having  been  opened,  and  being  tied  at  a  point  perfectly  sound, 
secondary  hemorrhages  are  less  to  be  feared,  and  much  less  frequent.  As 
the  continuity  of  the  tissues  is  not  so  much  interrupted,  the  circulation 
establishes  itself  more  easily  below  the  ligature  .;  the  reaction  in  the  general 
system  is  naturally  less  powerful,  and  the  gangrene  of  the  member  less  to  be 
apprehended.  But  by  the  opening  of  the  sac,  the  thread  can  be  applied  as  low 
as  possible ;  the  tumor  is  immediately  emptied ;  a  new  disease  is  not  added  to 
the  original  one  5  and  all  the  collateral  arteries  which  are  given  off  above  the 
aneurism,  are  preserved.  Tumors  situated  too  near  to  the  trunk  to  allow  of 
operation  by  the  method  of  Anel,  permit  the  tying  of  the  two  portions  of  the 
artery  at  the  aneurism.  Again,  if  an  arterial  trunk  has  just  been  wounded, 
and  the  place  of  the  opening  is  known,  it  appears  more  rational  in  the  first 
instance  to  expose  it  at  this  place,  than  to  endeavor,  by  inflicting  a  new^  wound, 
to  seek  for  it  higher  up.  These,  at  least,  are  the  reasons  which  have  been 
advanced,  and  which  Mr.  Guthrie  still  adduces  in  favor  of  the  method  of 
Keisleyre.  In  order  to  repel  these  arguments,  the  partisans  of  Anel  assert, 
that  after  the  lipture  of  an  artery  the  circulation  ceases,  not  only  in  the 
point  nearest  to  the  bandage,  but  as  far  back  as  the  first  considerable  collateral 
branch  given  off  in  the  direction  of  the  heart ;  so  that  in  placing  a  ribbon  on 
the  popliteal  artery,  the  femoral  itself  is  obliterated  as  far  as  the  beginning 
of  the  profunda,  which  shows  that  there  is  no  advantage  to  be  gained  by  dis- 
covering this  vessel  in  the  inferior  third  of  the  thigh.  Then,  in  regard  to 
tumors  which  are  very  near  the  origin  of  the  limb,  there  is  nothing  at  the 
present  day  which  can  render  the  method  of  Anel  inapplicable,  when  they  are 
susceptible  of  the  operation  of  opening  the  sac.  In  diffused  aneurism  it  can- 
not be  denied  that  the   embarrassment  produced  by  the  effused  blood,  the 


OPERATIVE    SURGERY.  53 

displacement  and  disorganization  of  the  tissues,  the  difficulty  of  immediately 
hitting  upon  the  wounded  part,  and  even  of  finding  the  vessel  itself  at  the 
bottom  of  a  wound  more  or  less  irregular,  and  the  depth  to  which  this  wound 
must  in  some  cases  extend,  present  obstacles  which  certainly  justify  the  prac- 
tice of  those  who  even  then  operate  at  a  higher  point  upon  the  limb,  especially 
since  any  hemorrhage,  which  might  return  by  the  inferior  portion  of  the  artery, 
could  be  easily  arrested  by  compression  properly  applied. 

Those  who  oppose  the  method  of  Anel,  say,  that  in  placing  a  ligature  at  some 
distance  from  the  seat  of  the  disease,  the  blood  and  pulsations  are  likely  to  re- 
appear in  the  cyst,  and  thus  a  grave  operation  will  have  been  performed  abso- 
lutely to  no  purpose.  Very  often,  it  is  true,  the  pulsations  are  revived  in  the 
aneurism  a  short  time  after  the  application  of  the  ligature,  according  to  the 
method  of  Anel ;  the  blood  may  return  by  anastomatic  arches  into  the  portion 
of  the  arterial  trunk  comprised  between  the  tumor  and  the  ligature,  and  enter 
into  the  aneurismal  sac  by  its  inferior  opening,  or  perhaps  arrive  there  directly 
by  some  secondary  branch;  but  experience  has  sufficiently  demonstrated  that 
these  pulsations  very  soon  cease,  or  at  least,  that  a  moderate  compression  is 
generally  enough  to  put  a  stop  to  them.  Reason,  too,  perfectly  explains  this 
result.  The  blood  which  enters  into  the  aneurism  cannot  do  so  under  such 
circumstances,  without  having  traversed  the  capillary  system,  having  passed 
through  very  fine  ramifications  into  the  larger  branches,  and  having  conse- 
quently lost  a  great  portion  of  its  ordinary  impetus.  Now,  as  it  is  sufficient 
to  determine  the  coagulation,  that  the  blood  should  remain  in  a  state  of 
oscillation  or  of  stagnation,  that  it  should  cease  to  circulate  in  any  point  of 
the  vascular  system,  it  is  easily  seen,  that  the  disadvantage  in  question  is  far 
from  having  the  importance  originally  ascribed  to  it.  \Vith  regard  to  the 
consecutive  opening  of  the  cyst,  its  suppuration,  and  inflammation,  which  have 
been  thought  capable  of  endangering  the  success  of  the  method  of  Anel,  they 
are  circumstances  generally  too  trifling  to  require  attention,  and  which,  even 
when  they  prove  otherwise,  render  the  operation  after  all  less  serious  than 
that  of  Keisleyre;  they  are  hardly  ever  seen  except  in  cases  where  the 
disease  is  much  advanced,  or  the  aneurism  enormous  and  enclosed  by  very 
slender  parietes  more  or  less  disposed  to  mortification.  The  method  of 
Anel,  then,  possesses  numerous  and  undeniable  advantages  over  the  ancient 
method.  Some  persons,  however,  still  persist  in  believing  that  this  latter 
should  not  be  entirely  rejected,  and  that  it  should  be  preferred,  for  example,  in 
cases  of  superficial  diffused  aneurism  ;  those  which  occupy  the  brachial  artery 
immediately  in  the  vicinity  of  the  armpit ;  those  of  the  axillary  itself,  when 
the  shoulder  is  infiltrated,  or  so  much  distorted  that  it  would  be  dangerous  to 
attempt  the  operation,  either  before  or  above  the  clavicle ;  in  aneurism  in 
general,  when  it  is  very  voluminous  or  threatens  to  gangrene,  or  is  seated 
near  a  large  and  important  collateral  branch ;  and  in  varicose  aneurism,  which 
imperiously  demands,  as  we  are  assured,  that  the  artery  should  be  tied  both 
above  and  below  its  opening.  This  doctrine  which  is  supported  with  great 
zeal  by  Mr.  Guthrie,  appears  to  me  to  be  very  just,  and  altogether  conformable 
to  the  principles  of  sound  surgery ;  several  facts,  among  which  are  the  ligature 
of  the  femoral  artery,  and  a  similar  operation  on  the  external  iliac,  which  will 
be  mentioned  in  their  proper  place,  have  demonstrated  to  me  the  truth  and 
justness  of  this  position. 

The  method  of  Brasdor,  which  is  but  a  modification  of  Anel,  possesses 
consequently,  as  an  operation,  the  same  general  advantages  and  disadvan- 
tages. It  is  nothing  more,  however,  than  a  make-shift,  a  last  resort,  applicable 
only  to  cases  which  do  not  permit  the  employmeht  of  either  of  the  others 


54  NEW    ELEMENTS   OF 

The  cures  obtained  by  this  method,  are  explained  in  the  following  manner : 
the  blood  circulates  with  less  force  in  the  aneurism  than  above  and  below, 
according  to  a  well-krfown  law  of  hydraulics.  With  this  predisposition,  the 
first  effect  of  a  ligature  applied  to  the  portion  of  an  artery  which  brings  the 
blood  to  the  aneurism,  should  be  to  arrest  the  circulation  first  in  its  cavity, 
and  afterwards,  as  far  back  as  the  supplementary  branches  by  which  tlie 
blood  can  deviate  from  its  usual  course. 

If  the  carotid,  for  example,  should  be  tied  near  its  bifurcation,  it  would  be 
obliterated  step  by  step  to  its  very  origin  ;  that  is  to  say,  to  the  point  where 
it  leaves  the  aorta  or  the  subclavian.  It  is  the  same  with  the  tibial,  radial, 
cubital,  popliteal,  brachial,  and  femoral  arteries,  respectively ;  but  if  it  is 
sufficient  to  close  an  artery  towards  its  capillary  extremity  in  order  to  efface 
the  canal,  it  is  evident  that  the  aneurism,  being  situated  between  these  two 
points,  would  disappear  almost  as  easily  and  as  surely  when  the  ligature  was 
used  below,  as  if  it  had  been  carried  above  the  seat  of  the  disease.  It  may  be 
presumed,  that  according  to  the  method  of  Brasdor,  the  pulsations  would  less 
frequently  reappear  or  be  maintained  in  the  cyst,  than  by  the  method  of 
Anel,  unless  one  or  more  considerable  collateral  branches  should  be  given 
oft*  between  the  ligature  and  the  lesion.  In  this  latter  case,  the  operation 
will  without  doubt  have  a  less  chance  of  success  ;  but  still  it  appears  to  me 
likely  to  very  often  succeed,  provided  the  supplementary  branches  should  be 
two  or  three  times  less  in  calibre  than  the  principal  trunk,  and  do  not  allow 
tlie  blood  a  sufficient  passage  of  deviation  to  prevent  its  stagnation  in  the 
aneurismal  sac ;  and  "provided  the  parietes  of  the  latter  should  preserve  suf- 
ficient density  to  resist  the  efforts  of  the  tumultuous  throbbings,  which  it 
generally  lias  to  sustain  immediately  after  the  operation. 

The  value  of  the  new  method  should  not,  however,  be  exaggerated.  Of 
fourteen  subjects  who  have  submitted  to  its  application,  eleven  have  died  and 
the  twelfth  has  incurred  the  most  imminent  danger.  A  multitude  of  facts 
scattered  through  the  annals  of  the  science,  prove  that  the  arteries  are  far 
from  being  always  obliterated  to  a  great  extent  above  the  ligature.  Warner 
quotes  a  case  of  brachial  aneurism  which  supervened  upon  amputation  above 
the  elbow,  and  which  it  was  necessary  to  treat  by  tying  the  vessel  towards 
the  armpit.  An  amputation  of  the  leg  presented  the  same  phenomenon  to  M. 
Roche,  in  1813,  at  Tarragona,  and  it  was  necessary  to  tie  the  posterior  tibial 
between  the  aneurism  and  the  popliteal  artery.  Two  instances  of  aneurisms 
have  been  presented  by  Mr.  Hodgson,  which  were  closed  at  their  inferior 
origin,  and  which,  nevertheless,  burst  or  mortified.  Mr.  Guthrie  says,  that 
several  preparations  in  Hunter's  collection,  show  a  complete  obliteration  of 
the  artery  beneath  the  bag,  without  a  cure  of  the  aneurism.  In  proceeding 
to  the  ligature  of  the  external  iliac,  according  to  the  method  of  Brasdor,  Mr* 
White  found  the  artery  impermeable,  and  yet  the  aneurism  continued  to 
increase,  and  I  have  at  this  time  under  my  own  observation,  a  woman  who 
undertook  a  month  ago  amputation  at  the  knee,  in  whom  the  popliteal  artery 
has  not  yet  ceased  to  beat  strongly  at  the  bottom  of  the  wound  ;  and  who  has 
not  witnessed  the  same  phenomenon  in  all  similar  amputations  ?  Now,  if  the 
arterial  cyst  continues  below  the  origin  of  the  collateral  branches,  and  at  the 
distance  of  one  or  two  inches  from  the  suppurating  surface  of  an  amputation, 
or  from  the  spontaneous  obliteration  of  the  vessel,  it  is  difficult  to  see  why  it 
must  be  otherwise  after  the  formal  application  of  the  ligature. 


OPERATIVE    SURGERY.  55 

Art.  7. — Manual. 

Is  it  necessary,  before  practising  the  ligature  of  an  artery,  to  subject  the 
patient  to  any  preparatory  treatment  ?  Is  it  necessary  to  wait  for  an  advanced 
period  of  the  aneurism  ?  Or  is  it  better  to  operate  as  soon  as  its  existence  is  well 
ascertained  ?  The  preparatory  compression  recommended  with  the  design 
of  favoring  the  development  of  the  supplementary  vessels,  is  wholly  unneces- 
sary. It  has  of  late  been  generally  abandoned,  and  it  is  not,  in  fact,  proper 
to  employ  it,  except  in  cases  where  it  offers  some  chances  of  being  of  itself  a 
means  of  cure.  According  to  the  old.  method,  there  was  no  risk  in  delaying 
the  operation.  The  partial  interruption  of  the  course  of  the  blood,  produced 
by  the  development  of  the  tumor,  would  naturally  render  the  collateral 
circulation  more  and  more  free,  and  allow  the  hope  of  a  certain  number  of 
even  spontaneous  cures.  Indeed,  at  the  present  time  these  feeble  accessaries 
are  no  longer  esteemed,  and  the  new  processes  are  resorted  to  as  early  as 
possible.  Some  persons  have  proceeded  so  far  (but  improperly,  according  to 
ray  opinion,  particularly  in  important  cases)  as  even  to  neglect  all  precautions 
in  regard  to  regimen  or  general  therapeutics.  One  or  two  bleedings,  if  the 
subject  is  of  a  robust  or  sanguine  temperament,  a  diminution  more  or  less  con- 
siderable in  the  quantity  of  aliments,  bitter  and  diluting  drinks,  anodynes, 
warm  bathing,  antispasmodics  if  there  is  agitation  or  great  irritability,  some 
preparation  of  digitalis  to  diminish  the  force  of  the  impulse  of  the  heart,  a  mild 
purgative  when  the  digestive  organs  are  clogged,  and  leeches  if  any  local 
mflamation  is  developed,  will  never  be  omitted  by  any  one  who  knows  how  to 
combine  the  principles  of  sound  therapeutics  with  those  of  enlightened  surgery. 

§  1.  Old  Method, 

Apparatus. — According  to  the  ancient  method,  the  necessary  apparatus  was 
composed  of  a  convex,  a  straight,  and  a  probe-pointed  bistoury,  a  female  sound, 
some  buttoned  stylets,  a  spatula,  needles  of  dilFerent  forms,  ligatures,  a 
tourniquet  or  a  garot,  agaric,  lint,  bandages,  sponges,  scissors,  &c.  The  skin 
whicii  covers  the  aneurism  and  the  parts  about  should  be  carefully  shaved. 

Position  of  the  Patient  and  of  ihe  Assistants. — Thepatient  being  placed  upon 
a  bed  or  table  conveniently  situated,  an  assistant  is  charged  with  the  duty  of 
compressing  the  artery  between  the  tumor  and  heart,  witb  his  lingers,  a  rolled 
bandage,  theg-arof  of  Morel,  the  tourniquet  of  Petit,  or  some  other  instrument 
of  the  kind ;  a  second  assistant  holds  the  sound  limb,  or  faces  the  operator ; 
a  third  presents  or  receives  the  instruments  according  as  they  are  required 
or  become  unnecessary  ;  a  fourth  and  a  fifth  are  sometimes  of  use  in  holding 
the  head  or  other  parts  of  the  body,  from  the  movements  of  which  any  danger 
might  be  apprehended. 

Operation. — The  passage  of  the  artery  being  accurately  known,  the  surgeon 
proceeds  to  divide  with  the  convex  bistoury,  first  the  skin  and  the  adipose 
stratum,  and  then  at  a  second  stroke  the  entire  thickness  of  the  cyst,  beginning 
a  little  above  and  finishing  by  about  an  inch  below.  After  having  removed 
the  coagula,  and  sponged  and  cleansed  the  botton  of  the  wound,  he  then  searches 
for  the  opening  of  the  vessel,  relaxing  for  a  moment  the  compression,  if  neces- 
sary, in  order  more  surely  to  arrive  at  it ;  introduces  by  this  opening  a  buttoned 
stylet,  the  female  or  the  grooved  sound;  raises  the  superior  extremity  of  the 
artery ;  assures  himself  anew  that  it  is  really  the  artery  which  he  has  before 
his  eyes ;  isolates  it  from  the  vein,  the  nerves,  and  the  other  tissues  which  he 
designs  to  avoid ;  passes  the  thread  under  it  so  as  to  embrace  the  sound  at  the 


56  NEW   ELEMENTS   OF 

same  time ;  seizes  the  two  principal  ends  of  this  thread,  which  he  draws  towards 
himself  with  one  hand  whilst  he  applies  the  fore-finger  of  the  other  upon  the 
raised  trunk  to  feel  the  pulsations,  to  make  himself  sure  that  the  artery  has 
been  well  taken  up  and  that  the  ligature  which  has  just  been  passed  around 
it  will  really  efface  its  calibre;  there  is  nothing  more  to  be  done  then,  but  to 
tie  the  ligature  with  a  simple  knot  while  an  assistant  withdraws  the  sound, 
to  fix  this  first  knot  by  a  second,  and  to  cut  one  of  the  ends  of  the  thread  very 
close  to  the  artery.  The  inferior  extremity  of  the  vessel  is  subjected  to  the 
same  operation.  The  bottom  of  the  wound  is  then  filled  with  agaric,  or  better 
with  pellets  of  soft  lint,  which  are  covered  with  large  pledgets  smeared  with 
cerate ;  over  these  are  applied  compresses,  and  all  are  confined  by  a  simple 
bandage  which  completes  the  dressing. 

§  2.  Method  of  Anel. 

When  we  operate  without  opening  the  sac,  we  may  omit  some  precautions 
which  are  necessary  in  operating  by  the  old  method.  The  position  of  the 
patient,  and  of  the  assistants,  is  not  materially  different ;  but  the  compression 
of  the  artery  above  the  tumor  has  no  longer  any  particular  object,  and  is 
notliing  more  than  a  matter  of  prudence.  The  point  upon  which  it  is  expe- 
dient to  apply  the  ligature,  not  being  determined  by  the  presence  of  the 
aneurism,  demands  some  further  attention  on  the  part  of  the  surgeon. 

Point  of  Election, — In  spontaneous  aneurisms  the  incision  should  be  made 
as  far  as  possible  from  the  tumor,  because  the  nearer  you  approach  it  the  more 
reason  is  there  to  apprehend  coming  in  contact  with  a  diseased  portion  of  the 
vascular  tunics.  A  contrary  rule  is  to  be  observed  in  cases  of  traumatic 
aneurism,  because  while  you  are  sure  in  placing  thethread  very  low  of  finding 
the  artery  as  healthy  as  any  where  else,  you  have  the  additional  advantage  of 
leaving  untouched  collateral  branches  more  or  less  important.  If  in  any  case 
the  operation  should  threaten  to  be  much  more  difficult  near  the  aneurism 
(unless  there  should  be  a  voluminous  supplementary  branch  to  sacrifice),  you 
would  proceed  to  search  for  the  vessel  in  that  region  where  it  would  be  more 
easy  and  less  dangerous  to  expose  it.  The  farther  from  the  cyst  you  operate 
the  less  vou  are  likely  to  determine  rupture,  suppuration,  or  inflammation^ 
But  we  should  not,  in  endeavoring  to  avoid  one  extreme  fall  into  another; 
that  is,  to  carry  the  thread  immediately  beneath  any  great  secondary  arterial 
branch.  In  fact  the  consequences  of  such  an  operation  rarely  fail  to  be  trouble- 
some ;  not,  as  it  has  been  too  often  repeated,  because  the  coagula,  of  which 
Jones  has  said  so  much,  cannot  be  formed,  but  because  the  blood,  finding  a 
free  and  very  large  passage  immediately  above  the  bandage,  does  not  permit 
the  arterial  parietes  to  approximate  and  form  mutual  adhesions.  As  it  is 
necessary  to  reach,  by  the  nearest  possible  way,  the  artery  which  is  to  be  tied» 
the  operator  should  first  of  all  be  perfectly  acquainted  with  its  course.  This 
knowledge  is  acquired  by  calling  to  mind  the  relations  of  the  muscular 
elevations,  and  of  the  furrows  which  separate  them,  as  well  as  by  the  assist- 
ance of  the  arbitrary  lines  invented  by  M.  Richerand,  which  are  drawn  between 
certain  osseous  projections. 

Incision. — Whatever  may  be  the  decision  on  this  point,  the  surgeon,  placing 
himself  on  the  same  side  with  the  aneurism,  begins  the  operation  by  stretching 
the  integuments,  either  transversely  by  means  of  the  thumb,  the  fore-finger, 
and  the  cubital  border  of  the  hand,  or  by  applying  the  extremities  of  all 
the  fingers  over  the  passage  of  the  vessel  in  a  line  parallel  to  its  direction,  as 
is  advised  by  M.  Lisfranc.    The  incision  is  then  made  through  the  skin  to 


OPERATIVE    SURGERY.  57 

the  length  of  from  two  to  four  inches.  This  incision  should  be  made  with  a 
bistoury  convex  on  the  edge,  rather  than  with  a  straight  bistoury ;  and  it  is 
better  to  make  it  a  little  too  long  than  too  short.  But  in  the  greater  number 
of  cases,  whenever  it  is  not  necessary  to  penetrate  deepljr,  it  is  enough  to 
make  an  incision  of  two  or  three  inches.  Most  commonly  it  is  made  in  the 
direction  of  the  artery,  but  sometimes  in  that  of  the  fleshy  fibres  ;  in  such  a 
case  it  may  cross  the  vessel  more  or  less  obliquely.  Care  should  be  taken'  to 
avoid  cutting  too  deeply  at  the  first  stroke :  it  is  much  better  to  repeat  it  a 
second  time  in  order  to  get  through  the  skin,  than  to  come  unawares  upon  the 
artery.  After  the  integuments  the  aponeurosis  is  encountered,  which  is  to 
be  divided  in  the  same  manner,  if  the  artery  still  remains  at  some  depth. 
If  not,  or  if  the  operator  is  not  very  sure  of  his  hand,  he  passes  a  grooved 
director  under  the  artery,  to  serve  as  a  guide  to  the  bistoury.  The  other 
lamellae  should  be  successively  divided,  with  the  same  precautions  and  to 
the  same  extent.  Having  arrived  at  the  lash  of  vascular  and  nervous  cords, 
the  surgeon  should  first  open  the  common  sheath.  The  director  is  here 
of  the  greatest  importance.  It  is  carefully  entered  either  from  the  upper 
towards  the  lower  part  of  this  sheath,  or  from  the  lower  to  the  upper,  taking 
the  precaution  to  raise  it  alone,  and  not  to  permit  any  of  the  parts  which  it 
may  be  dangerous  to  wound  to  slide  between  it  and  the  instrument.  In  order 
then  to  isolate  the  artery,  a  grooved  director  is  again  used,  which  should  be 
of  steel  (rather  than  of  silver  or  of  gold),  slightly  flexible,  somewhat  conical, 
without  a  cul-de-sac,  and  less  obtuse  than  the  ordinary  probe.  It  is  held  in 
the  manner  of  a  pen,  and  the  extremity  is  inserted  between  the  vein  and  the 
artery.  Then,  by  light  movements  to  and  fro,  sustained,  however,  by  a 
pennanent  though  moderate  pressure,  the  two  vessels  are  separated  to  the 
extent  of  several  lines.  In  the  same  degree  that  this  separation  takes  place 
the  operator  reverses  the  position  of  the  sound,  in  order  that  its  beak  (or  nib), 
inclined  by  degrees  as  it  passes  under  the  posterior  surface  of  the  vessel, 
may  present  itself  on  the  opposite  side  ;  at  this  point  the  fore  and  middle 
finger  of  the  other  hand  remove  the  nervous  trunks,  or  push  backwards  and 
to  the  outer  side  all  the  parts  which  it  may  be  designed  to  avoid.  This  same 
director,  before  being  withdrawn,  should  still  perform  another  duty,  that  of 
serving  as  a  guide,  as  it  is,  to  the  passage  of  the  ligature ;  whether  this  is 
effected  with  a  simple  silver  probe  with  an  eye  at  one  end,  such  as  is  used  by 
M.  Dupuytren,  Richerand,  and  nearly  all  the  French  surgeons,  or  whether  it 
be  thought  preferable  to  use  for  deep  ligature  the  curved  needle  held  with  the 
pincers  (described  in  the  work  of  Dr.  Dorsey),  or  the  needle  of  J.  L.  Petit, 
that  of  Deschamps,  &c.,  Desault  conceived  the  idea  of  using,  where  it  was 
necessary  to  operate  at  the  bottom  of  a  deep  and  narrow  cavity,  a  spring- 
needle  very  much  like  the  probe  of  Bellocque,  which  has  been  modified  m 
England  by  Messrs.  Ramsden,  Earle,  and  Brenner.  Sir  A.  Cooper  in  these 
difficult  cases  uses  a  steel  wire,  supported  by  a  handle  curved  at  its  free 
extremity,  and  terminated  by  a  knob,  in  the  thickness  of  which  is  an  opening 
destined  to  receive  the  thread.  Scarpa  much  extols  a  small  spatula  of  pure 
silver,  very  thin  and  flexible,  which  can  adapt  itself  to  the  form  of  every  part 
which  it  may  be  required  to  embrace.  But  the  grooved  director,  such  as  I 
have  already  described,  should  rarely  prove  insufficient  in  the  hands  of  a 
skillful  surgeon.  It  possesses  above  all  the  special  instruments,  and  the 
numerous  needles  which  have  been  so  carefully  described  by  M.  Holtz,  in  his 
Treatise  on  Arterial  Ligatures  (published  at  Berlin  in  1827),  the  inestimable 
advantage  of  being  able  to  isolate  the  artery  with  the  greatest  precision,  and 
almost  without  laceration  of  the  adjacent  tissues.  When  it  has  once  arrived 
8 


58  NEW    ELEMENTS   OF 

on  the  other  side  of  the  vessel,  I  cannot  see  how  it  should  be-  impossible  to 
slide  the  head  of  a  flexible  probe  along  its  groove,  and  by  this  means  to  pass 
the  ligature.  An  eye  might  even  be  placed  near  its  point,  so  that  it  might 
pass  the  ligature  at  the  same  time  that  it  separates  and  isolates  the  circum- 
ference of  the  artery.  For  the  rest,  every  practitioner  may  understand  the 
mechanism  of  these  instruments,  and  can  easily  decide  which  should  be 
preferred  to  the  others.  It  is  not  only  useless,  but  even  dangerous  to 
endeavor,  as  Scarpa  advises,  to  raise  and  separate  the  vessel  from  the  neigh- 
boring parts,  with  the  fingers.  By  this  method  the  tissues  are  lacerated,  and 
a  contused  wound  is  formed,  which  must  almost  necessarily  suppurate,  while 
it  is  of  the  greatest  consequence  that  it  should  be  as  clean  and  as  regular  as 
possible.  Those  who  recommend  to  cut  with  the  bistoury  in  a  horizontal 
position  all  the  cellular  lamellae  which  cover  the  artery,  render  themselves 
liable,  notwithstanding  the  most  minute  precautions,  to  wound  it,  or  at  least, 
in  the  most  successful  cases,  to  prolong  the  operation. 

The  sound  obviates  these  difficulties,  permits  the  operator  to  act  with  more 
safety  and  promptitude,  allows  him  to  place  the  ligature  around  the  organ  in 
some  sort,  without  displacing  it  or  deranging  its  natural  relations,  and  to 
expose  it  to  the  slightest  possible  extent. 

The  ligature  should  be  sufficiently  tight  to  arrest  completely  the  passage 
of  the  blood,  not  only  at  the  moment  of  the  operation,  but  afterwards,  which 
cannot  be  done  when  it  includes  with  the  artery  any  muscular,  tendinous,  or 
aponeurotic  fibres,  or  even  a  shred  of  cellular  tissue,  because  these  parts  of 
course  soften  and  relax  the  ligature,  and  soon  render  it  almost  inefficient.  In 
order  to  attain  this  end  it  is  necessary  to  avoid  passing  the  extremities  of  the 
thread  twice,  one  within  the  other,  and  forming  what  is  generally  called  the 
surgeon's  knot.  Under  this  knot,  in  spite  of  the  most  powerful  constriction,  the 
centre  of  the  circle  sometimes  remains  open  and  permeable.  This  happened 
to  Chopart  when,  among  the  first  in  France,  he  attempted,  in  1781,  the  ligature 
of  the  popliteal  artery.  Several  ligatures  were  successively  applied  without 
being  able  entirely  to  suspend  the  circulation  in  the  limb.  Amputation  was 
performed  before  the  patient  was  removed  from  the  table,  and  upon  examin- 
ation of  the  parts  it  was  discovered  that  not  one  of  the  ligatures  had  entirely 
effaced  the  calibre  of  the  vessel.  Two  simple  knots  are  then  to  be  preferred. 
If  the  lij^ature  is  of  an  animal  material,  the  two  ends  are  cut  off  so  as  to 
enclose  the  remainder  in  the  wound  ;  if  otherwise,  one  extremity  is  left  to 
hang  outside.  If,  after  having  laid  the  artery  bare,  the  operator  perceives 
that  it  is  diseased,  that  the  parietes  are  yellow,  fragile,  or  encrusted  with 
calcareous  plates,  it  might  then  be  prudent  to  flatten  it,  as  advised  by  Scarpa, 
instead  of  tying  as  in  other  cases.  Nevertheless,  Messrs.  A.  Cooper, 
Lawrence,  and  Briot  have  had  no  cause  to  repent  having  followed  a  different 
practice,  and  ventured  to  place  a  simple  ligature  about  arteries  obliterated, 
fragile,  or  entirely  morbid.  In  such  cases  the  strips  used  by  Dr.  Jameson 
may  be  of  great  service,  unless  there  be  some  chance  of  deriving  advantage 
from  making  a  new  incision,  and  practising  the  operation  higher  up. 

Dressing. — The  wound  after  being  cleansed  and  freed  from  all  foreign 
bodies  with  which  it  may  be  connected,  should  be  immediately  closed. 
Nothing  is  more  to  be  feared  than  suppuration  succeeding  the  ligature  of 
arteries.  Immediate  reunion,  on  the  other  hand,  in  almost  every  instance 
ensures  success  5  but  it  should  be  promoted  from  the  bottom  of  the  wound 
towards  the  edges,  and  not  from  the  skin  in  the  direction  of  the  deeper  parts, 
as  the  points  of  suture  used  by  some  surgeons  tend  to  favor  its  occurrence. 
Consequently  the  operator  should  confine  himself  to  bringing  the  lips  exactly 


OPERATIVE   SURGERY.  59 

together,  bj  the  aid  of  gradual  compresses  of  strips  of  plaster,  and  of  position. 
Then,  after  wrapping  a  small  piece  of  fine  linen  round  the  exterior  portion 
of  thread,  it  is  turned  towards  the  most  dependent  angle  of  the  incision,  or  to 
that  which  is  nearer  to  the  knot,  or  it  is  brought  directly  out  by  the  shortest 
way  between  two  strips  of  plaster.  A  compress  smeared  with  cerate  and 
pierced  with  holes,  is  applied  above,  or  sometimes  small  bats  of  lint  are  used 
instead.  With  these  precautions,  there  is  then  no  hindrance  after  the  first 
dressing  to  the  removal  of  the  difi*erent  parts  of  the  apparatus.  A  pledget 
of  substantial  lint,  or  one  or  two  oblong  or  square  compresses^  cover  these 
objects,  and  the  dressing  is  terminated,  according  to  the  method  of  Kiesleyre, 
by  a  few  turns  of  the  bandage  to  secure  the  whole. 

Subsequent  Treatment. — The  patient  being  returned  to  his  bed,  is  there 
placed  in  such  a  ^tuation  that  all  the  muscles  of  the  part  upon  which  the 
operation  has  been  performed  may  be  in  a  state  of  relaxation.  The  member, 
supported  by  cushions,  should,  according  to  some,  be  surrounded  by  warm 
aromatic  bladders,  or  bags  filled  with  ashes,  sand,  or  bran,  at  the  temperature  of 
about  thirty  degrees.  By  others  it  is  merely  surrounded  with  soft  and  pliant 
pillows,  suitably  warmed ;  some  even  neglect  all  special  precaution,  and  make 
no  addition  to  the  ordinary  bed  clothes  unless  the  sensation  of  cold  should 
become  very  considerable.  This  latter  practice  is  the  one  which  is  recom- 
mended by  reason.  For  either  the  circulation  is  re-established  in  the  parts 
where  it  has  been  for  a  time  arrested  by  the  operation,  and  the  temperature 
is  of  itself  sufficiently  elevated,  or  it  is  not  re-established,  in  which  case, 
artificial  warmth  has  no  effect  but  to  hasten  the  development  of  gangrene. 
For  the  rest  the  operator  proceeds  as  after  all  grave  operations.  Low  diet, 
repose,  the  most  perfect  quiet,  demulcent  drinks,  acidulous,  slightly 
anodyne,  or  antispasmodic,  are  imperiously  required.  General  blood-letting 
may  also  become  necessary,  in  order  to  prevent  or  to  relieve  congestion  of 
the  viscera.  It  is  most  commonly  useful  to  give  the  patient  by  spoonsful, 
during  the  first  twenty-four  hours,  a  potion,  into  which  enter  some  gently 
aromatic  liquid,  some  "of  the  tincture  or  extract  of  opium,  and  sometimes  a 
small  quantity  of  ether  or  of  Hoffman's  cordial,  in  order  to  calm  the  state  of 
nervous  irritation  or  agitation  into  which  the  patients  are  frequently  thrown. 
In  such  cases  tepid  linden-water  is  the  most  appropriate  drink. 

The  first  dressing  should  be  made,  at  the  soonest,  on  the  third  or  fourth 
day — the  most  exact  precautions  should  be  taken  to  avoid  giving  the  least 
motion  to  the  member,  exercising  the  slightest  traction  upon  the  ligatures,  or 
disturbing  in  the  smallest  degree,  in  raising  the  portions  of  the  dressing,  the 
apposition  of  the  lips  of  the  wound,  particularly  when  an  immediate  reunion 
has  been  attempted. 

The  same  care  is  necessary  in  all  the  subsequent  dressings  until  the  coming 
away  of  the  ligatures,  which  happens  on  the  tenth,  twentieth,  or  thirtieth  day, 
and  which  can  be  hastened  by  very  gently  pulling  at  the  threads,  if  they  are 
slow  in  coming  away,  as  soon  as  the  obliteration  of  the  artery  appears  to  be 
complete.  When  tne  time  of  reaction  is  past,  and  the  first  symptoms  have 
subsided,  when  the  limb  has  recovered  its  natural  temperature  and  sensibility, 
the  severity  of  the  regimen  is  gradually  relaxed,  and  the  patient  is  to  be  con- 
sidered in  this  respect  as  convalescent.  Yet,  even  after  the  complete  cicatri- 
zation of  the  wound,  he  should  for  a  considerable  time  indulge  only  in  gentle 
and  very  limited  movements,  unless  he  would  expose  himself  to  death  by 
consecutive  hemorrhage  from  the  re-opening  of  the  wound,  as  it  happened  ia 
one  case  cited  by  Beclard. 


60  NEW  ELEMENTS   OF 


§  3.  Results  of  the  Operation, 

The  operation  for  aneurism  is  sometimes  followed  by  accidents  or  pheno- 
mena which  require  particular  attention. 

1st.  The  limb,  as  we  have  said  before,  becomes  more  or  less  cold  during 
the  first  twenty-four  hours.  It  then  returns  by  degrees  to  its  habitual  tem- 
perature ;  sometimes,  however,  the  coldness  is  succeeded  by  too  much 
neat,  which  produces  an  irritation  high  enough  to  occasion  gangrene.  Vacca, 
and  some  other  modern  practitioners,  have  quoted  examples  of  this  descrip- 
tion. The  member  should  then  be  wrapped  in  flannel  soaked  in  some 
emollient  liquid,  or  covered  with  cataplasms  of  the  same  nature.  Perhaps  it 
would  be  as  well  to  apply,  according  to  the  advice  of  M.  Begin,  leeches 
to  the  points  which  are  most  painful  and  particularly  threaten  to  become  in- 
flamed. Several  reasons  also  lead  me  to  believe,  that  in  this  case  a  rolled 
bandage,  moderately  tight,  would  succeed  more  easily  than  any  other  means 
in  relieving  this  state.     Cold  water  too  would  be  a  resource  worthy  of  trial. 

2d.  Gangrene,  which  is  too  often  a  consequence  of  the  ligature  of 
arteries,  is  not  always  preceded  by  this  excess  of  heat.  It  more  frequently 
depends  upon  the  circumstance  that  the  circulation  is  not  re-established. 
The  inferior  part  of  the  limb  then  remains  cold  and  insensible,  changes  color, 
becomes  the  seat  of  phlyctena,  and  soon  develops  all  the  other  symptoms  of 
mortification.  If  the  gangVene  is  not  very  extensive,  or  seems  inclined  to 
limit  itself,  the  surgeon  proceeds  in  the  same  manner  as  when  it  is  pro- 
duced from  any  other  cause — he  waits  until  the  sloughs  are  detached,  and 
the  ulcers  which  result  from  them  are  cicatrized  5  but  if  it  involve  the  whole 
thickness  of  the  limb,  nothing  but  amputation  can  then  save  the  life  of  the 
patient. 

3d.  The  sudden  interruption  of  the  course  of  the  blood  in  a  voluminous 
artery,  sometimes  occasions  such  a  derangement  of  the  general  circulation  as 
results  in  a  high  fever,  signs  of  plethora  and  of  congestion,  or  a  great  tendency 
in  some  of  the  principal  organs  to  become  seriously  inflamed.  Under  these 
circumstances  the  antiphlogistic  regimen  should  be  enforced  in  all  its  rigor. 
Recourse  should  be  had  to  bleeding,  whether  general  or  local,  and  even  repeated 
as  often  as  the  strength  of  the  patient  or  the  acuteness  of  the  disease  may 
seem  to  demand. 

4th.  In  other  cases,  certain  nervous  symptoms  present  themselves,  and  become 
troublesome.  The  pulse  continues  irregular,  small,  and  quick ;  delirium  super- 
venes ;  convulsive  movements  take  place,  and  most  of  the  signs  of  the  ataxic 
fever  are  developed.  Antispasmodics  generally,  but  opiates,  above  all,  are 
the  remedies  which  are  recognized  as  best  in  cases  of  this  description.  It 
would  appear,  that  in  a  case  treated  by  M.  Gama,  at  Val-de-Grace,  he  found 
himself  forced  to  administer  laudanum  in  very  large  doses,  in  order  to  relieve 
this  state,  and  that  the  delirium  with  which  patients  are  attacked,  bears  some 
analogy  to  the  •'  delirium  tremens^^  to  which  drunkards  are  frequently 
subject. 

5th.  Ordinarily  the  tumor  subsides  or  at  least  is  diminished,  and  ceases  to 
beat,  immediately  after  the  application  of  the  ligature.  At  a  later  period  it 
becomes  hard,  and  contracts;  the  blood  which  it  contains  becomes  concrete 
and  is  gradually  absorbed  ;  and  the  whole  tumor,  after  a  certain  length  of  time, 
finally  disappears,  or  only  forms  a  small  tumor,  a  mere  kernel,  hard,  movable, 
and  free  from  pain.     Instead  of  these  phenomena,  others  sometimes  super- 


OPERATIVE    SURGERY.  61 

vene.  The  pulsations  which  had  ceased  for  a  time,  reappear  at  the  end  of 
several  hours,  or  of  several  days ;  the  tumor  resumes  its  original  size,  and  the 
operation  appears  to 'have  had  no  influence  whatever  upon  the  disease.  This 
takes  place  sometimes  because  the  superior  collateral  branches  open  either 
directly  into  the  tumor  or  between  the  tumor  and  the  ligature,  and  thus  in- 
troduce the  blood  in  too  great  abundance ;  and  sometimes  because  the  fluid 
returns  into  the  cyst  through  the  inferior  part  of  the  artery.  For  the  rest  it 
is  an  accident  less  important  than  it  was  at  first  considered.  Observation  has 
demonstrated,  that  in  a  majority  of  cases  the  system  will  finally  prevail. 
Whenever  topical  refrigerants,  with  the  due  application  of  the  rolled  bandage, 
or  any  kind  of  compression  continued  for  some  weeks,  produce  no  advan- 
tageous change,  it  is  necessary  then  to  see  whether  it  would  not  be  more  safe, 
if  possible,  to  apply  a  new  ligature  close  to  the  tumor,  either  above  or  below, 
or  else  to  operate  according  to  the  ancient  method. 

6th.  Instead  of  subsiding,  hardening,  or  finally  resolving  itself,  the  aneu- 
rismal  sac  sometimes  becomes  hot  and  even  inflamed,  and  tends  to  form  an 
abscess.  If  cold  topical  applications,  astringents,  or  compression,  do  not  pro- 
duce the  effect  we  desire  from  them,  then  leeches  and  emollient  cataplasms 
should  be  promptly  substituted.  But  if  suppuration  should  occur,  manifested 
by  decided  fluctuation,  it  would  be  necessary  to  treat  the  aneurism  as  a  simple 
abscess,  to  open  it  largely  with  the  bistoury  without  too  much  delay,  to 
empty.it  of  the  detritus  which  it  contains,  and  to  dress  it  then  like  any  other 
suppurating  wound. 

7th.  Immediate  reunion  is  not  always  effected^  although  every  thing  may  have 
been  done  to  attain  that  end.  Pus  sometimes  stagnates  at  the  bottom  of  tlie 
wound,  extends  itself  widely,  and  separates  the  tissues;  and  the  muscular 
sheath,  and  that  of  the  artery,  becoming  inflamed,  soon  suppurate  in  their  turn. 
The  patient  is  then  in  the  greatest  danger.  The  surgeon  is  then  obliged,  in 
order  to  resist  these  troublesome  symptoms  as  soon  as  they  are  perceived,  to 
divide  freely  the  skin  and  all  the  layers  wiiich  hinder  the  free  issue  of  pus  or 
other  effused  fluid,  to  lay  open  the  wound  to  the  bottom  and  through  its  whole 
extent,  and  to  give  up  entirely  the  hope  of  effecting  reunion  by  the  first 
intention.  When,  in  spite  of  all  his  efforts  the  surgeon  perceives  that  sup- 
puration is  fairly  established  and  spreading,  and  continuing  long  enough  to 
enfeeble  the  whole  organic  system,  or  to  give  rise  to  fears  of  adynamia  or  of 
exhaustion,  he  must  then  endeavor  to  retard  its  progress  by  general  remedies, 
to  sustain  the  strength  of  the  patient,  to  administer  the  extract,  syrup,  de- 
coction, or  other  preparation  of  Kina,  a  little  good  wine,  li^ht  but  substantial 
aliments,  &c.,  and  occupy  himself  at  the  same  time  in  modifying  the  ulcer  by 
topical  agents  or  appropriate  incisions. 

8th.  'llie  accident  which  has  most  occupied  the  attention  of  practitioners 
as  a  consequence  of  ligature  of  arteries,  is  that  of  "hemorrhage,"  though 
happily  the  degree  of  improvement  to  which  the  operative  methods  have 
arrived,  renders  it  at  present  but  of  rare  occurrence.  It  is  most  frequently 
observed,  when  in  operating  on  a  trunk  in  the  vicinity  of  the  heart,  it  has 
proved  impossible  to  avoid  placing  the  ligature  very  near  a  great  collateral 
artery ;  when  the  tape  has  been  badly  applied,  when  it  is  displaced,  when  it 
has  not  been  drawn  sufficiently  tight,"when  it  has  been  fixed  upon  a  diseased 
part  of  the  vessel,  or  when  this  by  any  cause  whatever  is  morbidly  affected 
either  above,  or  even  in  certain  cases  below  the  ligature.  The  hemorrhage 
again  may  be  ascribed  to  the  rupture  of  the  sac,  and  may  manifest  itself  m 
the  first  few  days,  or  may  delay  its  appearance  for  a  long  time  after  the 
operation ;  may  depend  upon  the  state  of  irritation  in  the  wound,  and  may,  in 


62  NEW   ELEMENTS    OF 

some  cases,  be  nothing  more  than  a  simple  exhalation.  The  compression  of 
the  artery  on  the  side  towards  the  heart,  compresses,  lint  steeped  in  cold 
water,  or  impregnated  with  the  powder  of  Bonafoux,  or  with  the  liquid  of 
Binclly,Talrrich,  or  Halmagrand,or  with  any  other  hemostatic  substance,  and 
applied  to  the  part  from  whence  the  blood  appears  to  emanate,  are  the  first 
means  to  be  put  in  use.  When  these  are  not  sufficient  for  the  purpose,  you 
are  then  compelled  to  remove  the  dressings  and  all  the  effused  blood,  to 
tampon  the  sac,  and  have  recourse  to  mediate  compression.  If  these  last  means 
should  prove  insufficient,  nothing  is  to  be  done  but  to  choose  whether  to  search 
for  the  two  extremities  of  the  artery  at  the  bottom  of  the  wound,  and  to  tie 
them  anew,  or  to  apply  the  ligature  at  a  higher  point  upon  the  limb.  But 
happily  we  can  more  irequently  dispense  with  this  resort,  and  suppress  the 
hemorrhage  without  a  renewal  of  the  operation. 

Art,  8.— Of  the  Suture, 

About  tlie  middle  of  last  century,  Lambert,  an  English  surgeon,  thought  he 
could  cure  wounds  in  the  arteries  by  means  of  a  twisted  suture.  Observing 
that  after  bleeding,  veterinary  surgeons  generally  close  the  vein,  with  a  needle, 
he  conceived  the  idea  that  this  method,  being  applied  to  the  arteries  of  the 
human  subject,  would  be  productive  of  the  same  results;  several  experiments 
confirmed  him  in  this  opinion,  and  his  efforts  in  this  were  crowned  with  com- 
plete success  in  the  case  of  a  patient  affected  with  a  traumatic  aneurism  in 
the  arm,  whom  he  caused  to  be  examined  by  the  members  of  a  medical  society 
in  London.  Suture,  it  must  be  observed,  appeared  important  in  the  eyes  of 
Lambert,  because  he  thought  it  would  permit  the  conservation  of  the  calibre 
of  the  artery  ;  but  Asmann  having  proved  that  he  was  mistaken  on  this  point, 
and  that  the  suture  never  succeeded  but  by  obliterating  the  vessel,  his  propo- 
sition was  soon  forgotten,  and  has  never  since  been  revived. 

Art.  9. — Torsion,  Bruising* 

Torsion,  which  is  sufficient  to  arrest  the  progress  of  traumatic  hemorrhage 
whenever  the  open  extremity  of  the  vessel  can  be  isolated  and  conveniently 
seized,  appears,  from  the  experiments  of  M.  Thierry,  to  be  also  capable  of 
curing  aneurisms.  After  having  publicly  advanced  this  idea  at  a  concours, 
where  he  contended  for  the  place  of  surgeon  to  the  central  bureau  of  hospitals, 
in  the  spring  of  1829,  M.  Thierry  made  a  certain  number  of  experiments  on 
the  carotid  arteries  of  horses.  This  process  consisted  in  raising  the  artery 
with  the  needle  of  Deschamps,  which  he  then  made  use  of  as  a  garot,  in  order 
to  twist  it  always  in  the  same  direction  a  number  of  turns  in  proportion  to 
its  size  or  calibre:  that  is  to  say,  four  turns  for  a  small  artery,  six,  for  one 
of  middle  size,  and  eight  or  ten  l"or  the  more  voluminous  trunks.  This  prac- 
tice has  always  effected  the  complete  obliteration  of  the  vascular  canal,  so  as 
to  permit  immediate  reunion,  and  to  leave  no  foreign  body  remaining  at  the 
bottom  of  the  wound  ;  I  do  not  think,  however,  that  tnis  new  method  should  be 
generally  adopted.  In  order  to  carry  it  into  execution,  it  requires  that  the 
artery  should  be  isolated  to  a  considerable  extent,  and  the  reduction  of  length 
which  it  must  undergo  cannot  but  endanger  the  success  of  the  operation.  It 
would  appear  almost  impossible  to  avoid  stretching  the  veins,  nerves,  and  other 
adjacent  parts,  even  if  we  proceed  in  the  manner  of  Mr.  Lieber,  who  has 
equally  interested  himself  in  this  subject.    And  afterwards,  it  is  by  no  means 


OPERATIVE   SUkGERY.  6S 

certain  that  the  twisted  organ  does  not  present,  in  case  of  mortification,  a 
foreign  body  more  injurious  than  a  simple  ligature. 

Others  have  thought  that,  after  exposing  the  artery  it  would  suffice  to  seize 
it  with  two  pincers  with  flat  blades,  to  twist  it  laterally  so  as  to  bruise  the 
internal  and  middle  coats,  to  crowd  up  the  broken  coats  acting  through  the 
cellular  coat,  and  to  close  the  wound  immediately  in  order  to  arrive  at  the 
same  result.  M.  Carron  du  Villards  says,  that  he  made  several  experiments 
on  this  point  with  M.  Maunoir,  and  that  they  were  generally  successful. 
These  experiments  were  suggested  to  me  in  1 820,  says  he,  by  Professor  Mau- 
noir, sen.,  who  at  that  time  spoke  to  me  of  an  instrument  for  breaking  the 
internal  tunic  of  the  arteries  without  having  recourse  to  the  ligature.  This  in- 
strument consists  of  a  forceps  similar  to  those  of  M.  Amussat,  for  the  torsion  of 
the  vessels,  but  has  no  teeth,  and  its  free  extremity  is  formed  by  two  little 
ridges  like  grains  of  barley,  which  meeting,  when  closed,  crush  the  artery  and 
break  the  inner  coats  without  affecting  the  outer.  With  the  instrument  of 
Maunoir,  the  closure  of  the  arterial  canal  is  almost  always  secured  :  but  care 
should  be  taken  to  bruise  it  in  several  places ;  for  if,  as  recommended  by 
Jones,  it  is  broken  in  only  a  single  point,  the  effusion  of  the  plastic  lymph, 
which  is  designed  to  dam  the  current  of  the  blood,  is  not  sure  to  be  determined. 
And  we  see  that  when  a  large  artery  is  to  be  acted  upon,  if  we  breathe  only 
one-third  of  its  canal,  or  apply  only  two  strokes  of  the  pincers,  as  if  to  remove 
a  lozenge  of  its  tube,  an  aneurismal  tumor  is  almost  always  in  a  short  time 
the  result.  I  had  the  honor  to  exhibit  a  tumor  thus  produced,  to  M.  Pacoud, 
surgeon  in  chief  of  the  Hotel  Dieu,  at  Bourg  who  had  favored  me  with  the 
privilege  of  the  amphitheatre  of  that  hospital  for  the  prosecution  of  a  series  of 
experiments  upon  animals. 

The  attempts  of  M.  Carron  have  been  since  repeated  by  M.  Amussat  with 
full  success  ;  but  with  this  surgeon  the  rolling  up  of  the  broken  tunics  is  the 
principal  point  of  the  operation,  and  this  is  the  characteristic  of  his  process. 
It  is  to  be  feared  that  we  maybe  deceived  in  signalising  this  latter  modification 
as  a  benefit.  The  membranes  thus  turned  Up,  will  no  doubt  sometimes  close 
the  artery  ;  but  besides  the  fact  that  such  an  event  does  not  always  take  place, 
I  see  the  disadvantage  of  being  obliged  to  expose  the  vessel  to  a  great  extent, 
to  isolate  it  from  the  vein  and  the  nerves  completely  around,  and  that  to  a 
great  length,  the  same  as  in  the  process  of  M.  Thierry — circumstances  calcu- 
lated to  prevent  immediate  reunion,  and  to  render  the  operation  more  tedious, 
more  painful,  and  less  sure,  than  the  application  of  the  actual  ligature. 

Acupuncture. 

Some  years  since,  whilst  1  was  endeavoring  on  a  certain  occasion  to  separate 
the  femoral  artery  of  a  dog  from  its  corresponding  vein,  and  was  just  pushing  it 
to  one  side  with  a  pin,  some  person  entered  and  obliged  me  at  the  moment  to 
suspend  my  operation.  A  motion  of  the  animal  caused  the  pin  to  sink  through 
the  artery,  and  it  was  lost  in  the  thickness  of  the  limb.  It  remained  there 
until  the  fifth  day.  On  careful  examination  of  the  parts,  I  was  fully  con- 
vinced that  the  obliteration  of  the  vessel  had  been  the  consequence  of  this 
puncture.  Such  an  effect  struck  me  with  some  surprise,  and  appeared  at  first 
quite  extraordinary.  But  I  soon  succeeded  in  explaining  it  in  a  satisfactory 
manner.  If  it  is  actually  true  that  it  is  sufficient  to  retain  the  ligature  for  an 
hour  or  two  on  large  arteries,  in  order  to  produce  the  obliteration,  as  we  are 
told  by  Jones,  Hutchinson,  Travers,  and  others,  it  should  then  be  possible  to 


64  NEW    ELEMENTS   OF 

attain  the  same  end  by  occasioning,  on  a  given  point  of  these  canals,  any  morbid 

Srocess  whatever,  which  shall  be  capjible  of  interrupting  the  course  of  the 
aids,  and  thus  producing  coagulation.  Impressed  with  the  idea  that  the 
contractions  of  the  heart  have  less  influence  on  the  motion  of  the  blood  than 
has  been  generally  imagined,  I  soon  conceived  how  a  foreign  body,  howeVer 
small,  kept  across  the  vascular  canal,  or  causing  any  elevation  upon  its  interior 
surface,  should  be  capable  of  producing  the  same  effect  as  the  ligature.  So 
if  an  osseous  or  calcareous  lamella,  free  at  one  of  its  edges,  and  adherent  at 
the  other,  turns  itself  and  juts  into  the  artery  where  it  was  first  developed, 
there  is  every  reason  to  believe  that  it  may  become  the  centre,  the  nucleus, 
or  the  cause  of  a  fibrinous  concretion,  capable  of  deadening,  in  a  greater  or  less 
degree,  the  impulse  of  the  blood,  and  of  finally  occasioning  the  obliteration 
of  the  vessel.  The  observations  published  by  Mr.  Turner,  those  which  have 
been  communicated  to  me  by  Mr.  Carswell,  and  some  others  of  my  own,  put 
this  fact  beyond  doubt.  What  I  have  advanced  in  regard  to  an  osseous  spicu- 
lum,  is  evidently  applicable  to  every  species  of  prominences,  asperities,  or  in- 
equalities, which  in  any  way  diminish  the  normal  regularity  of  the  conduit 
through  which  the  blood  should  circulate. 

I  am  aware  that  this  reasoning  is  liable  to  attack  on  more  sides  than  one ; 
80  I  give  it  for  what  it  is  worth,  without  attaching  to  it  too  much  importance. 
But  I  resolved  to  submit  it  to  some  trials,  in  order  to  see  if  it  would  be 
possible  for  me  to  produce  the  same  results,  at  will,  which  I  had  at  first  obtained 
by  chance. 

In  the  month  of  June  of  last  year,  I  made  some  experiments  with  this  view. 
An  acupuncture  needle,  an  inch  and  a  half  in  length,  was  passed  through  the 
artery  in  the  thigh  of  a  dog,  without  previous  dissection ;  I  then  placed  two 
others  on  the  opposite  side,  in  order  to  see  what  difference  of  effect  might  be 
the  result.  In  examining  the  parts  on  the  fourth  day,  I  found  my  first  needle 
on  the  external  third  of  the  femoral  artery,  which  was  only  one  half  closed ; 
of  the  last  two,  one  was  found  immediately  outside  of  the  vessel,  which  was 
obliterated  by  a  solid  clot  of  blood,  about  an  inch  in  length,  in  the  middle  of 
which  the  second  needle  was  discovered  firmly  fixed. 

I  renewed  these  experiments  in  the  month  of  November  following  :  thenin 
the  month  of  February,  1830.  They  were  again  repeated  in  April  last,  by 
M.  Nivert,  then  the  preparator  of  my  course  of  operations,  and  now  doctor  of 
medicine  at  Azai  le  Rideau.  I  have  more  recently  subjected  them  to  other 
proofs  at  the  hospital  of  La  Pitie,  and  always  with  the  same  effect.  In  order 
to  be  more  certain  of  not  following  upon  the  side  of  the  artery,  I  have  always, 
in  these  latter  experiments,  taken  tlie  precaution  to  expose  it ;  sometimes  I 
have  only  used  a  single  needle,  at  others  I  have  operated  with  two,  and  even 
three,  according  to  the  size  of  the  vessel.  Whenever  a  foreign  body  had 
been  able  to  retain  its  place  for  at  least  four  days,  a  small  clot  of  blood  has 
formed  itself  in  the  punctured  part,  and  the  obliteration  of  the  vascular  canal 
has  resulted.  The  aorta  under  tnis  treatment,  however,  experienced  no  change  5 
but  as  the  needles  had  only  remained  in  position  for  a  little  more  than  twenty 
hours,  I  do  not  think  it  just  to  draw  any  positive  conclusion  from  this  cir- 
cumstance. 

It  is  proper  besides  to  say,  that  up  to  the  present  time  my  experiments  have 
been  made  upon  dogs  of  inferior  size,  and  that  the  femoral  is  the  most  volu- 
minous artery  I  have  yet  pierced.  It  is  sufficient  to  say  that  before  drawing 
any  practical  inferences  from  these  experiments,  or  applying  them  to  the  human 
subject,  they  should  be  repeated  and  varied  upon  animals  of  a  larger  size 


OPERATIVE   SURGERY.  65 


than  the  dog.  I  should  even  add,  that  according  to  the  observation  of  M. 
Gonzales,  my  experiments,  upon  being  repeated  by  M.  Amussat,  have  not 
produced  results  equally  conclusive. 

A  single  pin  or  needle  has  appeared  to  me  sufficient  for  arteries  which  do 
not  exceed  in  size  the  barrel  of  a  quill ;  two  or  three  for  those  one-half  larger, 
and  there  would  be  no  objection  to  the  employment  of  four,  or  even  of  five, 
for  the  greater  arteries.  When  many  are  brought  into  operation,  it  is 
necessary  to  place  them  at  from  four  to  six  lines  apart,  in  zig-zag  position 
rather  than  in  straight  line. 

If  similar  results  could  be  hoped  for  on  the  human  subject,  the  immense 
advantages  which  would  be  gained  are  obvious  at  a  glance.  Thus,  instead 
of  the  hazard  of  wounding  the  nerves  or  the  veins  ;  instead  of  the  dissection 
so  minute,  and  often  so  dangerous,  which  is  required  for  the  ligature,  torsion 
or  bruising,  it  is  sufficient  to  expose  one  of  the  faces  of  the  tube  to  the 
slightest  possible  extent,  without  removing  any  part,  in  order  to  secure  its 
obliteration.  Perhaps  even  the  most  alarming  aneurisms  may  be  cured  by 
this  means,  those  of  the  thigh  and  of  the  popliteal  space,  among  others,  without 
dividing  the  skin  ;  that  is  to  say,  by  merely  piercing  the  femoral  artery  in 
the  bend  of  the  groin  with  an  ordinary  pin,  an  acupuncture  needle,  any 
metallic  wire  whatever,  or  even  piercing  the  aneurismal  sac  itself  in  difterent 
directions,  with  these  foreign  bodies ;  but  I  very  much  fear  that  it  will  fare 
with  puncture  as  with  seton,  torsion,  suture,  and  bruising  ;  and  that  ligature 
will  long  continue  to  be  preferred  to  these  different  means,  notwithstanding 
the  species  of  infatuation  with  which  many  practitioners,  otherwise  much  to 
be  commended,  have  been  seized  on  this  subject. 

Art.  10. — Changes  occurring  in  the  vessels  of  a  limb  after  the  operation  for 

Aneurism. 

When  an  artery  ceases  to  be  permeable  to  the  blood,  after  having  been 
strangled  with  a  ligature,  alterations  occur  about  the  wound  which  are 
worthy  particular  attention.  Among  these  alterations  some  are  generally 
admitted,  but  the  existence  of  others  is  not  fully  ascertained,  or  at  least  is 
still  under  discussion.  The  blood,  obliged  to  take  another  route  in  order  to 
arrive  at  the  inferior  part  of  the  limb,  crowds  into  the  collateral  branches, 
dilates  them  by  degrees,  speedily  gives  birth  to  anastomatic  arches  of  such 
dimensions,  that  branches,  before  hardly  visible,  now  acquire  the  size  of  a 
crow's-quill,  and  that  other  branches,  somewhat  larger,  at  last  equal  the 
third  part  or  even  the  half  of  the  principal  trunk.  The  ease  with  which 
these  supplementary  courses  are  formed  or  developed,  gives  to  the  operation 
•  for  aneurism  such  prompt  and  complete  success,  and  causes  the  throbbings 
of  the  pulse  which  have  been  for  a  moment  suspended,  to  reappear 
below  the  ligature.  But  if  all  are  of  the  same  opinion  on  this  point, 
it  is  otherwise  with  the  question  whether  new  arteries  are  developed 
in  order  to  re-establish  the  course  of  the  blood  after  the  interruption  of 
the  diseased  trunk.  Dr.  Parry  has  been  one  of  the  first  to  speak  of  the 
regeneration  of  the  vessels,  which  he  admits  as  an  incontestable  fact. — 
He  has  seen,  he  says,  the  two  ends  of  the  carotid  communicate  with  one 
another  by  many  small  vascular  branches,  a  long  time  after  having  been  tied 
or  divided.  It  was  with  difficulty  that  he  was  at  first  believed,  and  his 
assertions  did  not  command  the  attention  to  which  he  thought  them  entitled. 
At  the  same  time  or  shortly  after,  according  to' the  evidence  of  M.  Foerster, 
a  military  surgeon,  Mr.  Ebel,  arrived  at  nearly  the  same  results,  by  experi- 
9 


66  NEW    ELEMENTS  OF 

ments  repeated  upon  more  than  thirty  animals.  M.  Sallemi,  of  Palermo,  M. 
Zuber,  of  Vienna,  and  M.  Seller,  have  not  been  less  successful.  More 
recently  M.  Schcensberg  has  renewed  the  experiments  of  the  English 
physician  on  the  carotid  arteries  of  goats  and  bucks.  He  affirms  that  he  has 
found  upon  these  animals  new  branches  of  considerable  volume,  forming  a 
net-work  extremely  complicated  between  the  two  ends  of  the  divided  tube. 
If  the  drawing  presented  byM.  Foerster  represents  exactly  what  the  surgeon 
of  Copenhagen  professes  to  have  established,  nothing  can  be  more  admirable 
than  the  efforts  of  the  organization  under  such  circumstances.  It  appears  to 
me,  however,  that  the  operator  sometimes  deceives  himself  on  the  importance 
of  this  reproduction  of  the  vessels,  and  that  it  is  admitted  oftener  than  it 
really  occurs.  To  the  facts  reported  by  M.  Schcensberg,  even  allowing  them 
full  credit,  may  be  opposed  innumerable  observations  gathered  from  the 
human  frame.  If  the  new  arteries  reunited  the  two  ends  of  that  which 
had  been  divided,  they  would  have  been  found  upon  the  bodies  of  subjects 
who  had  died  sooner  or  later  after  the  operation  for  aneurism.  Now,  the 
finest  injections,  the  most  attentive  and  delicate  dissections,  have  never  been 
able  to  point  out  their  existence.  Instead  of  this  complicated  net-work, 
which  has  been  spoken  of  by  the  authors  Avhom  I  have  quoted,  there  is 
nothing  to  be  found  but  a  flexible  cellular  cord,  impermeable  to  fluids,  which 
is  insensibly  confounded  with  the  adjacent  cellular  tissue,  and  there  are  no 
new  arterioles  to  re-establish  the  continuity  of  the  intercepted  trunk. 

If  I  am  not  mistaken,  the  assertions  of  MM.  Parry,  Bell,  Mayer,  Foerster, 
Seiler,  Zuber,  and  Schcensberg,  are  founded  upon  a  phenomenon  not  yet 
sufficiently  observed,  but  which  might  perhaps  explain  the  results  at  which 
these  authors  think  they  have  arrived.  The  albuminous  effusion  which  is 
created,  and  which  concretes  around  the  ligature  in  order  to  form  the  ring 
spoken  of  by  M.  Pecot,  may  become  the  seat  (when  it  is  fairly  organized) 
of  a  vascular  net-work  of  new  formation,  a  thing  often  remarked  in  conformity 
with  a  general  law  in  a  great  variety  of  accidental  organic  productions  ;  these 
small  vessels  which  present  at  first  the  appearance  of  tortuous  capillaries,  of 
simple  hollow  canals  in  the  midst  of  an  irregular  substance,  and  in  which  the 
fluids  and  the  blood  circulate  rather  under  the  influence  of  chemical  or  physical 
laws  than  by  the  impulsion  of  the  heart,  continue  as  long  as  the  virole  remains 
isolated,  and  has  not  yet  become  a  part  of  the  surrounding  tissues  ;  but  as  this 
organic  mass,  abating  little  by  little,  gradually  assumes  the  character  and 
appearances  of  cellular  tissue,  properly  so  called,  these  small  canals  contract 
themselves  in  the  same  proportion,  and  finish  in  their  turn  by  differing  in  no 
respect  from  the  capillaries  which  run  through  the  general  lamellar  system ; 
whence  it  follows,  that  being  susceptible  of  distention  by  matters  of  injection, 
thej^  may  have  been  observed,  and  even  have  presented  a  considerable  volume 
during  the  first  and  second  week  after  the  operation,  whilst  at  a  more  advanced 
period  it  would  have  been  no  longer  possible  to  find  them.  They  have  then 
no  part  in  the  re-establishment  of  the  circulation  in  the  limb.  A  phenomenon 
of  a  similar  description,  but  much  more  important,  occurs  at  the  spot  where 
the  capillary  ramifications  of  the  superior  collaterals  communicate  with  the 
capillaries  of  the  inferior  branches  of  the  obliterated  artery.  According  to 
the  experience  of  MM.  Kaltenbrunner,  Wedmeyer,  Dcelinger,  Blainville,  and 
others,  the  arteries  discharge  the  blood  with  which  they  are  filled  into  the 
irregular  or  parenchymatous  cellular  tissue,  before  it  is  taken  up  by  the  other 
vessels.  In  this  organic  course  the  fluids  ooze  rather  than  circulate.  They 
act,  so  to  speak,  after  the  manner  of  water  which  escapes  from  a  river, 
spreading  itself  by  a  thousand  little  channels  through  a  plain  of  sand  ;  at  each 


OPERATIVE    SURGERY.  67 

moment  new  conduits  are  cut,  whilst  the  former  ones  disappear.  The  blood, 
no  longer  able  to  pass  by  its  primitive  central  canal,  creates  for  itself  a  number 
of  passages,  which  organize  themselves  afterwards  by  degrees,  in  order  to 
transfer  it  from  the  superior  part  into  the  inferior  of  the  closed  vessel ;  and 
it  is  without  doubt  to  this  effort  that  we  must  attribute  the  heat,  the  sensibility, 
and  the  redness,  which  are  sometimes  manifested  under  the  skin,  at  the  expi- 
ration of  one,  two,  or  three  days  after  the  operation  for  aneurism. 


CHAPTER  II. 

*  OPERATIONS    FOR   THE    PARTICULAR   ANEURISMS. 

SECTION    I. 

Operations  for  Diseases  of  the  Arteries  of  the  Inferior  Extremity. 

Exposed  more  than  in  any  other  part  to  external  agents,  being  very 
numerous  and  for  the  most  part  large,  the  arteries  of  the  inferior  limbs  are 
naturally  subject,  and  more  so  than  any  others,  to  all  the  diseases  of  the 
arterial  system.  The  surgeon  is  then  frequently  called  to  practise  upon  them 
very  serious  operations.  But  the  main  trunks,  and  their  principal  branches, 
are  the  only  ones  upon  which  these  operations  can  be  executed  with  advantage; 
so  that  we  need  only  speak  under  this  head  of  anterior  and  posterior  tibial, 
peroneal,  popliteal,  femoral,  circumflex,  and  iliac  arteries. 

Jt.  Anterior  Tibial  in  the  Foot. 
Art.  1. — Anatomical  Remarks. 

The  anterior  tibial  emerges  upon  the  foot  from  under  the  annular  ligament 
of  the  tarsus,  a  little  nearer  to  the  internal  than  to  the  external  malleolus  ; 
from  thence  it  is  carried  obliquely  inwards  towards  the  first  interosseal  space 
of  the  metatarsus,  which  it  penetrates  from  above  downwards,  to  reach  the 
sole  of  the  foot,  and  forms  there  the  plantar  arch  by  anastomosis,  with  the 
external  branch  of  the  posterior  tibial.  It  is  separated  from  the  bones  and 
their  ligaments  by  a  simple  layer  of  adipose  cellular  substance,  and  accom- 
panied, sometimes  on  the  inside  and  sometimes  on  the  outside,  by  the  internal 
branch  of  the  deep  dorsal  nerve  of  the  foot,  and  on  the  opposite  side  by  its 
satellite  vein.  It  is  covered,  proceeding  from  the  deeper  parts  towards  the 
skin  :  1st,  by  a  fine  fibrous  or  fibro-cellular  lamellae,  which  separates  it  from 
the  surrounding  tendons;  2d,  by  a  cellulo-adipose  stratum,  which  is  not 
always  present ;  3d,  by  the  dorsal  aponeurosis  of  the  foot,  which  must  be  care- 
fully preserved  from  being  confounded  with  the  subcutaneous  stratum  ;  4th, 
by  this  subcutaneous  lamellae,  which  is  thicker  and  fatter  upon  children, 
women,  and  others  who  are  somewhat  embonpoint,  than  upon  men,  or  upon 
persons  of  a  meagre  habit,  in  which  layer  lie  the  superficial  dorsal  nerves  and 
veins ;  5th,  lastly,  by  the  skin  the  thickness  of  which  is  also  very  variable. 


68  NEW   ELEMENTS    OF 

The  first  tendon  of  the  common  extensor  of  the  toes  is  on  the  external  side, 
that  of  the  extensor  of  the  great  toe  on  the  internal.  The  first  fasciculus  of 
the  extensor  brevis  muscle  crosses  very  obliquely  from  the  outer  to  the  inner 
side,  and  from  behind  forwards  the  anterior  half  of  its  length.  Its  tarsal 
and  metatarsal  branches  are  of  too  little  importance  to  be  described  here, 
but  it  is  not  so  with  its  anomalies.  I  have  once  met  with  it  immediately  under 
the  skin,  but  more  frequently  it  is  wanting.  A  branch  of  the  peroneal  some- 
times takes  its  place,  at  other  times  it  is  replaced  by  a  strong  branch  of 
the  posterior  tibial.  It  is  true  that  these  varieties  are  calculated  to  embarrass 
many  young  surgeons  who  are  practising  upon  the  dead  subject,  but  I  do  not 
see  that  this  embarrassment  can  occur  during  life.  In  fact,  if  Die  vessel  does 
not  exist,  there  is  no  lesion  which  can  render  the  search  necesstuy.  If  it  is 
given  off  by  the  posterior  arteries  of  the  leg,  its  dilatation  towards  one  of  the 
borders  of  the  foot  will  not  admit  the  idea  of  seizing  it  in  its  customary  place, 
Supposing  that  there  is  occasion  to  operate  upon  it  in  consequence  of  a  wound. 

Art.  2. — Surgical  Remarks,  ^ 

M.  Boyer  asks,  if  aneurism  of  this  artery  in  the  foot  has  ever  been 
observed.  Pelletan,  Scarpa,  Richerand,  and  Dupuytren,  also,  appear  never 
to  have  observed  it ;  whence  we  may  conclude  that  it  is  at  least  of  rare 
occurrence.  Guattani  mentions  having  seen  an  example  occasioned  bv  the 
operation  of  blood-letting;  and  M.  Roux  also  mentions  two  cases  where  the 
division  of  this  artery  was  tlie  cause  of  troublesome  hemorrhage.  M.  Vidal 
has  published  in  the  Clinique,  a  similar  observation  made  in  the  hospital 
Beaujon.  It  is  evident  that  should  such  a  thing  occur,  compression  would 
frequently  be  sufficient ;  and  that  in  operating  according  to  the  modern  method, 
the  artery  should  be  tied  in  the  leg  and  not  in  the  foot ;  but  as  it  may  become 
necessary  to  obliterate  the  vessel  before  and  behind  the  affected  part  in  con- 
sequence of  the  presence  of  the  plantar-arch,  to  operate,  in  short,  according 
to  the  ancient  method,  the  surgeon  should  know  how  to  expose  the  anterior 
tibial  in  the  foot. 

Art.  3. — Manual. 

The  patient  should  be  laid  upon  his  back,  with  the  leg  slightly  flexed  and 
the  foot  moderately  extended.  An  assistant  takes  hold  of  the  limb,  clasping 
it  above  the  ancles.  The  surgeon,  with  a  straight  or  convex  bistoury,  makes 
an  incision  through  the  skin  of  about  two  inches,  in  the  direction  of  the  oblique 
line  which  runs  from  the  middle  of  the  instep  to  the  first  interosseous  space; 
divides  the  subcutaneous  stratum,  endeavoring  to  avoid  the  principal  venous 
and  nervous  branches  which  it  contains;  arrives  successively  at  the  aponeurosis, 
at  the  space  between  the  tendons  of  the  first  two  toes,  at  the  second  fibrous 
stratum,  and  finally  at  the  artery  itself,  which  he  separates  from  the  veins, 
the  nerve,  and  the  cellular  tissue,  by  means  of  the  channeled  sound.  He 
tlien  passes  the  thread  and  ties  it,  after  being  well  assured  that  he  has  taken 
up  nothing  but  the  artery.  Two  diachylum  straps  bring  together  the  lips  of 
the  wound,  and  the  operation  is  finished. 


OPERATIVE    SURGERY.  69 

B.  Anterior  Tibial  in  the  Leg. 

Art.  1. — Anatomical  Remarks. 

Tlie  anterior  tibial  artery  arises  from  the  popliteal,  and  after  having  pene- 
trated nearly  at  right  angles  the  superior  part  of  the  interosseous  ligament, 
descends  in  the  direction  of  an  oblique  line  drawn  from  the  middle  of  the 
space  between  the  head  of  the  fibula  and  the  spine  of  tlie  tibia,  tov/ards  the 
middle  of  tiic  instep,  or  to  the  point  at  which  it  passes  under  the  annular 
ligament.  As  it  is  applied  almost  immediately  upon  the  interosseous  ligament 
in  the  upper  two-thirds  of  its  length,  and  afterwards  on  the  external  face  and 
front  of  the  tibia,  it  is  naturally  situated  at  a  depth  proportionate  to  the 
elevation  of  the  point  at  which  it  is  sought.  The  two  veins  which  attend  it, 
often  communicate  with  one  another  in  front  of  it  by  means  of  small  transverse 
branches.  The  nerve  of  the  same  name  crosses  very  obliquely  its  anterior 
face,  in  a  direction  downwards  and  inwards;  sometimes,  however,  it  remains 
outside  as  far  as  the  instep.  A  pliant  and  not  very  abundant  cellular  tissue 
surrounds  these  different  organs,  and  unites  them  without  furnishing  them  a 
real  sheath.  The  anterior  tibial  lies  between  the  common  extensor  muscle 
and  the  anterior  tibial  above ;  between  the  anterior  tibial  and  the  extensor  of 
the  great  toe ;  in  the  middle  and  between  the  extensor  of  the  great  toe  and  the 
common  extensor  in  the  lower  part  of  its  course,  and  seldom  presents  ano- 
malies worthy  of  the  attention  of  the  surgeon.  Neither  are  the  branches  which 
arise  from  it,  with  the  exception  of  its  recurrent  branch,  of  any  importance  in 
actual  practice. 

I  have  seen  it  twice  becoming  superficial  from  the  middle  of  the  leg.  In 
one  of  these  cases  it  proceeded,  as  is  usual,  from  the  popliteal  ;  in  the  other, 
instead  of  crossing  the  interosseous  ligament,  it  turned  the  outside  of  the  fibula, 
and  followed  the  track  of  the  musculo-cutaneous  nerve.  It  is  no  doubt  to 
one  of  these  two  variations  that  we  should  attribute  the  pulsations  observed 
by  Pelletan  in  the  front  of  the  leg  of  a  patient,  and  which  was  near  deceiving 
this  able  practitioner  into  the  belief  that  an  aneurism  existed  in  the  part. 
Fortunately  it  is  enough  simply  to  call  to  mind  the  possibility  of  such  an 
anomaly,  in  order  to  comprehend,  as  well  as  to  avoid  the  errors  which  it  might 
occasion. 

Art.  2. — Surgical  Remarks, 

Since  it  is  sustained  by  the  interosseous  ligament  behind  the  bones  of  the 
leg  on  tlie  sides,  and  by  muscles  which  are  forcibly  bound  down  in  front  by 
a  firm  aponeurosis,  the  anterior  tibial  artery  should  rarely  become  the  seat  of 
spontaneous  aneurism.  For  my  own  part,  I  do  not  know  of  a  single  instance, 
unless  the  sanguineous  tumor  mentioned  by  Pelletan,  which  destroyed  by 
erosion  a  large  part  of  the  superior  extremity  of  the  tibia,  may  be  regarded  as 
such.  Traumatic  aneurisms  of  this  artery  are,  on  the  contrary,  frequently 
remarked.    They  are  sometimes  circumscribed,  but  more  frequently  diffused. 


and  are  produced  by  puncturing  or  cutting  instruments,  by  balls  and  all 
descriptions  of  projectiles,  by  osseous  spicula  in  fractures,  &c.  J.  L.  Petit, 
Desault,  Deschamps,  Dupuytren,  Pelletan,  Boyer,  Roux,  and  Cowan,  cite 
observations  of  this  disease,  and  prove  that  it  may  occur  at  any  point  in  the 
length  of  the  limb.     . 

In  a  case  of  consecutive  false  aneurism  of  which  he  has  spoken,  Deschamps 
operated  according  to  the  old  method.    Mr.  Guthrie  exclusively  adopts  the 


70  NEW    ELEMENTS   OF 

same  in  such  cases,  and  strongly  opposes  those  who  operate  in  a  diiferent 
manner.  If  the  blood  continued  to  flow  from  the  wound,  if  the  accident  was 
but  of  recent  existence,  if  the  opening  of  tlie  artery  appeared  to  be  easily  dis- 
covered, one  might  or  even  ought  to  follow  the  practice  of  these  two  authors  5 
but  in  every  other  case  the  method  of  Anel  is  much  to  be  preferred.  It  does 
not  appear  to  me  by  any  means  necessary  to  place  a  second  ligature  beneath 
the  tumor  or  wound,  as  some  surgeons  have  advised,  as  a  moderate  pressure 
will  fully  supply  its  place.  If,  however,  the  disease  should  be  seated  in  the 
superior  third  of  the  leg,  it  would  be  difficult  to  tie  the  artery  above  without 
toucliing  the  tumor,  and  of  course  to  operate  by  any  other  than  the  old  method. 
In  that,  and  in  everv  other  case  where  there  is  much  difficulty  apprehended 
in  operating  on  the  feg,  there  still  remains,  as  a  final  resource,  the  ligature  of 
the  popliteal  or  the  femoral.  M.  Dupuytren  was  the  first  to  use  it  successfully. 
In  1810,  in  operating  upon  a  woman  of  sixty  years  of  age,  who  had  been 
brought  to  the  Hotel  Dieu,  affected  with  a  large  diffused  aneurism  resulting 
from  a  compound  fracture  of  the  leg.  M.  Roux  has  derived  the  same  advan- 
tage in  a  case  of  hemorrhage  following  amputation  below  the  knee,  and  M. 
Delpech  has  obtained  several  similar  successes.  Mr.  Guthrie,  however,  who 
professes  to  have  seen  this  operation  practised  at  the  battle  of  Albufera,  and 
of  Salamanca,  before  our  compatriots  had  even  thought  of  it,  strongly  objects 
to  this  practice.  In  the  case  of  a  soldier  operated  upon  in  May,  1814,  hemor- 
rhage returned  by  the  wound,  amputation  became  necessary,  and  the  patient 
died.  The  same  thing  occurred  with  a  soldier  wounded  at  Salamanca.  Accord- 
ing to  his  opinion,  it  is  much  better  to  open  the  tissues  freely  at  the  risk  of 
dividing  the  muscles,  but  it  appears  to  me  that  the  English  surgeon  goes  too 
far,  although  without  being  entirely  wrong.  Even  allowmg  it  true,  as  a  general 
rule,  tliatthe  operation  may  be  more  sure,  according  to  Mr.  Guthrie's  sugges- 
tion, yet  the  practice  of  M.  Somme,  of  Antwerp,  lias  sufficiently  proved  that 
tlie  advice  of  M.  Dupuytren  may  be  followed  with  advantage. 

Art.  3. — Manual 

The  patient  being  placed  in  the  same  position  as  in  the  operation  on  the 
lower  part  of  the  artery,  should  have  the  leg  held  with  the  toes  somewhat 
turned  inwards,  and  disposed  in  such  a  manner  that  the  muscles  of  its  ante- 
rior region  may  be  extended  or  relaxed  at  will,  by  the  assistant  acting  upon 
the  foot.  In  order  to  reach  the  artery  in  the  inferior  third  of  the  leg,  an 
incision  must  be  made  through  the  skin,  the  subcutaneous  stratum,  and  the 
aponeurosis,  to  the  extent  of  about  two  inches  on  the  above  described  lines ; 
then,  with  the  fore-finger  or  with  the  extremity  of  a  grooved  sound,  the  tendon 
of  the  extensor  muscle  of  the  great  toe  is  separated  from  that  of  the  anterior 
tibial  muscle,  by  pushing  it  outwards,  if  the  operation  is  performed  high  up, 
and  on  the  contrary  by  forcing  it  inwards  if  quite  low  down.  This  being 
done,  notliing  remains  but  to  isolate  the  artery  from  its  venas  comites  and  its 
accompanying  nerve  in  order  to  tie  it,  to  bring  together  the  lips  of  the  wound, 
and  to  apply  the  appropriate  bandage. 

In  its  middle  part,  or  in  its  two  superior  thirds,  this  artery  can  be  exposed 
by  several  different  means. 

1st.  Process  of  M,  Lisfranc. — In  the  process  attributed  to  M.  liisfranc, 
by  Messrs.  Coster  and  Taxil,  the  incision  in  the  skin  is  made  obliquely  from 
below  upwards,  from  the  crest  of  the  tibia  toward  the  fibula,  one  or  two  inches 
from  the  horizontal  line.  After  the  aponeurosis  has  been  cut  across,  the 
interstice  which  separates  the  anterior  tibial  from  the  extensors  is  sought  for. 


OPERATIVE    SURGERY.  71 

and  as  it  is  the  first  which  is  encountered  on  the  outside  of  the  tibia,  it  is 
easily  discovered. 

2d.  Ordinary  Process. — In  the  common  process,  the  incision  is  made  parallel 
with  the  direction  and  over  the  course  of  the  artery,  always  taking  as  a  guide 
the  above-mentioned  line,  or  the  middle  of  the  space  which  separates  the 
fibula  from  the  crest  of  the  tibia,  or  the  slight  depression  which  naturally 
corresponds  with  the  interval  between  the  muscles  to  be  separated  ;  or  lastly, 
the  operator  may  simply  carry  the  bistoury  an  inch  to  the  outside  of  the  ante- 
rior edge  of  the  ie^.  The  aponeurosis,  as  well  as  the  skin,  should  be  divided 
to  the  extent  of  three  or  four  inches  ;  a  yellowish  line  points  out  the  muscular 
interstice,  upon  which  the  fore-finger  is  placed  to  separate  the  muscles,  and 
to  descend  perpendicularly  upon  the  interosseous  ligament.  At  the  bottom 
of  this  interstice  is  found  the  vessel,  which  the  operator  endeavors  to  isolate 
or  to  take  up.     This,  however,  is  the  most  difficult  stage  of  the  operation. 

After  having  caused  an  assistant  to  flex  the  foot,  and  properly  to  separate 
the  muscles,  the  best  means  of  managing  the  artery,  in  my  opinion,  is  to  slide 
the  grooved  sound  beneath  it  very  obliquely  downwards  and  towards  the 
tibia,  instead  of  carrying  it  transversely  or  from  the  anterior  ridge  towards 
the  exterior  border  or  the  leg.  In  order  to  estimate  the  utility  of  this  direc- 
tion, it  is  sufficient  to  call  to  mind  that  the  fibula  is  almost  on  the  same  plane, 
whilst  the  crest  of  the  tibia  is  considerably  above  the  level  of  the  vessels.  The 
needle  of  Deschamps  might  nevertheless  be  easily  used,  as  well  as  any  other 
kind  of  port  ligature. 

No  one  at  the  present  day  will  be  tempted  to  follow  the  example  of  Dr. 
Hey,  in  cutting  out  a  portion  of  the  fibula,  to  arrive  more  easily  at  the  tibial 
artery  ;  as  this  sur;^eon  affirms  that  he  has  once  done  with  success. 

M.  Lisfranc  thinks  that  the  oblique,  rather  than  the  parallel  incision,  dis- 
plays more  clearly  the  interstice  which  is  to  be  our  guide,  and  also  the 
vascular  tube  itself.  This  decision  is  correct  on  the  first  point,  but  if  I  may 
believe  the  result  of  frequent  experiments  on  the  dead  subject,  it  is  not  alto- 
gether the  same  upon  the  second.  So  that  without  entirely  rejecting  his 
method  of  operating,  I  am  still  induced  to  prefer  that  of  the  other  surgeons, 
at  leasj/  in  ordinal y  cases,  and  in  every  instance  where  there  are  no  special 
indications  to  fulfill. 


a  Posterior  Tibial. 
Art.  1. — Anatomical  Remarks. 

The  posterior  tibial  artery  from  its  beginning,  a  little  below  the  popliteus 
muscle,  down  to  its  division  into  the  internal  and  external  plantar  arteries, 
follows  exactly  the  direction  of  a  line  somewhat  convex  inwards,  and  extending 
from  the  middle  of  the  beginning  of  the  calf  to  a  point  half  an  inch  behind  the 
internal  malleolus.  It  is  generally  accompanied  by  two  veins  of  considerable 
size,  which  even  sometimes  form  an  actual  net-work  around  it  by  frequent 
anastamoses.  On  its  fibular  side  lies  the  posterior  tibial  nerve,  which  is 
rarely  more  than  three  of  four  lines  from  it.  Resting  in  its  whole  extent 
upon  the  deep  seated  muscles,  it  is  covered  by  the  aponeurosis  which  lies 
between  the  two  fleshy  strata  of  this  region,  by  muscles  or  cellular  tissue, 
and  some  more  fibrous  lam ellse,  then  by  the  common  integuments.  But  there 
are  differences  at  some  points  in  its  length  which  it  is  important  to  note. 

1st.  In  the  Calcanear  Arch. — The  posterior  tibial  artery  is  applied  against 
the  fibrous  sheath  of  the  common  extensor  of  the  toes,  at  about  three  lines 


72  NEW    ELEMENTS    OF 

from  the  posterior  border  of  the  malleolus ;  the  nerve  is  behind,  and  the 
veins  on  the  inside;  a  lamellous  or  adipose  tissue  envelopes  it ',  the  internal 
ligament  of  the  tarsus,  a  species  of  fibrous  lamina,  continuous  with  the  apo- 
neurosis of  the  leg,  covers  and  confines  it,  and  confounds  itself  with  tlie  dense 
and  filamentous  tissue  which  separates  the  vessel  from  the  skin. 

2d.  Between  the  malleolus  and  the  calf  it  has  receded  somewhat  from  the 
internal  edge  of  the  tibia.  The  nerve  lies  rather  on  the  outside  than  behind. 
The  lamellae  which  immediately  surround  it,  are  very  pliant,  and  frequently 
loaded  with  fat.  The  deep-seated  aponeurosis,  which  is  here  quite  thin, 
keeps  the  vessel  applied  against  the  posterior  tibial  muscle,  the  long  common 
flexor,  and  the  long  flexor  of  the  great  toe.  On  the  outside  of  this  layer  is 
found  the  tissue  which  fills  the  sheath  of  the  tendo  Achilles,  and  then  just 
within  the  skin,  the  common  aponeurosis  of  the  leg. 

3d.  In  the  calf  of  the  leg  the  tibal  artery  is  deeply  seated,  almost  upon 
the  same  plane  with  the  posterior  face,  and  much  nearer  to  the  fibula  than  to 
the  free  side  of  the  bone  from  which  it  derives  its  name.  The  aponeu- 
rosis which  covers  it,  and  touches  it  almost  immediately,  is  striated,  lustrous, 
and  strengthened  with  very  strong  longitudinal  fibres.  Farther  up  it  is  con- 
cealed bv  the  tibial  portion  of  the  soleus  muscle,  the  inner  head  of  the  gas- 
trocnemius, the  superficial  aponeurosis,  and  the  subcutaneous  stratum,  in 
which  are  bedded  the  saphena  vein  and  the  corresponding  nerve. 

It  is  but  seldom  that  the  posterior  tibial  is  wanting,  but  it  may  happen  that 
it  is  very  small,  and  that  the  peroneal  takes  its  place  in  supplying  the  sole  of 
the  foot.  It  is  more  common  to  see  it  keeping  the  meaian  Tine  until  it 
approaches  the  malleolus.  The  nerve  is  in  such  cases  on  its  inner  side.  I 
observed  it  on  one  occasion  to  proceed  side  by  side  with  the  peroneal  for  two- 
thirds  of  its  whole  length,  and  then  to  enter  the  hollow  above  the  heel  at 
nearly  an  inch  behind  the  malleolus. 

Art.  2. — Surgical  Remarks. 

Like  the  anterior  tibial,  and  for  the  same  reasons,  the  posterior  tibial  artery 
is  but  rarely  the  seat  of  spontaneous  aneurism,  or  even  of  false  aneurism, 
whether  diffuse  or  circumscribed.  But  Ruysch  cites  an  instance  of  aneu- 
rism near  tlie  heel,  which  could  have  arisen  from  no  other  artery,  and  which 
was  opened  for  an  abscess.  Dr.  Dorsey  has  observed  a  varicoid  dilatation  of 
this  artery  accompanied  by  hypertrophia,  in  a  case  of  varicose  aneurism, 
Guattani  likewise  sneaks  of  pulsatile  tumors,  which  were  evidently  the  result 
of  some  lesion  in  tlie  posterior  tibial :  Wounds  of  this  vessel,  accompanied 
by  hemorrhage  or  diffused  aneurisms,  have  been  observed  of  late,  by  Messrs, 
Scarpa,  Hodgson,  Marjolin,  Dupuytren,  Earle,  and  others. 

The  ancient  method,  according  to  M.  Boyer,  is  the  only  one  which  should 
be  applied  to  these  affections ;  because,  by  the  method  of  Anel  the  blood  would 
certainly  be  returned  from  below,  through  the  plantar  arch  and  the  anterior 
tibial  artery.  Others  harboring  the  same  fears,  but  unwilling  to  operate  upon 
a  diseased  part,  have  proposed  an  intermediate  method,  that  is,  to  place  a 
ligature  above  and  another  below  the  aneurism,  without  touching  the  tumor. 
For  my  own  part  I  cannot  see  the  necessity  for  such  a  procedure.  Supposing 
that  the  reflux  of  the  blood  should  prove  a  hindrance  to  the  cure,  it  appears  to 
me,  that  in  order  to  prevent  it  there  needs  only  the  application  of  accurate  com- 
pression upon  the  passage  of  the  anterior  tibial  arterv  in  the  foot,  as  practised 
by  M.  Marjolin,  or  even  just  below  the  wound,  if  its  situation  will  permit. 
And  when  the  seat  of  the  disease  is  in  the  sole  of  the  foot,  and  when  com- 


OPERATIVE    SURGERY.  75 

pression  lias  not  succeeded,  it  is  plain  that  the  ligature  of  the  trunk  of  the 
tibial  can  be  practised  only  according  to  the  modern  method.  The  only  case 
where  the  ancient  operation  would  be  requisite,  or  at  least  preferable,  is  when 
the  aneurism  lies  in  the  superior  half  of  the  leg,  and  here  many  will  prefer 
the  ligature  of  the  popliteal,  or  the  femoral  itself.  Traumatic  diffused  aneu- 
risms are  not  subject  to  this  rule,  and  should  be  treated  as  they  have  hitherto 
been  by  Boyer  and  Guthrie,  that  is  by  the  method  of  Keisleyre. 

Art.  3. — Manual. 

At  whatever  point  the  posterior  tibial  artery  is  to  be  exposed,  the  leg  should 
be  flexed  and  laid  on  its  external  side.  If  compression  is  necessary,  it  should 
be  applied  in  the  thigh,  or  upon  the  body  of  the  pubis. 

1st.  Behind  the  Malleolus. — The  operator  makes  a  slightly  curved  incision, 
concave  anteriorly,  beginning  an  inch  above  and  ending  an  inch  below,  and 

fassing  at  least  three  lines  from  the  posterior  edge  of  the  malleolar  projection, 
n  operating  upon  the  beginning  of  the  calcanear  furrow,  it  is  necessary  to 
proceed  with  much  caution,  to  cut  the  tissues  by  laminae,  and  to  pass  the 
grooved  sound  under  the  aponeurosis  before  dividing  it  with  the  bistoury,  if 
we  would  avoid  wounding  the  artery,  which  is  here  sometimes  very  super- 
ficial. An  incision  nearer  to  the  malleolus  would  involve  the  risk  of  falling 
upon  one  of  the  fibro-synovial  sheaths,  which  it  contributes  to  form,  and 
nothing  can  be  more  dangerous  than  such  a  mishap,  on  account  of  the  inflam- 
mation which  might  result.  Farther  back  the  artery  would  be  difiicult  to 
find,  and  the  operation  much  more  laborious.  For  the  rest,  after  having  iso- 
lated the  vessel  from  the  adjacent  parts,  it  is  immaterial  whether  it  be  raised 
with  the  sound  from  the  inner  or  the  outer  side. 

2d.  Below  the  Calf. — In  order  to  discover  the  posterior  tibial  between  the 
malleolus  and  the  calf,  a  straight  incision  is  made,  from  two  to  three  inches 
in  length,  at  equal  distances  from  the  inner  edge  of  the  tibia  and  the  tendo 
Achilles.  The  skin,  the  adipose  stratum,  and  the  superficial  layer  of  the  apo- 
neurosis, having  been  divided,  the  next  step  is  to  denude  with  the  sound  the 
deep-seated  aponeurosis.  An  incision  is  then  made  through  that  membrane 
of  the  same  extent  with  that  in  the  skin,  the  bistoury  being  carried  only  in  the 
groove  of  a  director.  The  operator  will  here  be  sure  to  meet  with  the  artery, 
particularly  if  he  has  taken  the  precaution  to  cut  the  tissues  perpendicularly, 
that  is  to  say,  by  carrying  the  bistoury  forwards  and  outwards,  as  if  to  striice 
the  peroneal  side  of  the  tibia.  It  is  necessary  here  to  observe  that  if  the 
incision  of  the  integuments  is  commenced  nearer  to  the  bone  than  above 
directed,  there  will  be  only  one,  instead  of  two  aponeurotic  layers  to  tra- 
verse; but  then,  in  falling  upon  the  muscles  at  a  great  distance  from  the 
artery,  there  is  a  greater  risk  of  error,  than  by  the  method  previously- 
directed. 

Sd.  On  the  Calf  of  the  Leg. — Mr.  Guthrie  upon  one  occasion  proceeded 
to  seek  for  the  posterior  tibial,  by  penetrating  through  the  whole  thickness  of 
the  calf.  Gelee,  in  a  similar  case,  made  a  counter  incision,  passed  a  ribbon 
between  the  muscular  beds  and  tied  it  over  the  fore  part  of  the  limb,  which 
he  protected  with  compresses,  having  previously  insinuated  pieces  of  lint 
deeply  into  the  wound  between  the  muscles  and  the  artery,  for  the  purpose 
of  directing  upon  the  latter  a  sufficient  compression.  His  patient  recovered. 
But  most  authors  recommend  to  penetrate  by  the  inner  side  of  the  leg,  and  to 
detach  and  turn  outward  the  corresponding  portion  of  the  soleus  muscle  and  its 
aponeurosis,  from  the  posterior  face  of  the  tibia.  By  this  method,  however,  the 
10 


T4  NEW  ELEMENTS  OF 

operator  is  exposed  to  the  risk  of  denuding  the  bone,  of  being  unable  to  pene- 
trate to  the  artery  without  considerable  difficulty,  and  of  meeting  so  much 
opposition  from  the  muscles,  as  to  oblige  him,  after  the  operation,  to  divide 
their  fibres  crosswise  upon  the  outer  lip  of  the  wound,  as  occurred  to  Mr. 
Bouchet,  of  Lyons.  By  proceeding  in  the  following  manner  the  inconve- 
niences above-mentioned  will  be  avoided. 

Th^  surgeon  placing  himself  on  the  outside  of  the  limb,  makes  an  incision 
of  about  four  inches  in  length  in  the  direction  of  the  inner  edge  of  the  tibia, 
and  at  a  good  finger's  breadth  from  it,  draws  aside  the  saphena  vein,  divides 
the  aponeurosis,  and  falls  perpendicularly  upon  the  fibres  of  the  soleus 
muscle,  which  he  incises,  layer  by  layer,  as  if  to  gain  the  posterior  face  of  the 
tibia,  near  its  outer  border  5  he  soon  exposes  a  fibrous  bed,  thick,  white,  and 
shining,  into  which  the  fleshy  fibres  are  inserted — it  is  the  deep  aponeurosis, 
traversed  by  many  vascular  branches.  The  artery  is  immediately  below  it, 
enveloped  by  its  veins  and  accompanied  by  the  nerve,  which  may  be  distin- 
guished by  its  roundness,  its  size,  and  its  yellow  color. 

D.  Peroneal  Artery. 

The  peroneal  artery  rarely,  except  in  its  superior  half,  claims  the  assist- 
ance of  the  operative  surgeon.  Below  it  is  too  slender  and  deeply  situated, 
to  be  susceptible  of  much  relief  when  injured.  In  cases  where  aneurisms 
develop  themselves  upon  any  point  of  its  course,  of  which  the  practice  of  the 
Hotel  Dieu  last  winter  offered  an  example,  the  best  mode  of  procedure  would 
perhaps  be  to  tie  the  popliteal  or  the  femoral,  rather  than  the  diseased  trunk 
itself.  But  if  some  particular  circumstances  should  render  a  contrary  course 
of  conduct  necessary,  the  following  seems  to  be  the  most  eligible  method  to 
be  pursued. 

Operation. — As  it  would  be  necessary  in  the  calf  of  the  leg  to  seek  the 
peroneal  artery  at  the  depth  of  several  inches  (whether  the  operator  imitate 
the  practice  of  Mr.  Guthrie  or  follow  the  rules  given  for  the  posterior  tibial) 
and  as  in  the  lower  fourth  of  its  course  this  vessel  is  not  of  any  importance, 
it  is  only  at  the  place  where  the  soleus  muscle  separates  itself  from  the  gas- 
trocnemius, that  we  should  think  of  tying  it.  An  incision  three  inches  in 
length,  parallel  with  the  posterior  ed^e  of  the  fibula,  directed  toward  the  axis 
of  the  limb,  comprehending  the  skin,  the  adipose  stratum,  the  superficial 
aponeurosis,  the  external  origin  of  the  soleus  muscle,  and  the  deep  aponeu- 
rosis, would  serve  to  expose  it  and  to  isolate  it  in  the  substance,  or  on  the 
posterior  and  internal  face  of  the  long  flexor  muscle  of  the  great  toe.  Mr. 
Guthrie,  who  has  declared  himself  an  enemy  to  the  method  of  Anel  in 
traumatic  aneurisms,  in  order  to  reach  the  peroneal  artery,  which  had  been 
wounded  by  a  ball,  preferred  cutting  vertically  into  the  calf  of  the  leg  to  the 
extent  of  seven  inches,  dividing  crosswise  the  extreme  edge  of  the  wound, 
and  afterwards  encircling  it  with  a  mediate  ligature,  by  means  of  a  suture 
needle  instead  of  attempting  to  discover  the  artery  above.  I  am  of  opinion, 
that  in  such  a  case  it  would  be  better  to  follow  the  plan  of  Guthrie  than  to 
tie  the  trunk  of  the  femoral. 

For  all  these  ligatures,  M.  Lisfranc  recommends  that  the  incision  of  the 
integuments  should  cross  the  direction  of  the  artery  at  an  angle  of  35  decrees, 
instead  of  being  parallel  to  it.  *'By  this  expedient,"  says  he,  '^wiU  be 
obtained  greater  facility  in  holding  aside  the  lips  of  the  incision,  and  an 
almost  absolute  impossibility  of  missing  the  artery."  This  modification  may 
be  adopted  without  doubt,  and  would  perhaps  be  preferable  in  particular 


OPERATIVE    SURGERY.  75 

instances ;  but  it  does  not  appear  to  have  sufficient  advantage  over  the  ordi- 
nary practice  to  deserve  a  more  particular  recommendation. 

E.  Popliteal, 

Art.  1. — Anatomical  Remarks, 

The  ham,  much  noticed  in  surgery  during  the  last  century  on  account  of 
its  principal  artery,  is  an  excavation  in  the  form  of  a  lozenge,  formed  of  two 
triangles,  with  a  common  base,  and  of  which  the  larger  part  is  placed  above 
the  condyles  of  the  femur.  Here  the  Sartorius,  semitendinosus  and  semi- 
membranosus muscles,  together  with  the  adductor  magnus,  form  its  internal, 
the  biceps  the  external,  and  the  femur  the  anterior  wall.  In  the  portion 
lyino;  in  the  leg,  the  origins  of  the  gastrocnemius  and  the  condyles  of  the  femur 
limit  it  upon  the  sides,  while  the  posterior  face  of  the  articulation  and  of  the 
popliteus  muscle  form  its  floor.  Lastly,  an  aponeurosis,  with  transverse  fibres, 
sometimes  of  considerable  strength,  continuous  with  those  of  the  thigh  and 
leg,  closes  this  whole  space  from  behind. 

The  popliteal  artery  traverses  its  length  from  above,  inclining  a  little 
nearer  to  its  inner  edge  (which  conceals  it  in  the  upper  part  of  the  space) 
than  to  the  outer  edge,  as  far  as  the  point,  where  it  passes  into  the  fossa  be- 
tween the  condyles.  In  the  femoral  part  of  the  space,  the  vein  is  strongly 
united  to  the  artery  behind,  and  to  the  outside  ;  the  internal  branch  of  the 
sciatic  nerve  is  still  more  superficial,  and  four  or  five  lymphatic  ganglions, 
with  some  cellular  tissue  and  fat,  surround  the  vessel  and  separate  it  from 
the  aponeurosis.  On  the  leg  it  is  less  deeply  situated ;  the  vein  and  the 
nerve  are  frequently  found  on  the  inside;  at  other  times  the  former  lies  on 
the  peroneal  side,  while  the  latter  is  on  the  tibial.  Its  fatty  cellular  tissue, 
and  a  little  lower  down,  the  origins  of  the  gastrocnemius  conceal  it  from 
behind  while  its  anterior  surface  rests  on  the  posterior  ligament  of  the  articu- 
lation and  the  popliteus  muscle.  It  is  well  to  add,  that  the  external  saphena 
vein  ceases  to  be  superficial  when  it  enters  this  region,  on  the  median  line 
of  which  it  is  generally  observed,  and  that  it  empties  a  little  above  the  con- 
dyles into  the  popliteal  vein. 

Art,  2. — Surgical  and  Historical  Remarks, 

In  no  part  is  aneurism  more  common  than  in  the  ham.  Spontaneous  aneu- 
rism is  that  to  which  it  is  particularly  subject.  Traumatic  alieurism  is  also  of 
frequent  occurrence,  and  varicose  aneurism  is  sometimes  met  with.  The 
great  frequency  of  the  first  has  much  occupied  the  attention  of  surgeons. 
Some  have  attributed  it  to  efforts  at  the  extension  of  the  leg  upon  the  thigh. 
Scarpa,  M.  Delpech,  and  others,  oppose  this  opinion,  and  maintain  that  aneu- 
rism which  is  not  the  immediate  consequence  of  a  direct  wound,  is  always 
produced  by  a  disease  of  the  internal  or  middle  tunic  of  the  artery.  M. 
Kicherand  thought  to  solve  the  problem  in  favor  of  the  opinions  of  the  former 
surgeons,  by  the  following  experiment.  He  took  the  lower  extremity  of  a 
dead  subject,  which  he  briskly  forced  to  its  greatest  possible  extension  by 
acting  on  its  two  extremities,  whilst  the  knee,  or  middle  and  convex  part,  wa» 
supported  on  a  solid  body.  Dissection  afterwards  showed  the  internal  coats 
torn  and  bruised  in  several  places.  But  Mr.  Hodgson  mentioned  experiments 
which  have  been  attended  with  opposite  results,  and  the  greater  part  of 
modern  practitioners  adopt  the  opinion  of  Scarpa.    Has  this  question  ever 


76  NEW  ELEMENTS   OF 

been  presented  in  its  proper  light?  Would  it  not  be  possible  to  reconcile  the 
two  modes  of  viewing  it  ?  It  is  true,  that  whilst  the  artery  is  perfectly  sound 
no  extension  of  the  leg  appears  capable  of  breaking  its  coats  ;  but  if  its  inte- 
rior is  incrusted  with  calcareous  plates,  or  is  the  seat  of  ulceration  ;  if  one 
of  the  membranes  has  lost  its  flexibility  and  has  become  brittle,  why  reject  the 
explanation  of  M.  Richerand  ?  It  is  laborious  men — those  who  are  always 
€rect,  jockeys  for  example — that  most  frequently  present  this  malady. 

The  form  of  the  popliteal  aneurism,  the  effects  that  it  produces,  and  all  that 
concerns  its  development,  find  a  very  natural  explanation  in  the  anatomical 
disposition  above  described.  Arrested  by  the  bones  in  front,  and  by  the  apo- 
neurosis in  the  rear,  the  tumor  extends  itself  at  first  in  length  andi  breadth, 
and  remains  for  a  considerable  time  without  external  prominence.  Thus  con- 
fined, it  presses  upon  the  lymphatic  ganglions,  the  vein  and  the  nerves,  and 
occasions  swelling,  infiltration,  pain,  numbness,  and  sometimes  gangrene  of 
the  leg.  The  pressure  which  results  from  it  may  also  determine  the  absorp- 
tion of  a  part,  or  even  the  whole  of  the  thickness  of  the  bones,  of  which  several 
examples  are  cited.  Most  frequently,  however,  the  aponeurosis  yields  and 
becomes  thinner,  and  the  aneurism  comes  to  project  under  the  skin,  without 
producing  all  these  evils. 

Anatomy  teaches  us,  that  the  seat  of  the  opening  in  the  artery  cannot  be  cor- 
ectly  ascertained  by  the  point  occupied  by  the  external  tumor.  The  resist- 
ance offered  by  the  soft  parts  of  the  popliteal  regions  being  less  in  the  middle, 
than  in  any  other  part,  it  is  evident  that  here  the  aneurismal  cyst  will  always 
tend  to  project.  If  then  the  ulceration  take  place  in  the  tibial  angle  of  the 
space,  the  aneurism  will  nevertheless  make  its  appearance  above  the  condyles ; 
and  if  on  the  contrary,  it  occur  in  the  superior  angle,  it  will  be  seen  gradu- 
ally to  descend.  This  is  a  point  which  ought  always  to  be  kept  in  view  in 
practice,  at  least  in  operating  by  the  ancient  method. 

The  anastamoses  by  which  the  arteries  of  the  leg  communicate  with  each 
other  are  so  numerous  and  large,  that  the  surgeon  need  not  be  under  the 
slightest  apprehensions  with  regard  to  the  re-establishment  of  the  circulation 
in  that  part  of  the  member  after  the  operation  for  aneurism,  but  in  the  hollow 
of  the  ham  the  operation  is  not  attended  with  the  same  certainty.  There  the 
artery  is  alone,  and  the  supplementary  branches  are  very  small.  The  older 
surgeons,  persuaded  that  the  obliteration  of  such  a  trunk  would  produce  mor- 
tification of  the  parts  which  were  nourished  by  it,  had  no  other  resource,  after 
the  use  of  compression  and  a  weakening  regimen,  but  the  amputation  of 
the  thigh.  Even  J.  L.  Petit,  and  Pott,  labored  under  these  apprehensions. 
N.  Guenaud  vainly  endeavored  to  remove  them.  If  any  more  fortunate  results 
were  announced,  it  was  said  that  they  were  produced  by  an  irregular  distri- 
bution of  the  arteries ;  no  one  durst  believe  tnat  the  blood  could  arrive  at  the 
leg  after  the  ligature  of  its  only  arterial  trunk  ;  and  it  required  the  operations 
performed  by  Guattani,  Pelletan,  Desault,  Hunter,  &c.,  and  above  all,  the 
researches  or  the  laborious  Scarpa,  to  give  prevalence  to  the  opinion  opposed 
in  the  beginning  of  this  century.  At  the  present  day,  however,  there  no 
longer  exists  any  uncertainty  upon  this  point,  and  popliteal  aneurism  is  now 
attacked  with  almost  as  much  confidence  as  that  of  one  of  the  tibial  arteries. 

Nevertheless,  it  would  be  wrong  to  dissemble  that  this  operation  is  a  very 
serious  one,  and  ought  not  lightly  to  be  attempted.  In  this,  as  in  aneurisms 
of  the  superior  third  of  the  leg,  1  should  prefer  the  old  method,  or  even  that 
of  Brasdor.  . 

The  enfeebling  regimen  applied  to  aneurisms  of  the  popliteal  artery,  is  a 
resource  too  dangerous  and  uncertain  to  be  seriously  recommended.    Cold 


OPERATIVE   SURGERY,  77 

applications — ice  or  clay,  used  topically — so  highly  spoken  of  by  M.  Kalm- 
ski,  have  not  been  very  successfully  used,  excepting  by  Messrs.  Guerin  and 
Dutrouilh,  of  Bordeaux.  Mediate  compression,  either  upon  the  tumor  itself, 
above  it,  or  over  the  whole  limb,  has  been  attended  with  results  more  advan- 
tageous. Guattani,  Messrs.  Boyer,  Pelletan,  Richerand,  Ribes,  Dupuytren, 
Viricel,  &c.,  cite  examples  of  cures  obtained  by  these  means.  But  eleven 
months  of  care  and  absolute  rest  were  required  for  the  recovery  of  the  patient 
under  the  treatment  of  Eschard,  besides,  these  cures  are  rare.  M.  Roux 
mentions  a  case  where  compression,  directed  successively  upon  different  parts 
of  the  thigh,  was  followed  by  the  most  lamentable  effects,  and  that  without 
arresting  the  progress  of  the  aneurism.  Compression  may,  notwithstanding, 
be  used  upon  young,  feeble,  or  timid  subjects,  who  have  a  great  repugnance 
to  an  operation,  remembering  always  that  it  should  be  combined  with  refri- 
gerants and  the  treatment  of  Valsalva. 

If  the  patient  is  unable  to  support  it,  and  it  aggravates  instead  of  amelio- 
rating the  symptoms,  it  is  easy  to  remove  it  and  to  have  recourse  to  other 
methods.  When  the  disease  evinces  a  disposition  to  disappear  spontaneously, 
it  cannot  be  denied  that  compression  will  powerfully  assist  the  salutary 
efforts  of  the  system.  In  such  cases,  at  least,  it  is  likely  to  be  attended  with 
success.  Sometimes  the  tumor  has  disappeared  without  surgical  assistance. 
M.  Trousseau  relates  the  case  of  a  countryman  who  was  admitted  into  the 
hospital  at  Tours,  with  an  aneurism  in  the  ham.  A  consultation  of  the  prin- 
cipal surgeons  of  the  city  took  place,  and  the  necessity  of  an  operation  was 
unanimously  admitted.  The  next  day,  however,  the  pulsation  in  the  tumor 
was  found  in  a  great  measure  to  have  subsided  ;  three  days  afterwards  it  was 
not  to  be  felt,  and  at  the  expiration  of  two  months  the  patient  found  himself 
perfectly  restored,  without  having  undergone  any  operation  whatever.  M. 
Blizard  and  M.  Salmade  give  each  a  similar  example ;  and  the  records  of 
the  science  contain  several  others  not  less  remarkable. 

As  to  the  ligature,  it  would  seem  by  a  letter  from  Testa  to  Cotugno,  that 
Keisleyre  had  used  it  many  times  before  it  was  discussed  in  Italy.  Loch- 
man,  another  surgeon  of  Lorraine,  also  practised  it  successfully  upon  a  pa- 
tient at  Florence,  in  1752 ;  and  Burchall  ventured  to  do  the  same  at  the 
Manchester  Infirmary,  in  1757.  These  facts,  no  doubt,  were  what  awakened 
the  attention  of  Mazotti  and  Guattani.  In  two  operations  performed  by 
the  former,  he  placed  a  second  ligature  below  the  perforation  in  the  artery ; 
and  it  was  with  this  modification  that  the  practice  of  Keisleyre  was  attempt- 
ed for  the  first  time  amongst  us  by  Pelletan,  in  1780. 

If  requisite,  the  popliteal  artery  might  be  tied  according  to  either  of  the 
three  known  methods.  The  old  method  has  been  very  frequently  resorted  to 
in  France,  by  Pelletan,  Desault,  Deschamps  and  Boyer,  but  presents  so  many 
difficulties  that  it  has  been  very  little  practised  during  the  last  ten  or  fifteen 
years.  It  is  rarely,  also,  that  Anel's  method,  strictlv  taken,  can  be  applied 
to  aneurisms  of  the  ham.  Desault  is  the  only  one  that  has  so  used  it ;  and 
his  experience  tends  to  prove  that  it  is  infinitely  better  to  tie  the  femoral 
itself.  Although  the  plan  recommended  by  Brasdor  has  never  yet  been  tried, 
I  do  not  think  proper  in  this  place  to  pass  it  unnoticed.  In  fact,  if  the  tu- 
mor has  not  too  much  deformed  the  part,  is  not  too  voluminous,  occupies  the 
femoral  portion  of  the  popliteal  space,  it  appears  probable  that  the  ligature 
might  sometimes  be  placed  below  the  diseased  part.  Nevertheless,  as  the 
operation  would  thus  become  a  little  more  difficult  than  if  performed  upon 
the  thigh,  without  securing  any  very  manifest  advantage  over  either  of  the 
other  methods,  it  is  for  experienced  and  enlightened  surgeons  to  decide  upon 


?B  NEW  ELEMENTS    OF 

the  propriety  of  its  adoption  in  certain  cases.  It  is  only  then  in  aneurismal 
affections  of  the  superior  third  of  the  leg,  that  ligature  of  the  popliteal  artery 
will  be  found  advantageous  ;  Anel's  method  is  therefore  the  only  one  in 
'  which  it  can  be  practised.  It  need  not  after  all  be  attended  with  much  diffi- 
culty ;  perhaps  it  ought  even  to  be  preferred  when  the  patient  is  of  a  spare 
habit,  and  when  every  tiling  indicates  that  the  disease  does  not  extend  so  far 
as  tlie  ham. 

Art.  S. — Manual, 

1.  Ordinary  Process. — The  patient  is  laid  prostrate,  and  the  leg  is  mode- 
rately extended.  To  reach  the  artery  in  the  lower  part  of  the  popliteal  space, 
an  incision  is  made  through  the  skin  and  subcutaneous  layer  in  the  median 
line,  parallel  with  the  axis  of  the  member  and  three  or  four  inches  in  length  5 
care  being  taken  to  push  outwards  the  external  saphena  vein  if  it  presents  it- 
self under  the  edge  of  the  bistoury.  The  aponeurosis  once  divided,  the  cut- 
ting instrument  becomes  useless.  The  cellular  tissue  and  the  fat  are  then 
cautiously  torn ;  the  fibres  of  the  gastrocnemius  are  pushed  aside,  and  the 
vessel  is  separated  from  its  vein  or  veins  by  means  of  a  grooved  director. 
Above  the  Condyles  it  is  more  easy  to  avoid  the  saphena.  The  incision  should 
be  longer,  a  little  nearer  to  the  inner  than  the  outer  side  of  the  ham  (at  least 
high  up),  and  to  follow  a  slightly  oblique  direction,  so  as  to  come  over  the 
fossa  between  the  condyles.  Beneath  the  aponeurosis  are  the  nerves ;  a 
little  deeper  the  veins  ;  and,  quite  at  the  bottom,  the  artery ;  which  it  is 
usually  very  difficult  to  separate  from  the  vein,  and  which  is  always  here  more 
deeply  situated  than  in  its  inferior  half. 

2.  Process  of  Messrs.  Johert  and  Ashmead. — A  new  method,  totally  dis- 
tinct from  the  preceding,  has  been  invented  by  one  of  my  fellow-students. 
Instead  of  making  an  incision  upon  the  posterior  surface  of  the  popliteal  ro- 
gion,  M.  Jobert  recommends  that  the  artery  should  be  sought  by  penetrating 
in  the  depression  that  may  be  observed  when  the  leg  is  half  bent  above  the 
internal  condyle  of  the  femur,  between  the  vastus  internus  and  the  inner 
border  of  the  ham.  By  this  method  it  appears  to  me  that  difficulties  are  created, 
which  do  not  exist  in  the  ordinary  mode  of  procedure  so  long  as  the  operator 
keeps  in  view  the  anatomical  disposition  of  the  parts.  I  do  not  think,  there- 
fore, that  the  modification  of  M.  Jobert  ought  to  be  adopted,  notwithstanding 
the  more  precise  rules  to  which  Mr.  Ashmead  (who  believed  himself  to  be 
the  originator  of  this  method)  has  since  subjected  it. 

Results  of  the  Operation. — Whatever  may  have  been  the  means,  method,  or 
process,  by  which  a  cure  has  been  occasioned,  the  effiarts  of  the  organization 
m  re-establishing  the  circulation  of  the  blood  are  always  the  same.  The  oblit- 
eration of  the  vessel  extends  to  a  certain  distance  above  and  below  the  wound 
or  part  compressed  by  the  ligature;  the  branches  which  keep  up  the  commu- 
nication between  the  perforating  arteries  and  the  superior  articular  branches, 
together  with  some  branches  of  the  superficial  femoral,  and  the  inferior 
articular  arteries,  the  gastrocnemial  and  the  recurrent  tibial,  augment  gradu- 
ally in  volume,  and  at  last  form  a  beautiful  net-work  round  the  articulation. 
The  blood  then  passes  easily  from  the  thigh  into  the  arterial  canals  of  the  leg. 
There  is,  in  the  Museum  of  the  Faculty,  an  anatomical  preparation  taken 
from  a  patient  cured  a  long  time  before  by  Sabatier.  A  drawing  of  a  similar 
preparation  may  also  be  found  in  the  first  volume  of  the  Clinique  of  Pelletan. 
Messrs.  A.  Cooper,  Hodgson,  Dupuytren,  &c.,  have  also  observed  the  same ; 
and  I  had  an  opportunity  of  assuring  myself  of  its  reality,  on  the  body  of  the 


OPERATIVE    SURGERY.  79 

first  one  upon  whom  the  ligature  had  been  applied  at  Paris  for  popliteal  aneu- 
rism. It  was  in  1780  that  this  patient  placed  himself  under  the  care  of  M. 
Pelletan.  He  was  then  thirty-two  years  old,  and  died  at  the  a<j;e  of  eighty- 
four.  The  trunk  of  the  popliteal  artery  was  transformed  into  a  fibro-cellular 
cord,  quite  slender  and  pliant,  through  almost  its  whole  extent;  the  superior 
articular  arteries,  internal  and  external,  the  anostomica  magna  and  a  branch  of 
the  superficial  muscular,  furnished  by  the  femoral,  were  of  the  size  of  large 
crow-quills,  and  formed  large  and  irregular  arches,  upon  the  sides  of  the 
patella  and  the  condyles,  by  communicating  with  the  recurrent  branch  of  the 
anterior  tibial,  the  inferior  articulars,  &c.  The  limb  was  in  good  case,  and 
did  not  differ  in  any  respect  from  that  of  the  opposite  side. 

F.  Femoral. 
Art.  1. — Anatomical  Remarks. 

The  femoral  artery  extends  from  the  crural  arch  to  the  beginning  of  the 
inferior  third  of  the  thigh,  and  follows  a  line  somewhat  spiral,  descending 
from  the  middle  of  the  fallopian  ligament  obliquely  inwards  to  the  space  be- 
tween the  condyles  of  the  femur,  where  the  continued  trunk  is  called  the 
popliteal.  The  vein,  lying  on  its  internal  and  posterior  side,  is  united  to  it 
by  dense  cellular  tissue,  which  forms  for  both  a  sort  of  common  sheath.  The 
principal  branch  of  the  crural  nerve,  which  at  first  lies  upon  its  external  side, 
inclines  by  degrees  as  it  descends  towards  its  anterior  surface,  and  some- 
times to  its  internal  side ;  but  farther  down  abandons  it  altogether,  to  pass 
between  the  muscles  which  form  the  side  of  the  ham.  Another  nerve,  not  less 
voluminous,  sometimes  crosses  its  superior  part,  lying  before  it  and  the  vein, 
as  far  as  the  middle  of  the  thigh.  A  fibrous  sheath,  hollowed  from  the  thick- 
ness of  the  deep  layer  of  the  fascia  lata,  envelopes  the  whole,  and  presents  a 
disposition  of  parts  which  merits  particular  attention.  The  interior  wall  of 
this  sheath  gradually  increases  in  thickness  as  it  descends ;  for  at  the  groin  it 
may  be  easily  torn  with  the  sound,  while  below  it  often  presents  very  dis- 
tinct transverse  fibres,  a  pearly  appearance,  and  great  resistance.  At  its 
lower  extremity,  it  is  continuous  with  the  fibrous  expansion,  or  more  properly 
with  the  aponeurosis  given  off  by  the  termination  of  the  second  rather  than  of 
the  third  adductor.  The  artery  is  next  covered  by  the  sartorious  muscle, 
which  crosses  it  very  obliquely  from  the  outer  to  the  inner  side,  and  conceals 
in  reality  only  the  two  inferior  thirds.  In  the  superior  part  the  artery  is  covered 
by  the  deep  lymphatic  ganglions,  and  by  clusters  of  filamentous  cellular  tissue. 
It  is  only  when  the  sartorius  approaches  the  gracilis  muscle  to  form  the  apex 
of  the  inguinal  triangle,  that  its  internal  edge  begins  to  separate  the  artery 
from  the  superficial  layer  of  the  aponeurosis  of  the  thigh,  which  almost  touches 
it  in  the  bend  of  the  groin.  As  we  proceed  towards  the  skin,  after  the  sarto- 
rius muscle,  comes  the  first  lamina  of  the  fascia  lata,  pierced  in  the  upper  part 
by  one  or  more  openings  for  the  entry  of  the  superficial  veins  into  the  deep 
femoral,  then  the  subcutaneous  stratum  which  contains  the  branches  of  the 
saphena  vein,  which  latter  is  almost  always  situated  within  the  line  of  direc- 
tion of  the  artery. 

Among  the  branches  of  the  femoral,  there  is  a  certain  number  which  ought 
not  to  be  forgotten  by  the  surgeon,  viz.  1st.  The  profunda,  which  separates 
itself  from  the  femoral  about  two  inches  below  the  ligament  of  Poupart,  buries 
itself  in  a  line  with  the  lesser  trochanter  beneath  the  deep  layer  of  the  apo- 
neurosis, and  divides  into  the  three  perforant  branches.    2dly.  The  circum- 


80  NEW   ELEMENTS   OF 

flexes,  which  proceed  sometimes  from  above,  sometimes  from  beneath,  and 
frequently  from  the  profunda  itself.  Sdly.  The  superficial  muscular,  given 
off  by  the  external  circumflex  and  descending  to  the  knee  to  form  anasto- 
moses with  the  branches  of  the  popliteal.  4thly.  The  anastomica  magna, 
which  has  its  origin  near  the  commencement  of  the  popliteal,  and  proceeds 
towards  the  inner  side  of  the  leg  along  the  superior  surface  of  the  third  ad- 
ductor. 

Ano7nalies. — -The  secondary  branches  of  the  femoral  are  subject  to  nume- 
rous anomalies,  but  the  trunk  itself  presents  very  few.  Morgagni,  who 
believed  it  to  be  often  double,  merely  supposed  it  but  never  really  observed  it. 
Haller,  the  same.  But  Gooch  cites  three  examples;  Cassamayer  mentions  a 
fourth  ;  and  I  have  myself  met  with  a  fifth.  In  my  own  case  the  supernu- 
merary artery  was  evidently  only  a  continuation  of  the  profunda,  which,  after 
having  supplied  the  perforating  arteries,  preserved  sufficient  volume  to  enable 
it  to  descend  below  the  knee.  In  a  subject  aifected  with  aneurism,  Mr. 
Charles  Bell  found  the  femoral  artery  divided  into  two  trunks  of  equal  size, 
which  united  to  form  the  popliteal.*  Mr.  J.  Houston,  conservator  of  the 
anatomical  museum  in  Dublin,  cites  a  similar  fact.  Messrs.  Bronson  and 
Cromwell,  distinguished  young  physicians  of  America,  pointed  out  to  me  in 
1825,  in  the  pavilion  of  the  practical  school,  a  different  variety.  Instead  of 
remaining  contiguous  to  the  artery,  the  crural  vein  was,  on  the  contrary,  sepa- 
rate from  its  commencement,  and  did  not  rejoin  it  until  its  entry  into  the 
popliteal  space,  after  having  formed  a  long  arch  the  convexity  of  which  looked 
towards  the  internal  edge  of  the  thigh.  I  liave  once  since  met  with  a  similar 
disposition. 

Art.  Z. — Historical  and  Surgical  Remarks, 

If  spontaneous  aneurism  is  more  common  than  any  other  in  the  popliteal 
space  it,  is  not  so  at  the  thigh ;  although  even  there  it  is  not  of  very  rare  occur- 
rence, particularly  in  the  upper  part  where  the  artery,  badly  protected  in  front, 
is  obliged  to  follow  the  different  movements  of  the  articulation.  All  its  other 
parts  may  also  be  the  seat  of  spontaneous  anuerism,  but  the  thigh  is  more 
particularly  subject  to  traumatic  aneurism.  Diffused  and  circumscribed 
false  aneurisms  often  occur  there ;  nor  is  this  part  exempt  from  varicose 
aneurism  as  has  been  proved  by  the  observations  of  M.  liarrey,  and  by  a  case 
which  was  treated  at  the  Hotel  Dieu,  in  1824,  by  M.  Guersent,  jun.  In 
the  lower  part  the  sartorius  muscle  has  a  tendency  to  force  the  tumor  for- 
ward ;  in  the  superior  part  it  often  pushes  it  inward  ;  this,  added  to  the  thin- 
ness of  the  aponeurosis,  rent  the  fallopian  tube,  and  explains  the  remark  which 
has  been  made  by  so  many  practitioners,  viz :  that  in  the  eroin  the  opening 
of  the  vessel  almost  always  corresponds  with  the  inferior  tliird  of  the  aneu- 
rismal  bag.  As  they  are  not  surrounded  by  solid  parts,  aneurisms  of  the 
femoral  speedily  enlarge ;  yet,  as  they  comprise  neither  voluminous  nerves 
nor  important  articulations,  they  are,  other  things  equal,  attended  by  fewer 
unpleasant  symptoms  than  aneurisms  of  the  popliteal  artery. 

Spontaneous  Recovery. — Aneurisms  of  the  thigh,  notwithstanding  the  size  of 
the  artery  which  gives  them  birth,  are  not  always  fatal.  M.  A.  Severin  re- 
lates a  case  where  the  tumor  was  attacked  by  gangrene.  After  the  fall  of 
the  eschars,  the  wound  cicatrized  by  degrees;  there  was  no  hemorrhage, 
and  the  limb  returned  to  its  natural  state.  Lancisi  saw  an  aneurism,  which, 
though  very  voluminous,  decreased  by  degrees,  and  finally  disappeared 
Tinder  the  influence  of  simple  fomentations,  tepid  baths,  and  diluents.    Guat- 


OPERATIVE    SURGERY.  81 

tani  saw,  at  Rome,  in  1765,  a  similar  case  to  that  mentioned  by  M.  A.  Severin. 
Clarke,  in  1784,  witnessed  another.  Ford  saw  an  aneurism  of  the  thigh  cured 
without  other  assistance  than  that  afforded  bj  spare  diet  and  rest.  Mr.  Spal- 
ding, in  1808,  after  having  opened  and  cleansed  an  enormous  crural  aneurism, 
was  astonished  to  find  the  artery  completely  obliterated  above  and  below  the 
lesion,  and  not  a  drop  of  blood  to  issue  from  either  end.  Mr.  Hodgson,  in 
operating  upon  a  dead  subject,  encountered  an  aneurismal  bag  in  the  inferior 
third  of  the  thigh,  the  coagulum  of  which,  extremely  solid,  had  completely 
obliterated  the  artery  as  far  as  the  origin  of  the  profunda,  in  one  direction, 
and  to  the  commencement  of  the  leg  in  the  other.  Finally,  M.  Marjolin,  in 
his  lectures  before  the  faculty,  makes  mention  of  a  man  aged  sixty,  afflicted 
with  an  aneurism  of  the  middle  of  the  femoral,  which  transformed  itself  into 
an  abscess,  and  disappeared  after  a  long  suppuration.  Mr.  Guthrie  cites  a 
similar  example,  which  took  place  in  the  York  hospital. 

But  these  cases  ought  to  be  considered  only  as  happy  exceptions,  on  which 
it  would  be  imprudent  to  count  in  practice. 

The  refrigerant  method,  antiphlogistics,  regimen,  and  compression,  have 
also  produced  favorable  results.  Hodgson  adduces  numerous  examples.  At 
Bordeaux,  M.  Teyran  cured  a  femoral  aneurism  by  bleeding,  cold  applica- 
tions, &c.,  on  a  patient  who  had  another  aneurism  on  the  opposite  side.  M. 
Larrey  speaks  of  a  sergeant  of  the  guards,  who  received,  in  April  1817,  a 
stroke  from  a  sabre  in  the  superior  part  of  the  right  thigh;  a  circumscribed 
false  aneurism  was  the  consequence,  which  was  speedily  cured  by  the  treat- 
ment of  Valsalva,  aided  by  the  action  of  topical  refrigerants.  M.  Ribes 
reports  that  Sabatier  succeeded  by  the  same  means  with  a  patient  who  was 
afflicted  with  two  aneurisms  upon  the  same  limb— one  upon  the  thigh  and  the 
other  upon  the  ham. 

Compression. — The  observations  of  Arnaud,  Mayer,  Kinglate/Albers,  and 
MM.  Dubois  and  Dupuytren,  prove  that  simple  compression  is  capable  of 
producing  the  same  results.  For  this  purpose  Heister,  Senf,  Foubert,  Rava- 
ton,  and  Camper,  constructed  machines  more  or  less  analogous  to  the  tourniquet 
of  J.  L.  Petit ;  and  it  was  for  the  same  that  Guattani  and  Theden  so  earnestly 
recommended  their  particular  form  of  bandages.  If  such  means  cured  aneu- 
rism without  obliteration  of  the  artery  (as  was  believed  until  the  expiration 
of  the  last  century),  they  certainly  ought  to  be  tried  before  resorting  to  the 
ligature ;  but,  since  the  contrary  has  been  so  abundantly  proved  by  Scarpa,  it 
will  be  found  far  better  to  have  recourse  immediately  to  the  latter. 

"ligature. — Ligature  of  the  femoral  is  now  very  frequently  practised.  It 
is  usually  preferred,  as  we  have  seen  above,  in  treating  lesions  of  the  popliteal 
artery,  and  even  aneurisms  of  the  leg.  Many  centuries  elapsed,  however, 
before  any  one  dared  to  practice  it.  It  was  well  known  that  Severin  and 
Trullus  had  operated  successfully  for  an  aneurism  situated  at  eight  fingers' 
breadth  below  the  groin ;  that  Bottentuit  had  done  the  same  at  the  Hotel 
Dieu,  at  Paris,  in  1688  ;  that  Guattani  had  used  mediate  compression  at  the 
passage  of  the  artery  under  the  fallopian  ligament  with  equally  complete 
success,  but  nothing  was  then  able  to  open  the  eyes  of  surgeons.  It  was 
only  after  having  deeply  reflected  upon  the  numerous  anastomic  branches  in- 
dicated by  Winslow  and  Haller,  that  Heister  ventured  to  propose  ligature  in 
certain  cases  of  aneurism.  A  short  time  afterwards,  Anel,  Hamilton,  Burs- 
chall,  Leber,  Jussy,  &c.,  became  convinced  that,  after  the  ligature,  the  cir- 
culation of  the  blood  soon  re-established  itself  in  the  inferior  part  of  the  limb. 
As  the  experiments  that  were  made  in  England  from  1760  to  1780  were, 
according  to  Pott,  Wilmer,  and  Kirkland,  much  less  encouraging  than  they 
11 


82  NEW   ELEMENTS   OF 

had  been  twenty  years  before  in  Italy,  it  required  nothing  less  than  the  suc- 
cess of  Desault,  Hunter,  and  Pelletan,  to  bring  it  into  honor,  and  cause  its 
general  adoption 

The  ligature  may  be  used  at  any  point  in  the  length  of  the  thigh ;  but  not 
at  all  points  with  the  same  chance  ot  success.  As  long  as  the  profunda  femoris 
is  respected,  the  danger  is  not  greater  than  when  the  operation  is  practised 
upon  the  popliteal  artery.  But  when  it  is  necessary  to  sacrifice  the  great 
muscular  artery,  it  is  evident  that  the  blood  can  only  reach  the  limb  by  the 
secondary  branches  which  emerge  from  the  pelvis.  Of  the  three  methods 
generally  known,  that  of  Anel  is  almost  the  only  one  now  practised.  That 
of  Keisleyre,  so  frequently  used  by  Desault,  Pelletan,  Deschamps,  Messrs. 
Boyer,  Roux,  &c.,  and  which  prevailed  so  long  in  France,  is  no  longer  re- 
commended, even  by  M.  Boyer  himself,  in  the  second  edition  of  his  work, 
except  in  a  few  particular  cases.  Are  there  really  any  circumstances  under 
which  it  ought  to  be  preferred  ?  The  cases  mentioned  by  Hodgson,  and  those 
which  have  occurred  in  England  during  the  last  thirty  years,  seem  to  prove  the 
contrary.  Nevertheless,  some  individuals  of  an  imposing  authority  among 
us,  have  continued  to  use  it  in  cases  of  varicose,  and  in  diffused  traumatic 
aneurism;  particularly  when  the  arterial  tumor  approaches  so  near  to  the 
bend  of  the  groin  as  to  render  it  impossible  to  place  a  ligature  between  it 
and  the  profunda.  In  1826,  I  saw  an  operation  performed  in  this  manner  by 
M.  Roux,  for  an  aneurism  of  the  thigh.  It  was  successful.  It  is  also  true,  as 
has  been  observed  by  M.  Boyer,  that  if  the  tumor  extends  itself  to  the  bend 
of  the  groin,  v/e  may  by  opening  it  preserve  the  profunda. 

It  remains  to  be  seen  whether  this  advantage  is  sufficient  to  counterba- 
lance the  numerous  inconveniences  to  which  this  method  exposes  us.  Ligatures 
of  the  iliac  have  proved,  that  in  such  cases  as  the  above  the  muscular  artery 
is  not  indispensable  to  the  maintenance  of  life  in  the  limb.  What  regret,  too, 
would  a  practitioner  experience,  if,  after  having  emptied  the  aneurismal  bag 
he  found  the  femoral  opened  higher  up  than  he  had  supposed  ;  or  that  the 
walls  of  the  superior  portion  were  too  much  diseased  to  bear  the  action  of  the 
ligature ! 

It  is  not  absolutely  necessary,  then,  to  open  the  aneurismal  bag,  for  the 
purpose  of  tying  the  crural  artery  in  any  part  of  its  length,  except  in  aneu- 
risms from  external  causes,  or  those  which  are  diffused,  or  very  voluminous 
and  elevated. 

In  applying  the  method  of  Anel  to  the  treatment  of  aneurisms  of  the  infe- 
rior member,  Desault  aimed  for  the  upper  part  of  the  popliteal  space,  and  not 
Upon  the  femoral  artery,  properly  so  called.  M.  Martin,  of  Marseilles,  says 
that  Spezzanni,  an  Italian  professor,  practised  this  mode  of  operation  upon  the 
thigh  four  years  before,  with  the  intention  of  disarticulating  the  leg  when 
the  gangrene  should  have  become  limited,  and  that  the  patient  preserved  his 
limb. 

It  is  affirmed,  on  the  other  hand,  as  I  have  already  stated,  that  many  years 
before  the  merits  of  the  ligature  were  canvassed  in  England,  Brasdor  recom- 
mended it  publicly  in  his  lectures  in  the  schools  of  surgery.  To  Hunter, 
however,  unquestionably  belongs  the  merit  of  having  first  caused  to  be  felt 
the  importance  of  such  a  modification  in  the  treatment  of  aneurism,  and  of 
having  awakened  the  attention  of  the  surgeons  of  Europe  to  this  happy  im- 
provement. Hunter  made  his  incision  a  little  below  the  middle  of  the  thigh, 
upon  the  internal  border  of  the  sartorious  muscle,  exposed  the  artery  to  the 
<«xtent  of  three  inches,  and  then  tied  it  with  four  ligatures. 

Scarpa  says  that  the  operation  should  be  performed  at  four  fingers'  breadth 


OPERATIVE    SURGERY.  83 

from  the  ligament  of  Poupart  5  that  the  vessel  w^ill  then  be  most  easily  found; 
that  there  will  be  no  important  collateral  artery  to  avoid;  and  that  in  operating 
as  far  as  possible  from  the  aneurism,  there  will  be  a  greater  probability  of  falling 
upon  a  healthy  part  of  the  tube,  which  shall  be  able  to  support  the  ligature. 

The  reasoning  of  Scarpa  has  not  been  universally  admitted.  The  greater 
part  of  the  French  surgeons  are  still  of  opinion  that,  in  treating  aneurism  of 
the  popliteal  artery,  it  is  useless  to  go  so  high  up  as  the  inguinal  space,  nor 
even  for  aneurisms  of  the  thigh,  unless  the  seat  of  the  disease  renders  it  neces- 
sary. They  rarely  proceed  so  high,  lest  by  approaching  too  near  to  the  pro- 
funda they  should  hinder  the  formation  of  the  coagulum.  It  is,  therefore,  still 
proper  to  lay  down  the  method  of  tying  the  femoral  artery  in  the  two  principal 
points  of  its  extent ;  that  is  to  say,  above  and  below  its  middle  part. 

Art.  3. — Manual, 

§  1.  Inferior  Half, 

The  member  is  at  first  slightly  bent  and  turned  outwards,  in  order  to  place 
the  muscles  in  a  state  of  relaxation.  An  incision  of  about  three  inches  in 
length  is  then  made  in  the  soft  part,  at  such  a  point  that  half  the  incision  shall 
be  in  the  middle  and  half  in  the  inferior  third  of  the  thigh.  In  cutting  lower 
down,  at  three  or  four  fingers'  breadth  above  the  knee,  as  some  have 
recommended,  +he  artery  will  not  be  found,  as  it  there  enters  the  cavity  of 
the  ham.     In  operating  higher  up,  we  trench  upon  the  process  of  Scarpa. 

In  the*  operations  of  Hunter,  this  incision,  oblique  from  without  to  within, 
fell  upon  the  internal  edge  of  the  sartorius  muscle,  which  was  turned  forward 
for  the  purpose  of  exposing  the  sheath  of  the  vessels.  The  operator  will  then 
successively  encounter  the  skin  (generally  rather  thin),  the  adipose  stratum, 
the  saphena  vein,  which  must  be  carefully  avoided,  the  superficial  lamina  of 
the  aponeurosis  of  the  sheath  of  the  sartorius  muscle ;  and  beneath  this,  deeply 
situated,  near  the  femur,  in  the  furrow  which  separates  the  vastus  internus 
from  the  adductors,  a  second  fibrous  bed,  to  be  divided. 

M.  Roux,  on  the  contrary,  advises  that  the  incision  should  be  made  on  the 
external  edge  of  the  anterior  muscle,  which  should  be  pushed  inwards  so  as 
to  enable  the  operator  to  come  at  the  artery.  The  same  method  was  also 
recommended  by  Hutchinson,  in  1811.  *'Byit,"  says  he,  *'the  saphena  vein 
will  certainly  be  avoided,  and  there  will  be  just  the  same  number  of  beds  to 
divide  as  by  the  procedure  of  Hunter." 

Considering  that  in  both  ways  it  is  necessary  to  displace  the  muscle  which 
hides  the  vessels,  turning  or  pushing  it  either  inwards  or  outwards,  Mr.  Hodgson 
thinks  that  it  would  be  better  to  discover  the  middle  third  of  the  artery,  an 
opinion  which  had  been  already  advanced  by  Desault,  who  also  asserted  that 
we  may,  without  any  bad  result,  cut  across  the  fibres  of  this  muscle  whenever 
it  embarrasses  either  by  its  presence  or  its  contractions. 

M.  Lisfranc  adheres  to  the  principles  of  Hunter,  and  gives  as  his  reasons 
for  so  doing,  that  an  experienced  surgeon  cannot  be  arrested  by  the  saphena ; 
tiiat  by  Hunter's  method  the  wound  is  not  so  deep ;  and  that  being  placed 
near  to  the  internal  edge  of  the  thigh,  it  is  easy,  after  the  operation,  to  give 
it  a  dependant  situation,  and  thus  prevent  the  stagnation  of  fluids  between  its 
lip&.  These  motives  are  certainly  laudable,  and  ought  to  be  allowed  some 
importance.  It  may,  however,  be  objected,  that  all  practitioners  are  not 
equally  skillful ;  that  a  wound,  if  inflicted  upon  the  saphena,  although  not 
in  itself  dangerous,  is  likely  to  produce  gangrene,  if  the  crural  vein  should 


84  NEW   ELEMENTS    OF 

happen  to  be  included  in  the  ligature  or  obliterated  in  any  way  whatever,  as 
in  the  example  cited  by  M.  Begin ;  that  if  instead  of  falling  upon  the  sheath 
of  the  sartorius  muscle  the  operator  should  expose  the  gracilis,  he  would  be 
very  likely  to  be  deceived  ;  and  lastly,  that  the  dependent  position  so  much 
insisted  upon  in  theory,  may  be  altogether  neglected  in  this  instance  without 
much  inconvenience.  The'  process  of  M.  Roux,  is  also  liable  to  some  mis- 
takes. By  inclining  the  bistoury  too  much  towards  the  outside,  it  sometimes 
happens  that  the  operator  encounters  tlie  triceps  muscle,  and  that  if  he  do 
not  speedily  perceive  his  error,  the  case  becomes  very  laborious  and  is  seldom 
terminated  without  injurious  results.  To  escape  these  inconveniences,  it  is 
only  necessary  to  remember  that  the  fibres  of  the  sartorius  are  parallel  to 
each  other  and  to  the  axis  of  the  muscle,  and  also  that  of  the  member,  and 
are  without  any  admixture  of  fat;  whilst  those  of  the  vastus  internus  are  col- 
lected into  fasciculi,  mixed  with  cellular  or  adipose  lamellcB,  and  are  all 
oblique,  from  above  to  below,  from  rear  to  front,  and  from  the  internal  border 
towards  the  median  line  of  the  thigh.  However  this  may  be,  the  wisest 
course  is,  in  my  opinion,  to  conform  to  the  advice  either  of  Hodgson  or 
Desault,  by  which,  after  dividing  the  first  aponeurosis,  the  operator  may 
arrive  with  facility  either  upon  the  inner  or  outer  edge  of  the  sartorius ;  and 
afterwards  avail  himself,  with  equal  advantage,  of  the  practice  either  of  Roux 
or  of  Lisfranc.  As  to  the  division  of  the  muscle,  recommended  by  Desault, 
although  not  now  thought  so  dangerous  as  formerly,  it  ouglit  not  to  be  practised 
but  upon  occasions  of  absolute  necessity.  In  theory,  it  is  difficult  to  conceive 
that  it  can  ever  be  required,  except  in  operating  by  the  old  method. 

§  2.  Superior  Half. 

Above  the  middle  of  the  thigh,  an  incision  of  about  three  inches  in  length 
is  commonly  sufficient  to  discover  the  trunk  of  the  femoral.  The  middle  part 
of  this  incision  should  be  four  fingers'  breadth  from  the  fallopian  ligament,  un- 
less an  absolute  necessity  should  exist  for  making  it  immediately  under  the 
crural  arch,  so  as  to  fall  between  the  profunda  and  the  epigastric.  In  all  cases, 
the  bistoury  sliould  take  the  direction  of  the  line  represented  by  the  passage 
of  the  vessel,  and  should  incline  a  little  outwardly  rather  than  inwardly, 
on  account  of  the  saphena.  After  the  skin  and  the  adipose  stratum,  is  seen 
the  aponeurosis.  Before  dividing  this,  it  should  be  recollected,  that  low 
down  the  internal  edge  of  the  sartorius  usually  separates  this  lamina  from 
the  artery,  which  cannot  take  place  in  the  upper  part  of  the  inguinal  triangle. 
This  lamina  being  opened,  and  the  muscle  thrust  outwards  as  far  as  neces- 
sary, the  operator  passes  a  grooved  director  (to  serve  as  a  conductor  for  the 
bistoury)  under  the  superficial  layer  of  the  arterial  sheath,  and  then  makes, 
without  danger,  an  incision  of  the  same  extent  with  the  external  wound. 
Finally,  he  isolates  the  vessel,  taking  it  on  its  internal  side,  and  using  extreme 
caution  to  avoid  wounding  the  crural  vein  or  the  neighboring  nerves. 

§  2.  Results  of  the  Operation, 

After  the  preceding  operation,  whether  performed  high  up  or  low  down,  the 
vessels  charged  with  the  re-establishment  of  the  circulation  are,  in  either  case, 
the  same.  The  branches  of  the  superficial  muscular  pour  their  fluid  into  the 
anastomica  magna,  the  external  articular,  or  the  recurrent  tibial ;  and  those 
of  the  profunda  or  of  the  perforating  arteries,  into  the  internal  articulars. 
The  blood  sometimes  finds  its  way,  by  means  of  the  muscular  branches  inter- 
vening between  th«  ligature  and  the  tumor,  preserves  the  pulsations,  and 


I  OPERATIVE   SURGERY.  85 

sometimes  delays  considerably  the  resolution  of  the  aneurism.  This  incon- 
venience, which  at  first  appeared  serious,  no  longer  gives  much  uneasiness. 
Cold  and  discutient  applications,  aided  by  a  gentle  pressure,  will  generally 
cause  the  tumor  to  disappear,  when  it  is  not  thought  better  to  abandon  it  to 
its  own  action.  Yet  facts  contradictory  of  the  above  are  more  numerous  and 
authentic  than  would  be  supposed.  Mr.  Monteith,  of  Glasgow,  has  seen  the 
pulsations  reappear  several  months  after  an  apparent  cure.  An  aneurism, 
operated  upon  by  Mr.  Gumming  in  1821,  reappeared  in  1825,  so  as  to 
render  it  necessary  to  amputate  the  thigh.  In  a  case  in  which  I  had  tied  the 
femoral  three  inches  below  the  profunda,  hemorrhage  manifested  itself  at  the 
coming  away  of  the  ligature  on  the  thirteenth  day. 

When  it  has  not  been  possible  to  preserve  the  profunda,  the  circulation  is 
established  by  the  branches  of  the  hypogastric.  The  gluteal,  the  ischiatic, 
the  internal  pudic,  and  the  obturator  arteries  communicate  with  the  circum- 
flex and  perforating  arteries,  and  the  latter  then  empty  themselves  into  the 
arteries  which  encircle  the  knee.  If  those  aneurismal  tumors  which  develop 
themselves  in  the  substance  of  the  bones — tumors  which  were  first  observed 
by  Pott  and  Scarpa,  of  which  Pelletan  cites  several  examples,  and  which  have 
been  observed  three  times  at  the  Hotel  Dieu  by  M.  Dupuytren — if  such  tumors 
should  make  their  appearance  on  the  leg  or  upon  the  thigh,  it  would  not  be 
necessary  in  all  cases,  as  it  was  formerly  believed,  to  amputate  the  limb.  The 
ligature  of  the  femoral,  by  Anel's  method,  would  be  found  sufficient.  It  was 
used  with  complete  success  by  Mr.  Pearson,  and  M.  Lallemand  of  Mont- 
pellier. 

Caustics,  astringents,  styptics,  immediate  compression,  gradual  obliteration, 
and  temporary  ligatures,  have  also  been  tried  upon  the  crural  artery.  In  the 
case  of  a  young  and  robust  man,  twenty-two  years  of  age,  who  labored  under 
an  aneurism  of  the  superior  third  of  the  thigh,  produced  by  a  sabre-stroke, 
Sabatier,  after  having  opened  the  aneurismal  sac  and  placed  two  precaution- 
ary ligatures  under  the  artery,  contented  himself  with  filling  the  wound  with 
compresses  and  a  pyramid  of  agaric,  confined  with  a  bandage.  His  patient  was 
cured  at  the  expiration  of  two  months.  M.  Dubois  succeeded  upon  one 
occasion,  with  his  compressing  forceps  (j)ince  presse  artere),  and  Scarpa,  and 
several  surgeons  of  London,  have  been  so  fortunate  as  to  be  able  to  remove 
the  ligature  three  or  four  days  after  having  fixed  it  upon  the  artery. 

G.  Ligature  of  the  Circumflexes  or  of  the  Profunda. 

When  one  of  the  circumflexes  or  the  profunda  has  been  wounded,  or  has 
become  the  seat  of  aneurism,  there  is  generally  little  difficulty  in  applying 
the  ligature.  The  essential  point  is  to  ascertain  such  a  lesion.  By  exposing 
the  trunk  of  the  femoral  at  the  place  where  it  emerges  from  under  the  crurid 
arch,  a  thread  may  be  easily  applied  upon  the  rest  of  the  affected  artery. 
M.  Roux,  however,  is  the  only  surgeon  who  to  my  knowledge  has  had  occa- 
sion to  operate  upon  one  of  the  secondary  branches. 

H.  Exteraallliac. 
Art,  1. — Anatomical  Remarks, 

From  the  level  of  the  sacro-iliac  symphysis,  where  the  primitive  iliac  artery 
divides,  to  its  arrival  at  the  fallopian  ligament,  the  external  iliac  represents 
a  line  slightly  curved,  with  its  convexity  looking  outward  and  backward,  and 


86  NEW  ELEMENTS  OF 

more  marked  in  the  female  than  in  the  male ;  and  so  much  the  more  as  the 
pelvis  is  larger,  or  the  superior  strait  more  depressed.  It  rests  upon  the 
psoas  muscles  on  the  outside,  and  upon  the  iliac  vein  within  and  behind, 
and  is  covered  immediately  by  an  expansion  of  the  fascia-iliaca.  The  crural 
nerve  is  separated  from  it  by  the  tendon  of  the  psoas,  and  by  an  aponeu- 
rosis of  great  strength.  A  branch  of  the  genito-crural  nerve  sometimes  runs 
along  its  internal  and  anterior  surface,  which  is  crossed  by  the  ureters,  and 
in  the  female  by  the  ovarial  vessels.  The  peritoneum  which  hides  all  these 
different  objects,  adheres  to  it  slightly  by  means  of  a  very  loose  lamellar  and 
adipose  stratum,  and  leaves  it  altogether  in  front,  in  order  to  return  upon  the 
posterior  surface  of  the  abdominal  parietes.  At  its  entrance  into  the  crural 
canal,  it  again  gradually  rises,  becomes  more  superficial,  and  forms  new  con- 
nexions. In  this  latter  position  it  is  supported  by  the  body  of  the  pubis,  and 
by  the  origin  of  the  pectineus  muscle ;  the  vas  deferens  crosses  it  to  bury 
itself  in  the  pelvis,  and  the  spermatic  cord  does  the  same  in  passing  through 
the  inguinal  canal.  The  epigastric  vein  is  also  obliged  to  cross  the  inguinal 
canal  to  open  into  the  iliac  vein,  which  lies  attached  to  it  as  in  the  thigh ;  the 
fibrous  lamina  which  confines  it  against  the  psoas  and  iliacus,  here  becomes 
perceptibly  thinner.  The  circumflexa  ilii  and, the  epigastric  (the  only  branches 
which  it  furnishes)  separate  from  it,  the  one  a  little  on  the  outside,  and  the 
other  a  little  on  the  inside,  generally  on  a  level  with  the  linea  ileo  pectinea,  but 
sometimes  four,  six,  or  eight  lines  higher  or  lower.  The  lymphatic  ganglions 
which  surround  it  until  it  reaches  the  crural  arch,  and  possess  the  power  of 
compressing  it  by  swelling,  have  given  birth  to  apprehensions  of  disease  which 
have  no  foundation  in  reality.  The  coecum  on  the  right,  and  the  sigmoid 
flexure  of  the  colon  on  the  left,  are  the  only  viscera  by  which  it  is  separated 
from  the  parietes  of  the  abdomen.  Nothing  is  more  easy  with  patients  of  a 
meagre  habit,  and  when  all  the  muscles  are  in  a  state  of  relaxation,  than  to 
establish  upon  it  a  mediate  compression  capable  of  suspending  for  the  time 
the  circulation  in  the  limb,  as  has  been  demonstrated  by  Bogros,  and  as  I  have 
myself  proved  in  the  case  of  a  young  man  who  had  received  a  cut  over  the 
epigastric,  to  which  artery  I  applied  the  ligature.  Its  anomalies  are  almost 
exclusively  confined  to  its  length,  its  volume,  its  curvature,  and  the  points 
of  origin  of  its  principal  arteries.  It  is  possible,  however,  that  it  may 
consist  of  two  trunks  placed  side  by  side,  and  which  pass  together  under  the 
crural  arch,  as  was  remarked  by  Mr.  James,  in  a  case  where  he  had  tied  the 
iliac  artery  after  the  method  of  Brasdor. 

Art.  2. — Surgical  and  Historical  Remarks. 

The  external  iliac  artery  is  seldom  the  seat  of  other  than  spontaneous  aneu- 
risms. If  it  were  opened  in  fact  by  any  exterior  agent,  the  hemorrhage  which 
would  ensue  would  cause  the  death  of  the  patient  before  it  would  be  possible 
to  render  him  the  least  assistance.  Yet  M.  Larrey  says  that  he  has  seen  it 
in  the  subject  of  a  varicose  aneurism.  And  since  it  is  not  in  an  exposed 
situation,  and  is  not  more  than  four  or  five  inches  in  length,  even  aneurism 
occurring  in  it  from  internal  causes  can  scarcely  be  very  common.  The  case 
of  the  young  man  just  mentioned  who  recovered  after  the  operation,  is  almost 
the  only  one  of  its  species,  as  will  be  subsequently  seen. 

If  the  fear  of  gangrene  after  the  obliteration  ot  a  great  arterial  trunk  has 
been  able  for  so  many  ages  to  restrain  surgeons  in  tlieir  treatment  of  aneu- 
risms of  the  thigh  and  popliteal  region,  much  more  reason  is  there  why  they 
should  reject  the  mere  idea  of  tying  one  of  the  primary  divisions  of  the  aorta. 


OPERATIVE    SURGERY.  87 

Facts  passed  unnoticed,  science  could  not  profit  by  them.  In  the  practice 
of  Guattani  compression  was  established  upon  the  femoral  above  the  profunda, 
and  the  circulation  continued  in  the  Ijmb.  Baillie,  in  a  dead  subject  found 
the  femoral  obliterated  as  far  as  the  interior  of  the  pelvis,  while  the  inferior 
extremity  was  not  in  the  slightest  degree  affected.  A  similar  case  came  under 
the  observation  of  Guattani,  in  1767 :  his  patient  had  labored  under  an  ingui- 
nal aneurism,  and  had  been  cured  by  the  use  of  compression.  In  the  dead 
body  of  a  patient  treated  by  Gavina,  in  1775,  the  iliac  artery  itself  was  found  to 
be  completely  impermeable.  Similar  cases  have  been  reported  by  Clarke  and 
others.  All  these  proofs,  the  injections  practised  by  Guattani,  and  even  those 
of  Scarpa,  which  demonstrate  the  facility  with  which  fluids  forced  into  the  aorta 
pass  into  the  arteries  of  the  thigh  and  leg,  notwithstanding  the  previous  ligature 
of  the  external  iliac,  were  insufficient,  and  might  perhaps  have  remained  long 
unapplied,  had  not  Abernethy  been  obliged  to  appeal  to  them  for  the  first  time, 
in  1796.  An  individual  who  had  already  undergone  an  operation  according 
to  the  method  of  Anel  for  aneurism  of  the  popliteal  trunk,  came  to  St.  Bar- 
tholomew's hospital  affected  with  an  inguinal  aneurism  on  the  opposite  side. 
Abernethy  applied  a  ligature  below  the  crural  arch ;  a  hemorrhage,  which  took 
place  fifteen  days  afterwards,  left  him  no  other  resource  than  to  penetrate  into 
the  abdomen,  and  to  perform  upon  the  iliac  artery  the  same  operation  which 
he  had  previously  performed  upon  the  femoral.  The  patient  expired  some- 
time afterwards,  in  consequence  of  a  second  hemorrhage.  Another  operation 
performed  by  Abernethy  was  attended  with  the  same  unfortunate  result;  but 
the  third,  in  1806,  was  completely  successful.  Previously  to  this  period  no 
one  spoke  of  the  possibility  of  tying  the  external  iliac,  without  causing  the 
mortification  of  the  limb ;  now  it  is  one  of  the  most  common  operations  in 
surgery. 

Mr.  Freer,  in  1806,  Mr.  Tomlinson,  in  1807,  imitated  Abernethy,  and  with 
like  success.  Mr.  Tomlinson  again  successfully  performed  this  operation  in 
1809.  Four  out  of  seven  patients  on  whom  Sir  A.  Cooper  operated,  in  1814, 
recovered ;  the  remainder  died,  one  at  the  expiration  of  three  months  of  an 
aneurism  of  the  aorta,  another  from  mortification  of  the  limb,  and  the  third 
from  hemorrhage.  M.  Delaporte,  of  Brest,  was  the  first  French  surgeon  who 
had  the  courage  to  follow  the  example  of  the  English  practitioners ;  his 
patient  died  of  a  putrid  fever  on  the  twelfth  day  after  the  operation.  Messrs. 
Goodlad  and  Dorsey  each  performed  the  operation  successfully,  in  1811 ; 
M.  Bouchet  of  Lyons,  also  succeeded  in  curing  a  Spanish  prisoner,  in  1812; 
the  latter  died  the  next  year  of  an  aneurism  of  the  opposite  side.  The  same 
year  a  patient  under  the  care  of  M.Albert  died  of  tetanus  the  twentieth  day 
after  the  operation.  An  old  man  of  seventy -five  years  of  age,  in  the  hands  of 
Mr.  Ramsden,  sank  on  the  third  day.  In  1813,  two  successful  cases  rewarded 
the  efforts  of  Messrs.  Brodie  and  Norman.  Mr.  Lawrence  succeeded  in  his 
turn,  in  1814  ;  as  also  M.  Moulaud,  of  Marseilles,  in  1815;  but  gangrene 
occurring  on  the  fourth,  destroyed  the  hopes  of  Mr.  Collier  of  a  similar 
result.  Messrs.  Smith,  Sod  en,  and  Dupuytren  were  less  unfortunate :  each 
saved  the  life  of  a  patient  in  1816.  Mr.  Cole,  in  1817;  M.  Albert,  in  1818  ; 
and  Messrs.  Wilmot,  Kirby,  Newbegin,  and  Post,  successively  added  them- 
selves to  the  list.  The  patient  of  M.  Salmon  died  on  the  16th  day.  Messrs. 
Wright,  Richerand,  Vacca,  Killian,  White,  Dacrux,  and  Clot,  deserve  the 
credit  of  having  performed  this  operation  with  success.  M.  Delpech  was  not 
so  fortunate ;  the  patient  under  his  care  died  in  a  few  davs.  M.  Tait,  in 
1825  and  1826,  tied  successively  the  two  iliac  arteries  of  the  same  patient, 
and  with  complete  success,  although  on  one  side  the  peritoneum  was  woundeu 


88  NEW    ELEMENTS    OF 

in  the  operation.  M.  Arendt,  in  a  similar  case,  left  an  interval  of  only  eight 
days  between  the  two  operations,  and  was  equally  successful.  I  performed 
the  operation  myself  on  the  6th  of  October.  The  ligature  came  away  on  the 
11th  day,  and  the  patient  was  perfectly  cured.  This  case  was  a  remarkable 
one.  The  patient,  a  young  man,  seventeen  years  of  age,  large  and  strong, 
in  clearing  a  table  in  a  dark  place,  accidentally  forced  a  butcher's  knife  into 
his  groin,  and  cut  across  the  external  iliac  artery  three  lines  above  the  origin  of 
tlie  epigastric ;  the  blood  issued  from  the  wound  in  torrents.  Drs.  Layraud 
and  Durand,  who  attended  almost  immediately,  compressed  the  artery  at  two 
inches  above  the  wound,  and  thus  suspended  the  hemorrhage  until  my  arrival. 
Assisted  by  these  two  gentlemen  and  by  M.  Duvivier,  I  hastened  to  expose 
and  tie  the  injured  vessel.  No  unpleasant  symptoms  manifested  themselves  in 
the  limb;  the  emission  of  urine  was  somewhat  difficult  during  the  second  day, 
but  afterwards  became  free;  inflammatory  symptoms  about  the  side  during 
one  week  gave  us  some  uneasiness;  a  first  ligature  placed  very  high  up  with 
a  curved  needle,  in  order  to  afford  perfect  freedom  in  seeking  the  seat  of  the 
Avoimd,  did  not  detach  itself  until  the  thirty-fifth  day;  but  at  length  the  wound 
cleansed  itself,  and  the  health  of  the  young  man  is  now  perfectly  re-established. 
This  case  demonstrates  the  importance  of  knowing  how  to  compress  the  iliac 
arteries  in  the  pelvis  through  the  parietes  of  the  abdomen,  and  proves — first, 
that  without  preventing  dilatation  of  the  collateral  branches,  whether  occa- 
sioned by  compression,  as  has  been  proposed,  or  by  the  presence  of  an  aneu- 
rism, the  ligature  of  the  ileo-crural  trunk  may  be  practised  with  success ; 
secondly,  that  the  sudden  and  complete  division  of  that  trunk  is  not  abso- 
lutely mortal.  It  is  proper,  however,  to  mention  that  a  patient  on  whom 
Beclard  operated,  in  1822,  died  of  hemorrhage  on  the  thirteenth  or  fourteenth 
day ;  and  that  a  similar  fate  was  met  by  an  individual  under  the  care  of 
M.  Dupuytren,  in  1823  or  1824.  The  operation  has  been  successfully  per- 
formed forty  times  from  the  period  of  its  adoption  up  to  the  present  day. 

Art,  3. — Manual. 

Notwithstanding  the  two  examples  of  cure  by  refrigerants,  moxas,  and  a 
weakening  regimen,  which  have  been  so  recently  made  known  by  M.  Larrey, 
the  ligature  ought  always  to  be  preferred  in  such  cases  of  iliac  or  inguinal  aneu- 
rism as  will  permit  its  application,  and  when  the  patient  is  willing  to  submit. 
It  should  be  remembered,  however,  that  in  carrying  it  more  than  three  inches 
into  the  pelvis,  the  neighborhood  of  the  hypogastric  renders  the  operation  very 
hazardous;  so  that  instead  of  going  as  high  as  the  primitive  iliac  when  the 
tumor  occupies  the  iliac  fossa,  and  there  is  not  room  enough  left  in  the  groin 
for  tying  the  femoral  above  the  profunda,  it  will  be  right  to  resort  to  the  method 
of  Brasdor.  The  patient  of  Sir  A.  Cooper  lived  two  months  after  the  opera- 
tion ;  the  pulsations  had  ceased  in  the  tumor,  which  was  enormous,  and  it  is  not 
possible  precisely  to  account  for  his  death.  In  the  patient  of  Mr.  James,  who 
wan  not  more  fortunate,  the  iliac  artery  was  divided  into  two  nearly  equal 
trunks.  Yet  the  fruitless  attempt  of  Mr.  White,  although  the  femoral  was 
obliterated  below  the  tumor ;  the  pulsations  which  continued  to  be  felt  at  the 
bottom  of  the  wound  in  the  young  man  whose  case  has  been  just  related,  and 
the  facts  recorded  by  Mr.  Guthrie,  prevent  us  from  placing  much  confidence 
in  this  latter  method.  To  practice  it  with  any  possibility  of  success,  it  is 
necessary  at  least  to  be  able  to  place  a  ligature  between  the  tumor  and  the 
origin  of  the  epigastric  arteries  and  the  circumflexa  ilii;  or  else  that  those 
branches  should  have  been  displaced  by  the  aneurism  filled  with  coagula  and   : 


OPERATIVE    SURGERY.  89 

rendered  impermeable  by  the  pathological  process  described  by  M.  Berard. 
Numerous  processes  have  been  followed  for  the  purpose  of  arriving  at  the 
external  iliac  artery. 

1.  Process  of  Abernethy. — On  the  first  occasion,  Abernethy  made  an  inci- 
sion of  about  three  inches  in  the  direction  of  the  vessel  above  the  ligament  of 
Poupart.  This  method  has  been  recommended  anew  by  M.  Begin,  in  the 
Dict.de  Med.  et  de  Chir.  Pratique,  Upon  his  second  patient,  Abernethy, 
fearing  to  wound  the  -epiga-stric  artery,  made  the  incision  a  little  more  to 
the  outside  of  the  inguinal  ring,  giving  it  a  slightly  oblique  direction  upwards 
and  outwards  so  as  more  easily  to  avoid  the  peritoneum. 

2.  Process  of  Sir  A.  Cooper. — Sir  A.  Cooper  made  an  incision  in  the  form 
of  a  half-moon,  in  the  direction  of  the  fibres  of  the  tendon  of  the  external 
oblique — that  is  to  say,  with  a  convexit  downwards,  and  beginning  at  a  little 
distance  from  the  anterior  superior  spinous  process  of  the  ileum,  and  termi- 
nating near  the  inguinal  ring;  on  raising  the  semilunar  flap  thus  formed,  the 
operator  perceives  the  spermatic  cord,  the  opening  in  the  fascia  transversalisy 
and  the  epigastric  artery;  by  passing  the  finger  beneath  the  cord,  through  this 
opening,  "  he  will  then,"  says  this  author,  *'  easily  arrive  at  the  iliac  vessels." 

3.  Process  of  Mr.  Norman,  of  Bath,  and  of  Mr.  Roux. — Mr.  Norman  con- 
tented himself  with  making  an  incision  la  the  direction  of  the  fallopian  liga- 
ment, and  afterwards  following  the  directions  of  Sir  Astley  Cooper.  M. 
Roux  recommends  that  the  incision  should  commence  a  little  above,  and  about 
half  an  inch  distant  from  the  spine  of  the  ileum,  and  terminate  upon  the 
middle  of  the  crural  arch. 

4.  Process  of  Bogros M.  Bogros  believes  that  the  method  of  Sir  A. 

Cooper,  or  of  Mr.  Norman,  might  be  advantageously  modified,  by  directing 
the  middle  of  the  incision  upon  that  point  of  the  ligament  of  Poupart  whicn 
corresponds  with  the  artery,  and  afterwards  gaining  the  opening  in  the/a«cta 
transversalis,  for  the  purpose  of  finding  with  certainty  the  epigastric,  which 
■will  then  serve  as  a  guide  to  the  iliac  trunk. 

5.  Process  adopted  by  the  Author, — The  following  method  has  appeared  to 
me  the  most  simple  and  easy  of  application.  The  patient  is  laid  upon  his 
back,  with  the  limb  moderately  extended  and  retained  in  its  position  by  as- 
sistants. The  operator  then  places  himself  on  the  side  of  the  aneurism,  and 
makes  a  slightly  curved  incision,  three  inches  in  length,  parallel  with  and  a 
little  above  the  fallopian  ligament ;  the  middle  part  of  the  incision  is  on  a 
level  with  the  artery.  The  first  stroke  of  the  bistoury  passes  through  the  skin 
and  t\\Q  fascia  superficialis ;  if  the  flow  of  the  blood  from  the  branches  of  the 
external  epigastric  artery  is  so  great  as  to  impede  the  operation,  the  ligature 
or  torsion  is  applied  before  proceeding  further.  The  aponeurosis  of  the  ex- 
ternal oblique  next  presents  itself.  For  greater  security,  it  is  w^ell,  though 
not  indispensable,  before  making  the  incision  to  pass  under  this  tissue  a 
grooved  director.  The  fibres  of  the  lesser  oblique  muscle  are  next  seen, 
which  may  be  divided  without  fear  by  an  experienced  surgeon  with  tlie  cut- 
ting instrument ;  otherwise  their  inferior  extremity  is  to  be  detached  with 
the  point  of  a  director,  pushing  them  backward  and  upwards  with  a  certain 
degree  of  force,  while  the  left  index  finger  fixes  and  retains  the  inferior  edge 
of  the  wound  5  the  fascia  transversalis  is  th«n  torn  in  the  same  manner  as  ulv 
as  the  spermatic  cord,  which  is  pushed  aaide  in  tlie  same  direction  as  the 
fleshy  fibrf^s.  From  this  point,  in  order  to  avoid  the  peritoneum,  particularly 
when  the  ligature  is  to  be  carried  upon  a  very  elevated  point  of  the  iliac  fossa, 
the  finger  should  be  used  instead  of  the  sound;  in  otlier  cases  the  latter  is 
preferable.   After  having  proceeded  thus  far,  if  the  eye  of  the  operator  cannot 

12 


90  NEW   ELEMENTS   OF 

distinguish  the  objects,  the  fore-finger  tlirust  into  the  wound,  the  lips  of  which 
should  be  kept  separate,  will  easily  feel  the  artery  upon  the  internal  edge  of 
the  psoas  and  the  side  of  the  superior  strait.  By  taking  it  up  between 
the  fingers,  as  has  been  recommended  by  Scarpa  and  practised  by  many 
surgeons,  useless,  and  sometimes  dangerous  lacerations  are  produced.  It  is 
infinitely  better  to  penetrate  with  the  director  the  sheath  which  it  receives 
from  the  fascia  iliaca,  directing  the  beak  of  the  instrument  upon  its  internal 
side,  and  detaching  it  from  the  vein  by  careful  movements  to  and  fro. 
After  this  separation,  which  should  be  of  as  small  an  extent  as  possible,  but 
yet  should  comprise  the  whole  circumference  of  the  artery  so  as  to  disunite 
it  completely  from  the  iliac  vein  and  from  the  nervous  branch  which  crosses 
their  surface,  the  operator,  in  order  to  pass  the  ligature,  may  make  use  of 
an  eye-probe  conducted  along  a  director,  or  of  the  needle  of  Deschamps, 
or  any  other  convenient  instrument.  It  is  better  to  apply  the  ligature  a  little 
too  high  than  too  low;  it  is  at  least  necessary  to  place  it  above  the  epigastric. 
Beolard  is  said  to  have  lost  one  of  his  patients  by  having  unintentionally 
placed  the  ligature  below,  instead  of  above  that  branch.  In  consequence  of 
tliis  danger  also,  and  in  order  to  avoid  it  with  greater  certainty,  Bogros  re- 
commends the  exposure  of  the  epigastric  before  seeking  the  iliac  artery  ;  but 
in  proceeding  as  I  have  just  directed,  where  the  iliac  has  been  discovered,  it 
will  always  be  easy  to  find  the  epigastric,  and  to  leave  it  below  the  ligature. 
In  order  to  prevent  hemorrhage,  or  the  return  of  the  blood,  and  the  conti- 
nuance of  pulsation  in  the  tumor,  which  maybe  produced  by  the  artery,  some 
think  it  necessary  to  tie  the  latter,  whether  wounded  or  not,  at  the  same  time 
with  the  iliac  artery.  Though  this  advice  may  be  followed  without  much  in- 
convenience, the  practice  up  to  the  present  time  has  proved  that  it  is  by  no 
means  indispensable.  During  the  operation,  but  particularly  at  its  termination, 
it  is  of  the  highest  importance  that  the  abdominal  muscles  be  kept  in  a  state  of 
relaxation,  and  that  the  patient  should  refrain  from  any  effort  from  making 
the  slightest  movement,  otherwise  the  intestines  will  certainly  present  them- 
selves at  the  incision,  and  a  wound  of  the  peritoneum  will  be  the  almost  inevi- 
table consequence ;  and  although  such  an  injury  is  not  of  so  much  importance 
as  has  been  generally  supposed,  as  we  see  in  the  instances  mentioned  by 
Messrs.  Post  and  Tait,  yet  it  ought  to  be  guarded  against  with  the  greatest  care. 

Advantages  and  Disadvantages  of  the  Different  Modes  of  Operation. — The 
vertical  incision,  or  that  parallel  with  the  artery,  and  the  oblique  incisions  of 
Abernethy  and  M.  Roux,  present  but  one  advantage — that  of  enabling  the 
operator  to  penetrate  without  much  difficulty  as  high  as  he  pleases — an  ad- 
vantage which  is  amply  counterbalanced  by  the  greater  risk  which  he  incurs 
of  wounding  the  peritoneum.  The  inferior  or  internal  an^le  of  the  wound 
is  the  only  point  where  it  is  possible  to  separate  its  lips,  in  order  to  search 
for  the  vessel ;  and  it  is  perfectly  useless  to  give  a  greater  extent  to  the  di- 
vision of  the  abdominal  parietes. 

In  the  process  of  Sir  A.  Cooper,  modified  by  Norman  and  Bogros,  as  well 
as  in  that  upon  which  I  have  just  commented,  the  incision,  crossing  the  vessel 
almost  at  a  right  angle,  renders  it  impossible  to  miss  it.  True,  it  is  ob- 
jected that  this  method  does  not  permit  the  operator  to  reach  high  up  in  the 
pelvis,  and  tliat  it  renders  him  more  liable  to  wound  the  epigastric  artery. 
But  on  the  one  point  it  is  possible  by  its  aid  to  proceed  to  the  depth  of 
three  inches,  and  if  the  aneurism  rises  higher,  it  is  the  primitive  and  not  the 
external  iliac  that  the  operator  must  endeavor  to  tie  ;  and  on  the  other,  since 
the  tissues  are  divided,  lamina  by  lamina,  and  torn  rather  than  cut  from  the 
place  where  the  operator  reaches  the  deep   aponeurosis,  sometimes  long 

I 


*  OPERATIVE    SURGERY.  91 

before,  I  cannot  see  how  it  is  possible,  unless  by  design,  to  wound  the  epi- 
gasiitric  which  lies  behind.  Experience  has  proved  that  it  is  possible  to  use 
successfully  any  of  the  methods  which  have  been  above  described,  and  I  am 
perfectly  aware  that  the  question  as  to  which  is  the  best,  is  more  a  matter  of 
choice  than  of  necessity,  except  that  the  transverse  incision,  which  is  always 
sufficient  when  the  tumor  does  not  extend  above  the  crural  ligament,  may 
not  be  so  convenient  when  the  disease  has  reached  a  higher  point.  It  is, 
however,  for  the  skillful  surgeon  to  adopt  those  means  which  seem  most  appli- 
cable to  the  cases  which  may  come  under  his  hands. 

The  blood  is  conveyed  into  the  inferior  extremity  after  the  ligature  in  the 
iliac  artery,  in  the  same  manner  as  after  the  ligature  of  the  femoral  above  the 
profunda — by  the  gluteal,  the  ischiatic,  the  pudic,  the  obturator,  and  further 
by  the  epigastric  and  the  circumflexa  ilii,  by  means  of  their  anastomoses, 
with  the  internal  mammary,  the  lumbar,  and  the  ilio  lumbalis.  The  prox- 
imity of  the  urinary  and  seminal  passages,  of  the  peritoneum  and  of  the  lax 
cellular  tissue  of  the  iliac  or  lumbar  region,  demands  all  the  attention  of 
the  practitioner,  and  prompt  relief  when  the  slightest  accidents  occur  from 
that  quarter.  For  the  rest,  such  symptoms  are  to  be  treated  by  the  means 
generally  known. 

/.  Internal  Iliac. 

Art.  1. — Anatomical  Remarks. 

The  internal  iliac,  leaving  the  primitive  iliac  on  a  level  with  the  sacro- 
iliac symphysis,  separates  from  the  external  iliac,  and  descends  almost  per- 
pendicularly into  the  hollow  of  the  pelvis.  Its  external  surface  is  crossed 
at  its  origin  by  the  iliac  vein,  and  accompanied  in  the  rest  of  its  extent  by 
the  hypogastric  vein,  which  separates  it  from  the  psoas  muscle  and  the  arti- 
culation. On  the  inside  it  is  united  to  the  peritoneum  only  by  a  cellulo-adi- 
pose  stratum,  varying  in  thickness;  some  lymphatic  ganglions  also  rest 
against  it  on  the  same  side.  The  urethra  commonly  passes  above  and  a  little 
more  in  front ;  to  the  left,  the  commencement  of  the  rectum  covers  it,  but  at 
a  greater  distance;  on  the  left  its  relations  to  the  coecum  scarcely  deserve 
attention.  It  is  not  possible  to  reach  it,  except  in  the  part  between  its  origin 
and  that  of  the  gluteal,  an  extent  of  from  one  to  two  inches — -in  a  word,  as 
far  as  the  level  of  the  great  sciatic  notch.  The  ilio-lumbalis,  which  it  some- 
times gives  off  in  its  passage,  and  which  then  immediately  proceeds  outward 
and  upwards  between  the  psoas  muscle  and  the  bones,  should  also  be  noticed, 
altliough  the  primitive  iliac  artery  or  the  external,  more  frequently  give  it  off. 

Art.  %-^Surgical  and  Historical  Remarks. 

The  trunk  of  the  hypogastric  artery  is  too  deeply  situated  to  be  frequently 
the  seat  of  traumatic  lesions,  and  is  too  short  to  be  susceptible  of  relief  in 
any  aneurisms  which  may  affect  it.  Sandifort  is  the  only  one  who  has  ever 
reported  a  case  of  aneurism  of  this  artery  ;  but  it  is  not  so  with  its  principal 
branches.  After  leaving  the  pelvis  they  are  still  sufficiently  voluminous  to 
become  the  source  of  dangerous  hemorrhage  in  the  event  of  their  being 
wounded  or  experiencing  spontaneous  rupture;  the  gluteal  artery  particu- 
larly, which  is  distributed  to  the  muscles  of  the  same  name,  and  which  cannot, 
like  the  ischiatic  or  the  pudic,  be  easily  taken  up  from  without,  has  several 
times  produced  death  in  this  way.     Thedan  reports  an  instance.    In  dilating 


92  NEW   ELEMENTS   OF  * 

a  gun-shot  wound,  a  surgeon  divided  the  gluteal  artery,  and  tlie  unhappy 
soldier  very  soon  expired.  The  same  occurred  in  a  case  of  aneurism,  on  the 
patient  mentioned  by  Jeffreys,  of  Glasgow.  J.  Bell,  it  is  true,  was  more  for- 
tunate ;  he  saved  the  life  of  his  patient  by  tying  the  v/ounded  vessel.  Mr. 
Rogers  has  since  made  known  an  analogous  case  5  and,  in  1817,  Mr.  Brooke 
cured,  or  believed  that  he  had  cured,  a  gluteal  aneurism  by  compression,  di- 
gitalis, and  laxatives.  Yet  it  cannot  be  disputed  that  ligature  ot  the  internal 
iliac  is  the  only  method  which  can  be  counted  upon  for  relief  in  most  cases 
of  this  kind. 

Art..  3., — Manual, 

This  operation  was  performed  for  the  first  time  by  Mr.  Stevens,  upon  a 
negress,  who  had  in  the  left  buttock  an  aneurism  as  large  as  the  head  of 
an  infant.  The  woman  was  completely  cured,  and  lived  some  years  after- 
wards to  die  of  another  disease.  Dr.  Stevens,  professor  of  surgery  in  New 
York,  informed  me  that  he  had  seen  the  pathological  preparation,  fully  bearing 
out  the  assertions  of  the  surgeon  at  Santa  Cruz.  On  the  12th  of  May,  1817, 
Mr.  Atkinson,  of  York,  followed  the  example  of  Mr.  Stevens,  upon  a  boatman^ 
who  was  in  the  same  situation  as  the  negress  Maila :  several  hemorrhages 
and  an  abundant  suppuration  brought  on  death  at  the  expiration  of  twenty 
days.  Since  then,  Dr.  Pomeroy  White,  of  Hudson,  in  America,  has  been 
more  successful.  He  operated  upon  a  tailor  sixty  years  of  age.  A  great 
deal  of  pus  issued  from  the  parts  during  a  month,  but  the  health  of.  the 
patient  was  eventually  re-established. 

Processes. — 1.  Mr.  Stevens  at  first  divided  the  integuments,  the  aponeu- 
rosis, and  the  muscles,  to  the  extent  of  five  inches,  a  little  without,  and  in 
the  direction  of  the  epigastric  artery ;  then,  having  detached  the  peritoneum, 
pushing  it  towards  the  axis  of  the  body  from  the  spine  of  the  ileum  and  the 
division  of  the  primitive  iliac  artery,  he  isolated  the  hypogastric  trunk  with 
the  fore-finger,  and  applied  the  ligature  half  an  inch  below  its  origin. 

2.  Mr.  Atkinson  followed  the  same  method;  but  a  profuse  hemorrhage 
obliged  him  to  thrust  the  whole  of  his  fingers  into  the  iliac  fossa,  in  order  to 
reach  and  tie  the  artery. 

3.  Dr.  Pomeroy  White  njade  an  incision  upon  the  side  of  the  abdomen,  in 
the  form  of  a  half  moon  and  about  seven  inches  in  length,  the  convex  part 
turned  towards  the  ileum.  This  incision  commenced  near  the  umbilicus,  and 
terminated  near  the  inguinal  ring.  After  having  thus  divided  the  whole  thick- 
ness of  the  abdominal  walls,  tied  several  arteries,  and  detached  the  perito- 
neum, he  raised  the  hypogastric  trunk  with  the  handle  of  his  scalpel,  and 
tied  it  an  inch  below  the  point  of  its  origin,  using  afterwards  sutures  and 
adhesive  plasters  to  close  the  external  wound. 

As  this  operation  is  performed  upon  healthy  parts  far  from  the  seat  of  tlie 
disease,  it  is  easy  to  practise  it  upon  a  dead  subj<ict,  and  to  becon>,e  assured 
that  an  incision  of  five  inches,  as  made  by  Mr.  Stevens,  is  sufficient,  and  is 
even  preferable  to  that  recommended  by  Dr.  White,  because  it  enables  the 
operator  to  avoid  all  the  branches  of  the  epigastric  without  risk  of  wounding 
the  anterior  iliac. 

4.  Another  Method. — The  operation  may  be  performed,  I  think,  with  equal 
success,  by  prolonging  about  two  inches  the  external  extremity  of  the  inci 
sion  recommended  by  Sir  A.  Cooper  for  the  ligature  of  the  external  iliac. 
This  mode  of  procedure  was  preferred  by  Dr.  Anderson,  of  New  York,  "  in 
order,"  says  he,  *'  more  easily  to  preserve  tlie  peritoneum,  and  to  prevent  tlie 


OPERATIVE    SURGERY.  93 

consecutive  hernia,  which  occurred  to  a  patient  under  the  care  of  Mr.  Kirbj, 
as  well  as  on  the  negress  of  Mr.  Stevens."  The  incision  advised  by  Aber- 
nethy,  is  as  eligible  on  this  score  as  any  other;  whatever  method,  however, 
may  be  adopted,  great  care  must  be  taken  not  to  scrape  the  peritoneum,  or 
lay  it  too  bare  of  cellular  tissue,  in  separating  it  with  the  fore-finger  from 
the  parts  to  which  it  is  attached.  Having  reached  the  internal  edge  of  the 
psoas,  the  finger  is  also  used  in  separating  the  artery  from  the  large  veins 
which  partly  hide  it.  The  root  of  this  trunk,  like  that  of  the  external  iliac, 
is  to  be  bent  downwards  and  towards  the  centre  of  the  pelvis ;  then,  aided 
by  the  needle  of  Deschamps,  the  double  curved  needle  of  M.  Causse,  or  a 
flexible  probe  with  an  eye  at  its  beak,  the  operator  passes  the  ligature.  The 
greatest  caution  is  here  necessary ;  the  venous  trunks  should  be  carefully 
avoided ;  their  sides  are  thin  ;  nothing  is  more  easy  than  to  injure  them.  In 
displacing  the  artery  also,  there  is  a  possibility  of  wounding  the  ilio-lumbalis 
and  producing  a  dangerous  effusion  of  blood. 

Result  of  the  Operation. — The  ligature  of  this  artery,  although  it  may  at 
the  first  view  excite  apprehensions  in  the  mind  of  the  operator,  is  in  reality 
less  serious  as  to  its  effect  upon  the  circulation,  than  that  of  the  external  iliac 
or  even  the  femoral.  It  in  fact  leaves  untouched  all  the  vessels  proper  to 
the  corresponding  member,  and  the  two  hypogastric  arteries  communicate  by 
means  of  anastomoses  so  large  and  numerous,  that  after  the  obliteration  of 
the  one  the  blood  easily  finds  its  way  by  the  other  into  the  viscera,  which 
they  nourish.  But  it  is  dangerous  in  other  respects  j  at  first  from  the  diffi- 
culties attending  its  execution,  and  afterwards  from  the  separation  which  it  is 
necessary  to  make  in  an  abundant  cellular  tissue,  and  from  which  inflamma- 
tion and  suppuration  are  so  easily  propagated  to  a  great  extent. 

K.  Primitive  Uiac. 

Art.  1. — Anatomical  Remarks. 

Two  causes  effect  a  variation  in  the  length  of  the  common  iliac  5  first,  the 
aorta  often  divides  upon  the  body  of  the  fourth  lumbar  vertebra  instead  of 
the  fifth  ;  secondly,  the  root  of  the  secondary  iliacs  may  be  found  nearer  than 
ordinary  to  the  sacro-vertebral  angle.  One  may  also  be  sometimes  found 
larger  than  the  other,  because  the  trunk  from  which  they  originate  does  not 
always  lie  upon  the  median  line ;  still,  with  some  few  exceptions,  their  length 
scarcely  ever  varies  more  than  from  three  or  four  lines  to  an  inch.  They 
rest  upon  the  side  of  the  sacro-vertebral  anglfr,  upon  the  wings  of  the  sacrum, 
and  against  the  internal  face  of  the  psoas  muscles.  On  the  right,  the  vein 
is  first  in  the  outside,  and  then  behind ;  on  the  left,  on  the  contrary,  it  lies 
all  the  way  on  the  inside,  and  does  not  reach  the  artery  until  afteV  having 
previously  passed  under  the  root  of  the  arterial  trunk  of  the  opposite  side ; 
these  vessels  are  covered  only  by  the  peritoneum,  so  that  in  attenuated  subjects 
it  is  still  more  easy  to  compress  them  than  the  external  iliacs,  provided 
always  that  the  operator  has  previously  removed  the  mass  of  the  small 
intestines. 

Art.  2. — Surgical  and  Historical  Remarks. 

Bogros  opened  the  body  of  a  patient  who  had  been  wounded  in  the  primi- 
tive iliac  by  a  pistol  ball  thirty-six  hours  before  death.  Dr.  Gibson,  of  Bal- 
timore, reports  a  case  precisely  similar;  we  may  easily  conceive  that  aneu- 


94  NEW  ELEMENTS  OF 

risms  may  prolong  themselves  from  the  two  secondary  iliacs  to  the  common 
iliac,  and  even  invade  it  primarily. 

It  needed  more  than  common  hardihood  to  undertake  the  obliteration  of 
an  arterial  trunk  so  voluminous,  so  near  to  the  aorta,  and  so  deeply  situated* 
In  default  of  the  external  iliac  the  blood  passes  into  the  limb  by  the  internal 
iliac  ;  in  default  of  one  hypogastric,  that  fluid  is  furnished  by  the  other ;  but 
what  can  supply  the  place  of  the  common  iliac  ?  Who  can  deprive  a  fifth  of 
the  body  of  its  circulation  without  producing  death  ?  many  surgeons  still 
believe  it  to  be  impossible.  Yet  Mr.  Goodison,  in  1818,  remarked  upon  the 
body  of  an  old  woman  which  he  dissected  at  La  Pitie,  the  complete  oblite- 
ration of  the  two  primitive  iliacs,  without  the  lower  extremities  appearing  in 
any  way  to  have  suffered.  The  experiments  also  upon  dogs,  made  by  A. 
Cooper  and  Beclard,  together  with  those  of  Scarpa,  had  already  solved  the 
problem.  Were  these  facts  sufficiently  numerous  and  conclusive  to  warrant 
actual  application  upon  the  person  of  a  living  subject?  Practice  has  replied 
in  the  affirmative ;  and  if  refrigerants,  a  weakening  regimen,  laxatives,  and  digi- 
talis have  failed;  if  the  aneurism  rises  so  high  as  to  render  the  ligature  of 
the  external  iliac  uncertain  and  insufficient,  and  to  prevent  or  render  useless 
the  method  of  Brasdor ;  if  ther.e  is,  in  fact,  no  other  resource,  the  ligature  of 
the  primitive  iliac  ought  to  be  practised. 

Mr.  Gibson,  it  is  true,  tried  it  unsuccessfully  in  the  case  above  mentioned ; 
but  Professor  V.  Mott,  who  practised  it  for  the  first  time  according  to  fixed 
rules,  on  the  15th  March,  1827,  for  an  aneurism  of  considerable  extent,  saved 
the  life  of  his  patient.  The  year  following,  Mr.  Crampton,  in  endeavoring 
to  imitate  the  skillful  practitioner  of  New  York,  was  not  so  fortunate ;  his  pa- 
tient died  of  hemorrhage  on  the  fourth  day.  This  latter  case,  is  nevertheless 
extremely  important;  the  circulation,  the  warmth,  and  the  sensibility,  for  a  time 
suspended,  were  afterwards  completely  renewed  in  the  limb ;  every  thing 
announced  complete  success,  when  the  ligature  seemed  to  displace  itself,  and 
symptoms  of  internal  hemorrhage  disappointed  these  flattering  hopes.  On 
opening  the  body  every  thinff  tended  to  confirm  the  belief  that  the  cord  of 
animal  matter,  employed  by  Mr.  Crampton,  had  been  dissolved  or  broke  be- 
fore the  artery  was  obliterated.  The  authenticity  of  the  last  two  mentioned 
operations  is  sufficiently  guaranteed  by  the  names  of  the  operators ;  the  one 
enjoys  a  justly  merited  estimation  and  celebrity  in  America  and  throughout 
Europe,  and  the  other  is  at  the  head  of  a  public  establishment — a  hospital  in 
England. 

Art,  3. — Manual, 

The  mode  of  procedure  to  be  followed  is  exactl^r  the  same  as  for  the  liga- 
ture of  the  internal  iliac.  Dr.  Mott  commenced  his  incision  on  the  outside 
of  the  inguinal  ring,  half  an  inch  above  the  ligament  of  Poupart,  and  carried 
it  above  the  superior  spinous  process  of  the  ileum,  giving  to  it  a  semicircular 
direction  and  an  extent  of  about  eight  inches.  The  incision  of  Mr.  Crampton 
was  also  in  a  semicircular  form,  the  concavity  towards  the  umbilicus  and 
about  seven  inches  in  length.  It  extended  from  the  last  rib  to  the  superior 
and  anterior  part  of  the  crest  of  the  ileum.  Both  operators  detached  the 
peritoneum  with  the  fingers;  and  there  is  no  circumstance  which  tends 
to  prove  that  they  experienced  any  difficulty  in  reaching  or  in  tying  the 
vessel. 

Here  the  circulation  of  the  fluids  is  re-established  by  the  anastomoses  of 
the  internal  mammary  and  of  the  epigastric  of  the  last  lumbar  and  circumflexa 


'  OPERATIVE    SURGERY.  95 

ilii  or  the  ilio  lumbalis,  and  then  by  the  branches  of  the  h3rpogastric  of  the 
healthy  side  with  those  of  the  side  affected. 

L.  Abdominal  Aorta. 

Art.  1. — Anatomical  Remarks. 

The  abdominal  aorta  is  placed  upon  the  front  and  a  little  to  the  left  of  the 
bodies  of  the  vertebrae,  accompanied  by  the  vena  cava  on  the  right ;  enveloped 
by  a  fibro-cellular  sheath  ;  crossed  behind  by  the  lumbar  veins ;  in  front 
by  the  pancreas,  the  duodenum,  the  splenic  vein  or  the  trunk  of  the  vena- 
portae,  and  the  left  venal ;  and  surrounded  by  vessels  and  lymphatic  ganglions. 
It  has  in  front,  the  stomach,  the  transverse  meso-colon,  and  the  root  of  the 
mesentery ;  and  from  its  passage  between  the  pillars  of  the  diaphragm  to  its 
bifurcation  above  the  sacro-vertebral  angle,  furnishes  a  great  number  of  branches 
worthy  of  notice.  The  coeliac,  the  emulgent,  and  the  great  mesenteric,  derive 
their  origin  from  its  superior  half,  that  is  to  say,  they  originate  above  or  in  the 
meso-colic  portion  of  the  mesentery.  A  great  interval  consequently  separates 
them  from  the  inferior  mesenteric,  which  is  given  off  at  an  inch  and  a  half  or 
two  inches  above  the  common  iliacs.  In  crossing  the  body  of  the  vertebrae, 
the  lumbar  arteries  pass  under  small  fibrous  arches,  extremely  firm,  and  thus, 
like  fixed  roots,  prevent  the  displacement  of  the  aorta  in  either  direction  more 
than  a  few  lines,  unless  they  are  themselves  previously  broken. 

From  what  has  been  said  it  is  plain  that  by  pushing  to  the  right  the  small 
intestines,  or  removing  them  in  any  way,  it  will  be  easy  to  compress  the  aorta 
against  the  vertebrae,  either  between  the  two  mesenteries  or  immediately  above 
its  bifurcation ;  that  these  are  the  only  points  at  which  it  is  accessible  to  the 
surgeon,  and  that  over  one  or  the  other  of  these  the  thumb  should  be  applied 
so  as  to  act  through  the  abdominal  parietes  when  it  becomes  necessary  to  sus- 
pend a  serious  hemorrhage  of  the  inferior  arterial  system. 

Art.  2. — Historical  and  Surgical  Remarks. 

No  artery  of  the  splanchnic  cavities  is  more  frequently  the  seat  of  aneu- 
risms from  internal  causes,  than  the  abdominal  aorta;  and  no  where  does  aneu- 
rism or  the  slightest  traumatic  lesion  occasion  greater  danger,  or  is  it  more  con- 
stantly followed  by  death.  If  it  be  true,  and  it  is  scarcely  possible  at  the  present 
day  to  doubt  it,  that  obliteration  of  the  affected  vessel  is  required  for  the  cure  of 
any  wound,  ulceration,  or  solution  of  the  continuity  in  its  coats,  how  is  it 
possible  to  conceive  that  such  a  state,  supposing  it  possible  in  the  aorta,  could 
be  induced  there  without  fatal  consequences  ?  The  following  facts,  however, 
prove  that  even  this  artery  may  be  obliterated  without  causing  death  :— 

1st.  Stenzel  states  that  he  found  two  steatomatous  tumors  in  the  very 
thickness  of  the  sides  of  the  aorta  below  its  arch.  The  arterial  trunk  was 
almost  impermeable  to  the  blood,  and  yet  nothing  during  life  had  indicated  the 
existence  of  such  a  disposition  of  parts. 

2d  and  3d.  In  two  bodies,  the  inferior  extremities  of  which  were  well 
supplied  with  blood,  Meckel  found  the  aorta  considerably  contracted  below 
its  arch, 

4th.  M.  A.  Severin  speaks  of  a  subject  in  which  the  aorta  was  completely 
closed  below  the  emulgent  arteries  by  a  solid  concretion. 

5th.  Staerk  cites  a  case  similar  to  those  of  Meckel. 

6th.  Paris  saw  the  aorta  so  much  contracted  for  several  lines'  below  the 


96  NEW   ELEMENTS    OF 

arch,  that  he  had  great  difficulty  in  introducing  a  crow-quill  into  the  passage  % 
Brasdor  saw  this  preparation  in  the  cabinet  of  Desault. 

7th.  An  instance  of  complete  obliteration  at  the  same  point  of  the  parent 
artery,  is  related  by  Graham  in  the  Medico-Chirurgica'  Transactions. 

8th.  Mr.  Rainy  states  that  he  observed  a  similar  case  at  the  Glasgow  Hos- 
pital in  1814,  and  that  he  presented  the  preparation  to  Mr.  Monteith.  May 
not  this  be  the  case  alluded  to  by  Mr.  Graham  ? 

9th.  Doctor  Monro  mentions  an  example  of  the  aorta  obliterated  imme- 
diately above  the  primitive  iliacs,  by  the  remains  of  an  old  aneurism. 

lOtn.  A  similar  case  came  under  the  observation  of  Mr.  Goodisson,  in  which 
the  obliteration  had  extended  to  the  two  common  iliacs. 

11th.  M.  Reynaud  has  recently  made  known  an  additional  case  of  extreme 
contraction  of  the  thoracic  aorta. 

Lastly.  A  peasant,  thirty-three  years  of  age,  died  suddenly  in  the  begin- 
ning of  February  1828,  after  having  suifered  during  fifteen  or  twenty  days 
from  a  painful  gastric  affection.  On  opening  the  body,  M.  A.  Meckel  disco- 
vered that  the  death  of  the  patient  had  proceeded  from  an  injury  of  the  auricle 
of  the  heart,  and  afterwards  perceived  that  the  aorta  was  so  contracted  as 
scarcely  to  allow  the  passage  of  a  straw.  Mr.  Crampton,  of  Dublin,  also 
mentions  a  case  of  complete  obliteration  of  the  abdominal  aorta.  Sir  A.  Cooper 
says  that  his  attention  was  directed  to  another  case  of  this  kind,  and  that  a 
similar  one  was  also  witnessed  by  M.  Larrey.  Mr.  Key  also,  has  recently 
published  another  example  in  the  case  of  a  paraplegiac. 

In  nearly  all  the  above  cases,  the  state  of  the  aorta  was  evidently  the  re- 
sult of  disease,  and  in  all,  the  circulation  continued  below  the  interception. 
The  patients  spoken  of  by  Messrs.  Rainy  and  Key,  were  the  only  ones  who 
complained  of  habitual  feebleness  in  the  legs  or  of  paralysis.  Messrs.  A, 
Cooper  and  Beclard,  in  their  experiments  upon  dogs,  are  said  several  time* 
to  have  tied  the  ventral  aorta  without  producing  gangrene.  In  1813^  I  dis- 
sected  a  cat,  upon  which  M.  Pinel  Grandechamp  had  four  months  before 
practised  this  operation.  The  animal  had  perfectly  recovered,  and  the  ab- 
dominal aorta  was  transformed  into  a  fibro-cellulous  filament,  from  the  supe- 
rior mesenteric  to  the  origin  of  the  primitive  iliacs.  M.  Scoutetten  obliterated 
successively  the  two  femorals,  the  two  carotids,  and  the  two  subclavians  of  a 
dog,  and  afterwards  tied  the  aorta'without  producing  death.  The  animal  lived 
six  days,  although  an  intense  j9er27owi7is  developed  itself  the  morning  after 
the  operation,  wlien  a  laceration  of  the  aorta  took  place  above  the  ligature  on 
the  seventh  day,  and  caused  the  animal  to  die  suddenly. 

If  the  above  facts  do  not  authorize  the  conclusion  that  ligature  of  the  vea- 
tral  aorta  may  without  temerity  be  practised  upon  a  human  subject,  they 
prove  at  least  and  most  incontestably,  that  the  blood  would  find  some  other 
way  to  reach  the  inferior  members.  The  intercostals  and  the  superior  lum- 
bars,  the  internal  and  external  mammaries,  the  transverse  and  posterior  cer- 
vicals,  are  sufficiently  voluminous,  in  fact,  to  convey  the  fluids  to  the  parts 
below  the  ligature.  By  examining  the  engraving  which  accompanies  the  ob- 
servations of  M.  Reynaud,  together  with  what  has  been  said  of  it  by  Graham, 
Paris,  Al.  Meckel,  &.C.,  the  reader  will  immediately  comprehend  the  great  re- 
sources possessed  by  the  system  in  these  cases.  Moreover,  if  the  thread  is 
placed  between  the  two  mesenteries,  instead  of  below  them,  large  arches  v/ill 
be  formed  by  the  meeting  of  the  right  and  left  colic  branches.  The  human 
body  is  in  reality  but  a  vast  net-work — a  great  vascular  circle — and  no  one 
need  now  fear  that  the  course  of  the  fluids  can  be  arrested  by  the  obliteration 
of  any  one  of  its  points. 


OPERATIVE    SURGERY.  97* 

Let  us  now  consider  whether  tlie  ligature  of  the  aorta  is  useful  and  practi- 
cable. Practicable  it  certainly  is,  for  Messrs.  Cooper  and  James  have  per- 
formed it,  but  its  utility  has  not  been  yet  so  conclusively  demonstrated.  For 
aneurism  of  one  or  both  common  iliacs,  and  for  those  which  develop  them- 
selves above  the  superior  mesenteric,  there  appears  to  be  no  other  resort — 
and  the  observations  of  Messrs.  Monro  and  Goodisson,  the  case  of  spontaneous 
cure  of  an  aneurism  of  the  aortic  arch,  published  by  Dr.  W.  Darrah,  of  Phila- 
delphia, and  a  similar  case  mentioned  by  M.  Calmeil,  prove  the  power  of  the 
organization  under  circumstances  like  these.  Internal  treatment,  cold  to- 
pical applications,  moxas,  the  cor.  .ned  methods  of  Valsalva,  of  Guerin  and 
of  M.  Larrey — do  not  these  means  offer  greater  chances  of  success  than  all 
the  operations  that  could  be  continued  ?  Time  and  the  experience  of  able 
practitioners  will  eventually  solve  this  grave  problem;  in  the  mean  time,  as 
it  may  become  necessary  to  imitate  the  attempt  of  the  English  surgeon,  I  shall 
give  the  rules  for  the  operation. 

Art.  3. — Manual 

I  do  not  see  any  merit  in  the  idea  of  penetrating  the  left  side,  so  as  to" 
reach  the  aorta  without  opening  the  peritoneum ;  on  the  contrary,  I  am  of 
opinion  that  such  a  method  oun:;ht  never  to  be  resorted  to.  If  it  is  doubtful 
whether  it  might  not  be  applied  in  nephrotomy,  or  in  forming  an  artificial 
anus,  it  is  certain  that,  for  ligature  of  the  aorta,  it  ought  not  even  to  be 
thought  of.  The  only  method  which  can  be  prudently  attempted  is  the  fol- 
lowing : — 

The  patient  should  lie  upon  his  back,  with  the  head,  the  thighs,  and  the  legs 
moderately  flexed,  so  as  to  place  the  parietes  of  the  abdomen  in  a  state  of  per- 
fect relaxation.  An  incision  three  or  four  inches  in  length  is  then  made  upon 
the  linea  alba,  a  little  to  the  left,  in  order  to  avoid  the  umbilicus — above  which 
I  think  it  will  be  found  convenient  to  extend  it  a  little  farther  than  below. 
Having  arrived  at  the  peritoneum,  the  operator  pierces  it  to  divide  it  more 
extensively  with  a  probe-pointed  bistoury  conducted  upon  the  finger;  by  this 
opening  the  fore-finger  removes  the  intestines,  penetrates  to  the  vertebral  co- 
lumn, distinguishes  the  pulsations  of  the  artery,  separates  with  the  nail  the 
left  lamina  of  the  mesentery  and  the  subjacent  cellular  sheath,  and  removes 
gently  the  p.orta  from  the  vena  cava  and  from  the  body,  or  rather  the  cartilage 
of  a  vertebra,  so  as  suitably  to  isolate  it.  If  the  patient  is  of  a  meagre  habit, 
if  the  walls  of  the  abdomen  are  very  near  the  vertebral  column,  if  the  eye  in 
short  can  follow  the  instruments  to  this  place,  a  sound  may,  in  this  stage  of 
the  operation,  be  advantageously  substituted  for  the  finger.  The  ligature  is 
passed  by  means  of  the  needle  of  Deschamps,  or  by  the  ordinary  method,  and 
tied  with  a  double  knot ;  one  end  is  cut  near  the  artery,  and  the  other  is  suf- 
fered to  remain  in  the  wound,  which  should  be  closed  with  a  few  stitches, 
and  strips  of  adhesive  plaster.  If  the  ligatures  of  animal  substance,  proposed 
by  Messrs.  Physick,  Lawrence,  Jameson,  &c.,  offered  the  same  security  as 
others,  they  ought  in  this  case  to  be  preferred,  leaving  the  knot  in  the  depths 
of  the  parts ;  experience,  however,  not  having  yet  pronounced  upon  the  merits 
of  this  kind  of  ligature,  I  do  not  venture  at  present  to  recommend  them. 

In  the  case  of  the  patient  operated  upon,  ^th  June  1817,  at  nine  o'clock 
in  the  evening,  who  died  on  the  27th,  at  eighteen  minutes  past  one,  Sir  A. 
Cooper  placed  his  ligature  three  quarters  of  an  inch  from  the  primitive  iliacs. 
It  would  probably  have  been  better  to  carry  it  above  theJnferior  mesenteric 
jytery,  for  reasons  which  must  be  obvious  to  every  one.  Before  tying  the 
13 


98 


NEW    ELEMENTS    OF 


aorta,  at  the  Exeter  hospital,  on  the  5th  July,  1829,  Mr.  James  had  attempted 
on  the  2d  of  the  previous  month  to  obliterate  the  external  iliac  by  the  method 
of  Brasdor,  without  any  decided  advantage.  His  patient  died  in  a  few  hours. 
On  opening  the  body  it  was  found  that  the  iliac  artery  was  divided  into  two 
trunks,  which  fact  shows  why  the  first  operation,  which  was  followed  by  a 
diminution  in  the  pulsations  of  the  tumor,  did  not  prevent  them  from  regain- 
ing their  original  force  a  short  time  afterwards.  The  process  of  Mr.  James 
was  very  similar  to  that  of  Sir  A.  Cooper. 


SECTION    II. 
ARTERIES  OF  THE  SUPERIOR  EXTREMITY. 

A.  Arteries  of  the  Hand. 

Art,  1. — Anatomical  Remarks. 

The  deep  palmar  arch,  extended  in  the  form  of  the  segment  of  a  circle 
convex  towards  the  fingers,  from  the  beginning  of  the  first  interosseous  space 
to  the  hypothenar  eminence,  where  it  is  completed  by  the  termination  of  the 
ulnar,  imbedded  between  the  muscles  and  the  bones  of  the  metacarpus  behind, 
and  the  flexors  of  the  fingers  or  other  soft  parts  of  the  palm  of  the  hand  in 
front,  is  so  deeply  situated  as  to  render  useless  any  farther  study  of  it  with 
reference  to  aneurism.  The  ulnar,  or  superficial  arch,  represents  with  toler- 
able exactness  the  direction  of  a  curve  of  about  fifteen  lines  in  depth,  the 
extremities  of  which  fall  upon  the  prominences  of  the  pisiforme  and  the  tra- 
perzium.  It  is  covered  at  its  origin  by  some  fibres  of  the  muscles  of  the  little 
finger,  in  the  middle  by  the  palmar  aponeurosis,  and  by  the  subcutaneous 
substratum  through  its  whole  extent ;  and  furnishes,  from  its  convexity,  the 
lateral  arteries  of  almost  all  the  fingers.  The  branches  of  the  median  nerve, 
the  tendons  of  the  superficial  and  deep  seated  flexors,  the  lumbricales,  and  a 
very  loose  synovial  membrane,  separate  it  from  the  deeper  arch,  with  which 
the  anterior  branch  of  the  radial  artery,  a  collateral  of  the  thumb,  and  the 
deep  branch  of  the  cubital,  open  to  a  free  communication. 

Art,  2. — Surgical  Remarks, 

We  often  meet  in  the  hand  with  wounds  of  the  arteries,  capable  of  becom- 
ing dangerous  by  hemorrhage.  The  hand  is  sometimes  also,  though  rarely, 
subject  to  circumscribed  aneurism.  Guattani  met  with  one  as  large  as  an 
orange  in  front  of  the  thenar  eminence.  Becket,  and  F.  de  Hilden  also 
mention  each  a  similar  example.  If  compression  have  proved  insufficient  to 
suspend  the  hemorrhage,  or  discuss  the  aneurism,  the  operator  may,  if  the 
extremities  of  the  wounded  artery  are  perceptible  at  the  bottom  of  the  wound, 
imitate  the  practice  of  M.  Roux,  in  seizing  and  tying  them.  The  difficulties, 
however,  experienced  by  M.  Roux  himselt  m  a  second  operation,  and  by  M. 
Manoury  in  another,  together  with  the  dangers  of  all  kinds  which  attend  in- 
cisions in  the  palm  of  the  hand,  are  enough  to  prove  that  it  would  be  preferable 
to  apply  the  ligature  upon  the  radial,  or  upon  the  cubital,  above  the  wrist. 

Art,  S. — Manual, 
Nevertheless,  the  operator  will  find  no  difficulty  in  reaching  the  super- 


OPERATIVE    SURGERY.  9!^ 

ficial  palmar  arch,  near  its  root,  by  beginning  an  incision  upon  the  side  of 
the  OS  pisiforme,  and  prolonging  it  for  about  an  inch  forwards,  and  in  the 
direction  of  the  last  metacarpal  space.  He  will  have  to  divide  successively 
the  skin  and  its  cellulo-filamentous  lining,  a  thin  aponeurosis,  and  several 
fleshy  fibres. 

It  would  also  be  equally  easj  to  tie  the  origin  of  the  deep  arch  upon  the 
back  of  the  hand  ;  the  extremity  of  the  radial  is  there  at  the  bottom  of  the 
groove  which  separates  the  proximal  extremity  of  the  first  two  metacarpal 
bones.  A  fibrous  lamella  separates  it  from  the  tendons  of  the  thumb,  from 
the  cephalic  vein,  and  from  the  skin.  The  thumb  and  the  index  finger  should 
be  extended  and  forcibly  held  apart,  so  that  the  surgeon  may  not  be  hindered 
by  the  dorsal  tendons  of  those  two  fingers.  An  oblique  incision,  about  an 
inch  and  a  half  in  length,  is  made  at  three  lines  from  the  cubital  side  of  the 
long  extensor  of  the  thumb,  and  in  the  direction  of  that  tendon.  Beneath 
the  skin  may  be  perceived  one  of  the  great  metacarpal  veins,  and  one  of  the 
branches  of  the  radial  nerve.  If  pushing  them  aside  is  not  found  sufficient, 
they  must  be  cut.  The  artery  is  still  concealed  bv  the  aponeurosis,  which 
ought  not  to  be  divided  except  upon  a  director.  Finally,  in  isolating  the 
vessel  with  the  beak  of  the  director,  the  operator  must  be  careful  not  to  lose 
sight  of  the  vicinity  of  the  carpo-metacarpal  articulation. 


JB.  Arteries  of  the  Fore-arm. 
Art.  1. — Anatomical  Remarks, 

In  the  fore-arm,  the  posterior  interosseal  artery,  distributed  between  the 
two  corresponding  muscular  layers  and  the  anterior  interosseal,  accompa- 
nied by  its  nerve  and  resting  upon  the  ligament  of  the  same  name,  are  both 
of  them  too  small,  and  too  deeply  situated,  to  receive  any  assistance  from 
the  ligature.  The  radial  and  the  cubital,  then,  are  the  only  arteries  to  which 
the  attention  of  the  surgeon  should  be  directed. 

1st.  In  its  inferior  third,  the  radial  artery  runs  in  the  groove  which  sepa- 
rates the  tendons  of  the  flexor  radialis  and  the  supinator  longus,  and  is 
covered  only  by  a  single  aponeurotic  lamina,  the  subcutaneous  stratum,  and  the 
skin  ;  one  or  two  veins  accompany  it,  the  nerve  is  some  lines  to  the  outside, 
and  it  lies  almost  immediately  upon  the  anterior  face  of  the  radius.  Its  re- 
lations are  also  somewhat  complicated.  It  rests  upon  the  pronator  teres  or 
the  radial  portion  of  the  flexor  sublimis,  upon  which  it  is  fixed  by  a  fibrous 
lamina,  and  is  covered  by  the  internal  edge  of  the  supinator  longus.  It  is 
also  separated  from  the  integuments  here  as  well  as  below,  by  the  brachial 
fascia  and  the  superficial  cellular  lamina.  Throughout  its  whole  extent,  its 
passage  is  represented  by  a  line^  drawn  from  the  middle  of  the  elbow  to  the 
base  of  the  styloid  process,  or  by  the  outermost  groove  on  the  front  of  the 
fore-arm.  It  sometimes  runs  immediately  under  the  skin;  but  more  fre- 
quently it  runs  down  upon  the  external  surface  of  the  radius,  from  the 
middle  of  its  length;  while  in  other  cases  its  principal  branch  remains  in 
front  and  forms  almost  alone  the  superficial  palmar  arch. 

2d.  The  ulnar,  covered  in  the  upper  part  of  its  length  by  the  whole 
thickness  of  the  superficial  muscular  stratum,  is  on  that  account  accessible  to 
the  surgeon  only  in  the  three  inferior  fourths  of  its  extent,  where  it  is  found 
upon  tlie  flexor  profundus,  between  the  flexor  sublimis  and  the  flexor  carpi 
ulnaris.  The  vein  is  on  the  outside  and  the  nerve  on  the  inside ;  that  is,  on  the 
ulnar  side ;  first  an  aponeurosis,  then  tlie  flexor  ulnaris  muscle  or  its  tendon, 


100  NEW    ELEMENTS    OF 

and  lastly  a  second  fibrous  lamina  and  the  adipose  stratum,  separate  it  from 
tlie  skin.  Its  direction  in  its  two  inferior  thirds  is  traced  by  means  of  a  line 
extending  from  the  internal  condyle  of  the  humorus  to  the  radial  side  of  the 
pisiforme ;  and  in  its  upper  third,  from  the  middle  of  the  elbow  to  the 
junction  of  the  middle  with  the  superior  third  of  the  ulna.  Its  anomalies  of 
position  are  much  more  frequent  than  those  of  the  radial ;  I  have  often  found 
it  between  the  aponeurosis  and  the  skin,  sometimes  in  the  whole  and  some- 
times only  in  part  of  its  length,  and  am  acquainted  with  several  individuals  in 
whose  persons  it  is  thus  placed.  At  other  times  it  is  found  between  the  apo- 
neurosis and  the  muscles ;  and  in  certain  cases  it  remains  for  a  considerable 
time  near  the  axis  of  the  limb,  only  approaching  the  ulnar  nerve  near  the 
wrist. 

Art.  2. — Surgical  and  Historical  Remarks. 

Aneurisms  of  the  radial,  near  the  wrist,  may  doubtless  yield  to  compres- 
sion :  Tulpius  cites  an  example ;  and  this  means  certainly  should  be  tried, 
as  has  been  remarked  by  M.  Roux,  with  patients  who  are  irritable  or  timid; 
like  him  mentioned  by  Petit,  of  Lyons,  who  died  of  Convulsions  in  conse- 
quence of  the  ligature  of  the  radial.  Doubtless,  also,  the  greater  number  of 
hemorrhages  of  the  hand  and  fore-arm  may  be  arrested  by  a  well-applied  com- 
pression. This,  however,  does  not  invalidate  the  assertion  that  ligature  is 
the  surest  and  least  dangerous  remedy  in  all  injuries  or  diseases  of  this  nature- 
These  are  two  means  which  it  is  often  found  advantageous  to  combine.  For 
example,  instead  of  ty in^  at  the  same  time  both  arteries  of  the  fore-arm  for 
a  wound  in  the  hand,  wliich  would  seem  to  be  required  by  the  free  commu- 
nication established  by  the  two  palmar  arches,  it  is  sufficient  to  apply  a  ligature 
upon  the  principal  trunk,  and  to  compress  the  other.  At  the  wrist,  or  above, 
if  the  superior  extremity  of  the  open  artery  is  tied,  it  will  be  sufficient  to 
compress  the  inferior  extremity  to  prevent  hemorrhage  from  the  return  of  the 
blood.  These  directions  apply  also  to  circumscribed  aneurisms.  If  the  affec- 
tion, whether  traumatic  or  spontaneous,  occurs  on  the  dorsal  branch  of  the  ulnar 
artery  (of  which  Messrs.  Petit  and  Baretta  observed  an  example  in  the  hos- 
pital at  Lyons),  or  on  any  other  branch  of  the  same  region,  the  ligature,  which 
is  almost  perfectly  safe  and  easy  to  apply,  ought  to  be  preferred  to  all  other 
means,  and  should  be  placed  both  above  and  below  the  disease.  Unless  the 
ligature  is  applied  within  the  wound  itself,  it  should  be  placed  immediately 
above  the  wrist,  or  else  in  the  superior  third  of  the  fore-arm. 

Art.  3. — Manual. 

1st.  The  Radial  above  the  Wrist. — When  the  radial  artery  is  to  be  tied 
above  the  wrist,  the  hand  should  be  held  supine,  the  surgeon  then,  standing 
on  the  cubital  side,  makes  with  a  straight  or  convex  bistoury  an  incision  of 
the  integuments  one  or  two  inches  in  extent,  over  the  course  of  the  artery, 
taking  care  not  to  proceed  too  deeply  at  first.  He  afterwards  divides  the 
aponeurosis  upon  a  grooved  director,  so  as  to  avoid  touching  the  vessels 
M'ith  the  bistoury.  As  the  nerve  is  at  a  considerable  distance,  and  the  col- 
lateral vein  is  almost  unimportant,  it  is  indifferent  whether  the  artery  is 
raised  from  its  internal  or  external  side,  but  the  operator  should  avoid  de- 
taching it  too  extensively. 

2d.  Ulnar  above  the  Wrist. — The  hand  and  the  fore  part  of  the  arm  are 
placed,  as  for  the  radial  in  a  supine  posture;  the  incision  is  also  of  the  same 
extent  and  in  the  same  direction.     It  is  not  necessary  that  it  should  descend 


OPERATIVE    SURGERY.  101 

to  the  level  of  the  radio-carpal  articulation  ;  and  it  should  be  made  upon  the 
radial  edge  of  the  iiexor  ulnaris  muscle,  or  in  the  groove  in  the  front  of  the 
fore-arm  which  lies  nearest  the  ulnar  edge.  After  having  divided  the  skin, 
the  adipose  stratum,  and  the  thin  fibrous  lamina  which  covers  the  tendon  of 
the  flexor  ulnaris,  and  pushed  that  tendon  outwards,  the  artery  will  be  per- 
ceived through  a  second  aponeurotic  lamina,  a  little  before  and  to  the  radial 
side  of  the  ulnar  nerv'e. 

3d.  Radial  in  the  superior  third  of  the  Fore-arm. — As  it  is  necessary  to 
penetrate  more  deeply  in  the  superior  lialf  of  the  fore-arm  than  into  the  infe- 
rior half,  the  incision  must  be  at  least  two  inches  in  length,  and  should  be  a 
little  oblique  from  within  outwards,  so  that  it  may  not  fail  to  pass  over  the 
line  of  direction  of  the  artery.  If  the  superficial  radial  vein,  or  the  common 
median  vein  presents  itself  under  the  skin,  it  must  be  pushed  aside  with  the 
director.  It  is  better  to  fall  some  lines  on  the  outside  than  on  the  inside  of 
the  edge  of  the  supinator  longus  muscle.  In  the  former  direction  the  aponeu- 
rosis is  not  yet  double,  but  presents  only  a  single  lamina,  while  in  the  other, 
that  is  to  say,  over  the  edge  of  the  muscle,  a  primary  lamina  must  first  be 
divided,  and  the  fleshy  fisciculus  drawn  somewhat  outwardj  a  second  lamina 
appears  beneath  which  is  cut  upon  the  director,  and  the  artery  may  then  be 
easilv  taken  up. 

4tt\.  Ulnar  in  the  superior  third  of  the  Fore-arm. — Ligature  of  the  cubital 
towards  its  superior  third,  is  counted  one  of  the  most  difficult  operations  per- 
formed upon  the  upper  extremity.  This  impression  doubtless  proceeds  from 
the  fact,  that  the  greater  part  of  authors  have  given  only  vague  and  indefinite 
rules  for  its  execution.  I  have  never  found  that,  when  performed  in  the  fol- 
lowing manner  the  operation  required  greater  skill  than  the  ligature  of  the 
radial:  an  incision  is  made  three  or  four  inches  in  length,  beginning  at  three 
fingers'  breadtli  from  the  trochlea  of  the  humerus  and  descending  to  the 
middle  of  the  fore-arm,  in  the  line  above  described.  The  aponeurosis  being 
laid  bare,  the  interstice  betw^een  the  flexor  ulnaris  and  the  flexor  of  the  little 
finger  is  next  sought  for.  To  prevent  the  possibility  of  error,  it  is  only  neces- 
sary to  draw  the  internal  edge  of  the  wound  towards  the  cubital  side  of  the 
member ;  and  in  returning  afterwards  towards  the  median  line,  the  first  yellow 
or  greyish  trace  indicates  positively  the  interstice  required.  An  incision 
is  then  made  in  the  aponeurosis  upon  the  external  edge  of  this  line,  of  the 
same  extent  with  that  in  the  skin;  this  done,  the  flexor  ulnaris  and  the  flexor 
minimi  digiti  are  separated  from  each  other  by  means  of  the  index  finger,  the 
handle  of  a  scalpel,  or  a  director;  the  operator  will  then  see  at  the  bottom 
of  the  wound  a  large  yellow  or  whitish  cord,  which  is  the  cubital  nerve,  having 
the  artery  on  its  radial  side..  In  taking  up  the  latter  it  is  not  even  necessary 
to  see  it.  It  may  be  safely  and  surely  raised  by  passing  the  beak  of  the  sound 
between  it  and  the  nerve.  If  the  disease  occupies  a  more  elevated  point  of 
the  cubital  artery,  since  that  vessel  changes  its  direction  and  becomes  more 
and  more  difficult  to  discover,  it  will  evidently  he  preferable  to  tie  the  brachial. 


C.  Arteries  of  the  Elbow. 

Art.  1. — Anatomical  Remarks. 

At  the  bend  of  the  arm  the  humeral  artery  usua'lr  divides  into  the  radial 
and  ulnar  branches ;  but  instead  of  being  always  opposite  or  below  the  coro- 
noid  process,  its  bifurcation  occasionally  takes  place  in  front  of  the  articulation. 


102  NEW    ELEMENTS    OF 

and  sometimes  even  still  higher.  In  descending  it  takes  an  oblique  direction 
from  within  outwards,  lies  upon  the  inner  portion  of  the  brachialis  anticus 
muscle  between  the  biceps  and  the  pronator  teres,  and  lower  down  tends  to 
cross  in  the  same  direction  the  anterior  surface  of  the  tendon  of  the  biceps.  The 
deep  vein  runs  along  its  radial  side,  and  the  median  nerve,  which  sometimes 
touches  its  cubital  edge,  is  frequently  separated  from  it  by  a  fasciculus  of  the 
brachialis  anticus  muscle.  A  cellular  sheath,  more  or  less  dense,  envelopes 
it  with  the  vein.  It  is  crossed  and  confined  by  the  anterior  tendon  of  the 
biceps,  and  is  farther  covered  by  the  aponeurosis  of  that  region.  It  has  in 
front,  first,  the  trunk  of  the  basilic  vein,  then  the  corresponding  median 
vein,  the  branches  of  the  internal  cutaneous  nerve,  and  the  cellular  adipose 
stratum,  which  remove  it  more  or  less  from  contact  with  the  skin.  When  its 
division  takes  place  higher  than  usual,  the  nerve  generally  lies  between  the 
two  arterial  trunks^  in  which  case  particularly  the  cubital  is  disposed  to  come 
forward  under  the  skin. 

Art.  2. — Surgical  and  Historical  Remarks. 

The  bend  of  the  arm  is  more  subject  to  aneurism  than  any  other  part  of  the 
body,  particularly  to  false  and  traumatic  aneurisms,  whether  diffuse,  circum- 
scribed, or  varicose.  Spontaneous  aneurism  takes  place  here,  as  in  front  of  all 
the  great  articulations,  in  consequence  of  violent  extension  as  in  case  of  the 
carter  mentioned  by  Saviard.  It  is  much  more  rare,  however,  in  this  part  than 
at  the  ham,  or  even  at  the  bend  of  the  groin.  Besides  the  cases  reported  by 
Fordyce,  Flajani,  Paletta,  Lassus,  Pelletan,  p,nd  Roux,  we  can  scarcely  find  an 
example  of  the  kind  in  the  most  esteemed  authors.  Scarpa  himself  does  not 
seem  to  have  met  with  one.  The  bend  of  the  arm  is  the  favorite  seat  of  vari- 
cose aneurism,  whether  simple,  false,  or  circumscribed.  I  have  also  seen  a 
varicose  dilatation,  a  true  hypertrophia  of  all  the  arteries  of  the  hand  and  fore- 
arm, extending  to  the  height  of  the  tendon  of  the  biceps.  Formerly,  when  minor 
surgery  was  in  the  hands  of  barbers  and  persons  without  any  notion  of  ana- 
tomy, it  was  thought  that  in  performing  the  operation  of  phlebotomy  the  artery 
must  of  course  be  frequently  wounded.  Now,  however,  tliat  this  brancji  of 
the  art  is  confided  exclusively  to  young  surgeons  or  medical  students,  this 
accident  is  far  more  rare  than  formerly. 

To  understand  the  different  forms  and  various  directions  taken  by  aneu- 
risms of  the  elbow,  it  is  necessary  to  give  the  most  serious  attention  to  the 
situation  of  the  aponeurosis.  If  the  puncture  take  place  under  the  super- 
ficial tendon  of  the  biceps,  the  aneurismal  tumor  finding  here  an  opening 
somewhat  similar  to  that  in  the  fascia  lata  in  the  inguinal  region,  will  be  able 
to  develop  itself  with  great  rapidity  in  an  equable  manner,  and  may  cor- 
respond by  its  centre  to  the  perforation  of  the  vessel.  Above  this  barrier,  the 
fibres  of  the  aponeurosis,  which  are  separated  by  small  intervals  and  not  firmly 
united,  will  at  first  for  a  time  resist  and  mask  the  tumor,  but  eventually  they 
will  give  way,  and  its  progress  will  from  that  time  cease  to  be  impeded.  If, 
on  the  contrary,  the  lesion  is  immediately  behind  the  lamina  in  question,  the 
tumor  to  enlarge  itself  must  deviate  from  a  vertical  direction;  will  more  fre- 
quently expand  itself  below  than  above,  towards  one  of  those  points  which 
have  been  mentioned  ;  and  will  afterwards  issue  sometimes  at  a  considerable 
distance  from  the  place  of  its  origin.  Ligature  of  the  brachial  artery  in  this 
region  is  practised  not  only  for  aneurisms  of  the  bend  of  the  arm,  but  also  for 
those  which  occupy  the  superior  third  of  the  fore-arm.  At  the  present  day  it  is 
even  more  frequently  applied  in  the  latter  than  in  the  former  cases,  since 


OPERATIVE    SURGERY.  lOS 

AneP6  method  renders  it  necessary  to  carry  the  ligature  upon  a  point  more 
or  less  elevated  above  the  elbow. 

Spontaneous  cures  of  aneurisms  of  the  bend  of  the  arm,  or  cures  assisted 
by  compression,  have  been  so  frequently  seen  as  to  have  become  quite  a  com- 
mon affair.  D.  Pomaret,  of  Montpeliers,  gives  an  account  of  a  patient  who 
would  not  submit  to  an  operation,  and  who  was  perfectly  cured  by  the  burst- 
ing of  the  aneurism.  Monte^gia  speaks  of  a  man  aged  seventy-seven  years, 
who  had  the  artery  opened  m  the  operation  of  phlebotomy,  and  an  attempt 
made  to  close  the  wound  with  a  bandage.  The  patient  was  not  able  to  bear 
this  treatment.  Several  symptoms  occurred  to  disquiet  the  surgeon,  but  they 
soon  vanished  and  with  them  the  aneurismal  tumor.  Galen  cured  an  aneu- 
rism at  tlie  elbow  of  a  young  man  by  means  of  regulated  compression. 
Genga  appears  to  have  frequently  succeeded  by  means  of  the  bandage  com- 
monly ascribed  to  Theden,  White",  Desault,  Foubert,  Scarpa,  and  Stoker,  and 
quite  recently  the  German  journals  have  reported  examples  in  favor  of  this 
metliod.  The  Abbe  Bourdelot  caused  it  to  be  generally  adopted  more  than 
a  century  ago,  by  applying  it  with  success  upon  his  own  person,  for  circum- 
scribed aneurism  at  the  elbow. 

Again,  the  malady  may  proceed  so  slowly  as  scarcely  to  interfere  with  the 
usual  avocations  of  the  patient.  An  aneurism  of  the  bend  of  the  arm,  says 
Saviard,  *•  happened  to  a  man  after  the  operation  of  phlebotomy;  it  was  of  the 
size  of  a  nut,  and  was  carried  by  the  patient  for  seventeen  years,  during  the 
whole  of  which  time  he  pursued  his  ordinary  labor  in  a  coal  mine.  Suddenly, 
however,  the  tumor  increased  to  such  a  degree  as  to  produce  a  considerable 
swelling  of  the  arm,  and  it  was  with  great  difficulty  that  gangrene  of  the 
member  was  prevented."  These  aneurisms  always  sooner  or  later  (with  a 
few  rare  exceptions)  come  to  endanger  the  life  of  the  patient ;  the  surgeon, 
therefore  in  ordinary  cases,  should  never  suffer  himself  to  be  stopped  or  influ- 
enced by  the  consideration  of  such  cases  as  those  above  mentioned.  If  com- 
pression does  not  appear  to  him  to  be  sufficient,  or  is  not  attended  with 
marked  amendment,  it  is  his  duty  immediately  to  have  recourse  to  the  liga- 
ture. 

The  methods  of  Aetius,  of  Paul  of  Egina,  and  of  Guillemeau  were  only 
applied  to  aneurism  of  the  elbow,  until  Keisleyre,  and  the  Italian  surgeons 
ventured  to  apply  the  same  mode  of  treatment  to  aneurisms  of  the  popliteal 
space.  And  it  is  in  this  part  that  Anel  cured  an  aneurismal  tumor  without 
touching  it,  by  simply  tying  the  artery  above  the  seat  of  the  disease.  Mirault, 
of  Angers,  was  the  first  amongst  us  who  imitated  him  in  this  operation  towards 
the  commencement  of  the  present  century.  Although  it  is  generally  admitted 
that  the  method  of  Anel  is  here  sufficient,  that  of  Keisleyre  is  still  sometimes 
practised ;  in  diffused  aneurisms,  for  example,  and  in  varicose  or  circum- 
scribed aneurisms,  when  the  sides  have  become  extremely  thin  or  much  dis- 
eased. The  reason  assigned  in  the  first  case  is,  that  in  limiting  the  operation 
to  ligature  of  the  artery  above  the  lesion,  there  is  a  possibility  of  a  return  of 
hemorrliage  from  below^;  in  the  second,  that  by  the  obliteration  of  the  artery 
above,  the  blood  is  not  prevented  from  passing  from  the  vein  by  the  opening 
of  communication ;  in  the  third,  that  by  Anel's  method  it  is  impossible  when 
the  disease  has  reached  this  stage  to  obtain  resolution  of  the  aneurismal  sac, 
which  it  is  necessary  to  open  and  empty  of  coa^ula  in  order  to  prevent  gan- 
grene, and  that  in  all,  the  method  of  Keisleyre  -will  preserve  a  greater  number 
of  anastomic  branches. 

These  motives  do  not,  really  in  any  way  demonstrate  the  absolute  neces- 
sity of  the  ancient  method  in  these  cases.    The  application  of  a  ligature  above 


104  ,  *  NEW    ELEMENTS   OF  IT' 

the  injury  is  always  easy  and  simple,  but  through  an  opening  in  the  sac  or  over 
the  place  of  the  wound  it  is  sometimes  more  laborious  and  difficult.  If  the 
tumor  do  not  contract  after  the  operation,  if  it  threatens  to  gangrene,  or  form 
an  abscess,  there  is  nothing  to  prevent  its  being  treated  as  a  purulent  collec- 
tion. Compression,  even  moderately  used,  will  rarely  fail  to  arrest  hemor- 
rhage, supposing  it  should  take  place  after  the  :  pplication  of  a  ligature  above 
^  recent  traumatic  aneurism.  It  is  true  that  in  the  case  of  a  patient  operated 
upon  by  the  new  method  at  the  Hotel  Dieu,  by  M.  Breschet,  the  advance  of 
the  aneurismal  sac  yielded  only  to  the  opening  of  the  bag  and  the  ligature  of 
both  ends  of  the  artery,  but  it  is  not  certain,  from  the  details  of  the  operation, 
that  the  humeral  artery  was  embraced  in  the  ligature  at  the  time  of  the  first 
operation.  But  Mr.  Guthrie,  a  declared  partizan  of  Keisleyre's  method,  reports 
a  case  which  furnishes  matter  for  reflection  upon  this  point  A  man  of  good 
constitution  had  the  artery  pricked  with  a  lancet.  It  was  tied  above  the 
■wound.  Hemorrhage  re-appeared.  It  was  tied  still  higher.  A  new  incision 
-was  made.  The  member  was  amputated  and  the  patient  died.  "It  was 
necessary,"  says  Mr.  G.  "  to  tie,  not  only  the  brachial,  but  even  the  origin 
of  the  radial  and  the  ulnar."  As  to  varicose  aneurism,  it  rau^t  be  acknow- 
ledged that  a  certain  number  of  facts  seem  fully  to  justify  exclusive  resort  to 
the  old  method,  as  recommended  by  Messrs.  Richerand  and  Dupuytren. 
Four  examples  cited  by  M.  D.  in  support  of  this  opinion,  may  be  found  in 
Sabatier's  Operative  Surgery.  In  the  first  case,  notwithstanding  the  appli- 
cation of  the  ligature  by  Anel's  method,  amputation  of  the  member  became 
necessary.  In  the  second,  a  false  anchylosis  of  the  fingers,  and  other  unfor- 
tunate results  rendered  amputation  also  necessary.  Finally,  in  the  third  and 
fourth,  the  patient  underwent  a  second  operation  in  which  the  surgeon  tied 
the  artery  above  and  below  the  wound. 

Art,  3. — Manual. 

When  he  has  decided  to  tie  the  brachial  artery  at  the  elbow,  the  operator 
proceeds  as  follows  : — The  fore-arm  is  extended  upon  the  arm,  more  or  less 
removed  from  the  trunk,  and  held  supine.  An  incision  is  then  made  three 
inches  in  length,  parallel  to  the  radial  or  superior  edge  of  the  pronator  teres 
muscle,  commencing  nearly  an  inch  above  the  epitrocnlea,  and  terminating  in 
the  middle  of  the  bend  of  the  arm.  Beneath  the  skin  are  the  superficial  veins, 
the  median  basilic  vein,  and  the  branches  of  the  cutaneous  nerve  which 
accompany  it.  These  are  held  aside  by  an  assistant  with  a  blunt  hook,  or 
the  beak  of  a  probe  bent  for  the  purpose.  Whenever  any  of  their  branches 
impede  the  operation,  or  cannot  be  conveniently  displaced,  they  should  be  cut 
between  two  ligatures,  or  even  without  that  precaution  when  they  are  not  too 
voluminous.  The  aponeurosis  is  next  seen,  and  must  be  divided  upon  the 
4iirector,  even  when  it  would  be  possible  to  preserve  the  superficial  tendon  of 
the  biceps,  it  is  better  to  sacrifice  it :  the  remainder  of  the  operation  will  thus 
become  much  more  easy,  and  a  powerful  cause  of  inflammatory  strangulation 
"will  be  destroyed.  After  having  disembarrassed  the  artery  from  the  lamellar 
and  adipose  cellular  tissue  which  surrounds  it;  after  having  separated  it  from 
the  deep  vein  or  veins  and  from  the  median  nerve,  the  operator  passes  be- 
tween it  and  this  latter  cord  the  extremity  of  a  probe,  which  he  then  causes  to 
glide  behind  it  so  as  to  raise  it,  whilst  with  a  nail  of  the  other  hand  he  hinders 
the  veins  from  following  it,  or  from  lying  under  the  point  of  the  instrument. 
After  this  the  ligature  is  applied,  and  the  operation  is  done. 

The  course  of  the  blood  for  a  time  interrupted,  quietly  re-establishes  itself 


.^l  OPERATIVE    SURGERY.  ,-  105 

bj  means  of  the  two  anastomic  circles  formed  by  the  internal  and  external 
collateral  branches  of  the  brachial  round  the  epicondyle  and  the  epitrochlea, 
with  the  recurrent  branches  of  the  radial  and  the  ulna.  Thus  it  is  not  bj  any 
means  necessary,  in  order  to  explain  this  phenomena  (as  it  was  for  a  long  time 
believed),  that  the  artery  of  the  elbow  should  be  divided  into  two  trunks  above 
the  obliterated  point. 


B.  The  Brachial. 

Art.  1. — Anatomical  Remarks. 

The  humeral  artery  is  situated  in  the  middle  of  the  internal  bicipital  chan- 
nel. Its  passage  corresponds  with  an  oblique  line  drawn  from  the  hollow  of 
the  arm-pit  to  the  midd^e  of  the  bend  of  the  elbow.  The  median  nerve,  which 
in  the  upper  part  of  its  course  runs  along  the  radial  edge,  afterwards  covers 
the  cutaneous  surface,  which  it  crosses  very  obliquely  to  take  low  down  a 
position  on  its  cubital  side.  Two  venae  comites  usually  attend  it,  sometimes 
touching  and  even  covering  it,  and  separating  it  from  the  median  nerve. 
The  ulnar  and  internal  cutaneous  nerves  which  are  next  it  above,  recede  from 
it  more  and  more  as  they  descend,  so  to  reach  the  internal  side  of  the  fore- 
arm. At  first  it  lies  against  the  humerus,  between  the  ceraco-brachialis  and 
the  tendon  of  the  latissimus  dorsi,  but  soon  arrives  upon  the  brachialis  anticus 
behind  the  biceps,  wliich  it  accompanies  to  its  termination.  Upon  attenu- 
ated subjects,  the  aponeurosis  is  nearly  in  contact  with  it,  and  doubles  itself 
so  as  to  envelope  its  trunk  and  that  of  its  collateral  vein,  and  furnishes  a 
sheath  to  the  median  nerve  and  other  lamellse  which  unite  these  different 
organs  so  as  to  form  of  all  a  sort  of  common  mass.  The  whole  is  covered,  as 
elsewhere,  by  the  common  integuments ;  in  the  inferior  third  by  the  trunk  of 
the  basilic  vein.  Its  anomalies  are  so  frequent  that  every  body  knows  them. 
I  have  sometimes  seen  it  divided  into  two  trunks  near  the  axillary  cavity — 
sometimes  at  some  inches  below— sometimes  at  the  middle  of  the  arm — some- 
times just  above  the  elbow — in  fact,  at  all  heights  of  the  limb.  In  one  sub- 
ject, one  of  these  branches  divided  at  two  inches  from  the  epitrochlea,  in 
in  order  to  form  tl\e  ulnar  and  the  posterior  interosseal.  In  another  case,  the 
latter  was  given  off  independently  of  the  radial  and  ulnar.  The  two  trunks 
sometimes  remained  side  by  side,  as  far  as  the  fore  arm.;  at  other  times  they 
cross  each  other  at  one  or  more  points.  It  is  not  at  all  extraordinary  to  see 
one,  generally  the  ulnar,  piercing  the  aponeurosis  and  running  immediately 
under  the  skin ;  whilst  the  other,  which  then  furnishes  the  radial  and  inter- 
osseal, preserves  its  customary  relations. 

Art,  2. — Surgical  and  Historical  Remarks., 

The  brachial  artery  may  become  the  seat  of  aneurismal  affections  almost 
indifferently,  upon  almost  all  points  in  its  extent;  it  is  however  infinitely 
more  disjjosed  to  them  at  the  bend  of  the  arm  than  at  any  other  part.  As 
nothing  hinders  their  equable  development,  the  tumors  caused  by  these  mala- 
dies are  ordinarily  regular,  speedily  acquire  considerable  size,  and  fre- 
quently lie  with  the  centre  over  the  opening  of  the  artery. 

Previously  to  having  recourse  to  the  ligature,  it  is  sometimes  admissible  to 
employ  compression  and  refrigerants;  the  humerus  here  offers  a  reacting 
surface,  which  is  particularly  favorable  to  the  employment  of  these  means. 
14 


106  ^  NEW    ELEMENTS    OF 

M.  Lisfranc  mentions  a  patient  who  had  four  aneurisms  upon  the  arm,  the 
progress  of  which  he  arrested  for  a  whole  year  by  means  of  a  laced  sleeve. 
The  Queen  of  Bavaria,  and  another  personage  of  the  north,  were  cured  of 
aneurisms  of  this  kind  by  M.  Winter,  with  a  compressive  bandage.  But  it  is 
upon  the  humeral  artery  that  Anel's  operation  for  aneurism  is  most  commonly 
performed.  There  the  vessel  is  superficial,  easy  to  be  taken  up,  and  sur- 
rounded by  healthy  parts  preserving  their  natural  relations ;  whilst  in  front  of 
the  articulation,  the  tumor  sometimes  masks  the  seat  of  the  perforation  in 
such  a  manner  as  to  render  it  very  difficult  to  discover.  The  application  of 
the  ligature  near  the  arm -pit  or  the  elbow,  provided  the  principal  collateral 
can  be  preserved,  causes  a  disturbance  in  the  circulation  in  both  cases  almost 
the  same.  Nevertheless,  as  a  grand  rule,  the  ligature  should  be  practised 
at  as  low  a  point  as  the  situation  of  the  malady  will  permit.  No  case,  except 
a  diffused  aneurism  or  a  still  bleeding  wound,  appears  to  call  for  the  old 
method  in  preference  to  the  new.  If  the  aneurism  is  too  high,  the  axillary 
should  be  tied,  unless  it  is  judged  better  to  adopt  the  method  of  Brasdor. 

Art.  3. — Manual. 

The  member  being  placed  as  previously  described,  the  operator  seeks  the 
groove  at  the  edge  of  the  biceps,  carries  the  bistoury  in  the  direction  of  the 
arterial  line  from  above  downwards  for  the  right  arm,  and  from  below  upwards 
for  the  left,  and  makes  an  incision  of  two  or  three  inches  through  the  integu- 
ments. Immediately  afterwards  he  slips  the  left  index  finger  into  the  wound, 
and  endeavors  to  feel  the  median  nerve,  \vhich  presents  a  cord  of  consider- 
able firmness  and  which  may  be  distinguished  from  the  artery  by  the  pulsa- 
tions of  the  latter ;  he  then  divides,  one  after  the  other,  upon  a  director,  the 
aponeurosis,  and  the  sheath  which  it  gives  to  the  medio-digital  nerve  ;  tears 
always  with  the  beak  of  the  sound  the  cellulo  fibrous  sheath  of  the  vessel, 
separates  the  artery  from  the  veins  which  accompany  it,  and  passes  the  liga- 
ture. This  operation  cannot  become  difficult  except  in  consequence  of  some 
anomaly  or  change  in  the  relations  of  the  organs.  The  median  nerve  is  the 
first  cord  which  presents  itself  behind  the  biceps  muscle ;  I  have  only  once 
seen  it  under  the  artery,  between  that  vessel  and  the  brachialis  anticus  muscle. 
Whenever  it  is  recognized,  the  operator  maybe  sure  that  the  vessels  are  not 
far  oft". 

When  the  brachial  is  obliterated,  the  circulation  continues  below  by  means 
of  the  numerous  muscular  branches  which  this  trunk  furnishes  at  different 
points  of  its  length,  by  the  great  collateral  or  external  collateral,  and  by  the 
anastomica  manrna,  if  this  latter  have  not  been  sacrificed. 


E.  Axillary. 

Art.  1. — Anatomical  Remarks. 

I  shall  call  by  the  name  of  the  axillaiy  artery,  only  that  portion  of  the 
brachial  trunk  which  extends  from  the  clavicle  to  the  origin  of  the  humeral 
artery.  It  may  be  considered  in  two  points  of  view — from  the  hollow  and 
from  the  anterior  face  of  the  axilla.  1st.  In  tlie  first  direction  it  is  only  sepa- 
rated from  the  skin  by  the  two  sorts  of  the  median  nerve,  by  that  nerve  itself, 
by  the  axillary  vein,  a  stratum  of  adipose  filamentous  cellular  tissue,  becom- 
ing thicker  as  it  approaches  the  apex  of  the  axilla,  by  the  aponeurosis,  and  bv  a 
second  cellular  stratum.   The  sorts  of  the  thoracic  and  subscapular  veins,  kc. 


>  OPERATIVE    SURGERY.  *  lOT 

cross  it  and  hide  it  at  different  points,  whilst  the  other  nerves  of  the  brachial 
plexus  which  first  lie  in  front,  soon  pass  behind  it  to  gain  the  cubital  side  of 
the  arm.  Outwardly,  it  rests  upon  the  tendon  of  the  subscapular  muscle  and 
upon  the  humeral  articulation  upon  the  head  and  the  neck  of  the  humerus, 
and  between  the  tendon  of  the  teres  major  behind  and  the  pectoralis  minor 
or  coraco  brachialis  in  front.  2dly.  In  the  other  direction  it  is  at  a  consi- 
derable distance  from  the  skin,  and  ought  to  be  studied  above  and  below  the 
pectoralis  minor,  which  crosses  it  at  two  or  three  inches  in  front  of  the  cla- 
vicle, producing  two  triangular  spaces,  of  which  the  superior,  which  I  shall  call 
clavi-pectoraU  limited  below  by  the  edge  of  the  muscle,  above  by  the  clavicle, 
and  outwardly  by  the  coracoid  process,  is  the  more  remarkable.  A  fibro- 
cellular  lamina,  sometimes  quite  dense,  which  I  have  named  the  coraco-clavi- 
cular  aponeurosis,  covers  its  plane,  and  separates  it  from  the  pectoralis  major. 
Below  is  the  vascular  and  nervous  plexus.  The  vein  is  placed  on  the  inside 
towards  the  breast,  and  the  anterior  root  of  the  median  nerve  on  the  outside 
towards  the  shoulder,  in  such  a  manner  that  both  partly  cover  the  artery, 
which  lies  between  and  a  little  behind  them.  This  disposition  is  almost  in- 
variable, and  greatly  facilitates  the  operation.  At  the  summit  of  the  triangle, 
the  cephalic  vein,  together  with  those  that  come  from  the  promontory  of  the 
shoulder  to  empty  into  the  axillary  beneath  the  clavicle,  are  obliged  to  cross 
its  interior  face.  This  is  true  also  of  one  or  two  thoracic  branches  of  the 
nervous  plexus.  It  there  furnishes  the  acromial  artery  and  the  principal  ex- 
ternal thoracic,  before  passing  under  the  pectoralis  minor  muscle. 

The  second  triangle,  which  is  bounded  by  the  inferior  edge  of  the  lesser 
pectoral  muscle  above,  the  superior  fourth  of  the  humerus  on  the  outside, 
and  the  anterior  edge  of  the  axilla  below,  is  entirely  covered  by  the  pectoralis 
major  muscle.  Here  the  median  nerve  is  in  front,  the  ulnar  on  the  outside, 
the  radial  or  musculo-spiral  behind  the  vein,  on  the  inside  of  the  artery ;  in 
fact,  it  is  completely  enveloped  by  these  organs,  to  which  it^is  also  united  by 
a  cellulo-fibrous  sheath  of  considerable  strength.  The  subscapular  and  ex- 
ternal thoracic  veins  and  sometimes  the  basilic,  come  in  to  add  to  the  complexity 
of  these  numerous  affinities.  The  lymphatic  ganglions  are  thrown  back  much 
more  towards  the  breast,  and  thus,  in  addition  to  the  cellular  tissue,  remove  it 
from  the  external  surface  of  the  serratus  ma^nus.  Finally,  an  adipose  stratum, 
of  greater  or  less  thickness,  the  pectoralis  major,  a  lamella  rather  cellular 
than  fibrous,  the  subcutaneous  tissue,  and  the  skin,  cover  all  these  various 
objects. 

Art.  2, — Surgical  and  Historical  Remarks. 

Aneurisms  and  wounds  of  the  axillary  artery  demand  the  most  serious  atten- 
tion. Although  they  are  less  frequent  here  than  at  the  ham,  at  the  groin,  or 
at  the  bend  of  the  arm,  they  are  more  so  than  upon  any  of  the  other  part  of 
the  body.  This  fact  is  easily  accounted  for  by  the  position  and  volume  of  the 
vessel,  its  relations  to  the  articulation,  and  its  proximity  to  the  heart.  It  is 
subject  to  every  species  of  aneurism ;  even  varicose  aneurism  has  been  ob- 
served in  the  axillary  by  Larrey,  of  Toulouse,  and  by  M.  Boisseau.  The 
pressure  which  aneurismal  tumor  here  exerts  upon  the  nerves,  the  veins,  the 
ganglions,  the  articulation,  and  all  the  surrounding  parts,  renders  it  a  malady 
which  for  a  long  time  was  the  terror  of  surgeons,  and  which  was  believed, 
until  the  end  of  the  last  century,  to  be  wholly  beyond  their  art. 

But  Van  Swieten  mentions  a  case  of  a  traumatic  aneurism  of  this  region,  which 
was  spontJaneously  cured  without  the  loss  of  the  limb.    Mr.  Samuel  Cooper 


108  NEW   ELEMENTS   OF 

also  speaks  of  a  patient  at  St.  Bartholomew's  Hospital,  who  recovered,  without 
treatment,  of  an  aneurism  in  the  arm -pit.  Sabatier  caused  one  to  disappeai* 
by  the  method  of  Valsalva  and  the  assistance  of  refrigerants.  Hall,  too,  towards 
the  middle  of  the  last  century,  and  Mr.  Keate,  in  1801,  tied  the  axillary  artery 
with  complete  success.  Amputation,  then,  should  not  be  thought  of  in  these 
cases ;  I  do  not  know  that  it  was  indispensably  necessary,  even  in  the  instance 
of  diffused  aneurism  observed  in  1812,  by  M.  Debaig,  at  Val-de  grace. 

The  cures  obtained  by  the  efforts  of  the  organization,  weakening  regimen, 
digitalis,  purgatives,  or  cold  topical  application,  appear  to  me  to  have  been 
too  few  and  too  much  accidental  to  be  counted  upon  in  the  way  of  encourage- 
ment. The  operation  is  incomparably  more  certain,  and  ougiit  always  to  be 
practised  when  possible.  White  performed  it  unsuccessfully :  the  limb  was 
invaded  by  gangrene,  but  the  nervous  plexus  had  been  comprised  in  the  liga- 
ture. Desault  was  equally  unfortunate,  but  he  had  also  included  in  the  first 
ligature  the  whole  of  the  brachial  plexus.  On  another  occasion,  he  was  not 
able  to  arrest  the  progress  of  a  hemorrhage,  which  was  quickly  mortal.  In 
the  case  reported  by  Pelletan,  the  whole  thickness  of  the  arm-pit  was  traversed 
with  a  needle,  and  the  artery  was  not  seized.  Another  attempt  of  Desault, 
which  proved  equally  unsuccessful,  is  also  on  record.  M.Roux  says  that  a 
patient  died  at  the  Beaujon  Hospital  from  the  consequences  of  a  similar  attempt. 
M.  Delpech,  who  thought  it  necessary  to  cut  across  the  pectoralis  minor,  and 
to  raise  the  whole  of  the  axillary  plexus  with  the  fore-finger  of  the  left  hand 
bent  into  a  hook  in  order  the  better  to  isolate  the  artery,  was  also  unsuccessful 
in  1814.  These  cases,  however,  do  not  prove  any  thing  against  the  operation  5 
the  cause  of  failure  was  the  improper  mode  of  procedure  adopted,  or  else  the 
untoward  circumstances  in  which  the  patients  were  placed. 

To  the  two  examples  of  success  mentioned  by  Hall  and  Keate,  maybe  added 
a  third,  t)y  M.  Maunoir,  and  two  others  which  have  been  communicated  by 
Messrs.  Chamberlayne  and  Monteith. 

Art,  3. — Manual. 

1.  Process  of  M.  Lisfranc. — If  a  free  space  remain  above  the  tumor,  or  if 
the  operation  is  for  a  simple  wound  in  the  upper  part  of  the  arm-pit,  it  is  better, 
according  to  Messrs.  Lisfranc,  Hall,  and  Maunoir,  to  search  for  the  artery  from 
the  hollow  of  the  arm -pit  than  to  divide  the  anterior  wall  of  that  space. 

The  patient  being  placed  upon  his  back,  and  the  limb  removed  as  much  as 
possible  from  the  trunk,  an  incision  is  made  of  three  inches  in  extent  parallel 
to  the  vessels,  and  a  little  nearer  to  the  anterior  than  to  the  posterior  border 
of  the  axilla;  the  skin,  the  cellular  stratum,  and  the  filamentous  aponeurosis 
present  themselves  successively,  as  in  the  arm.  The  remainder  of  the  opera- 
tion is  performed  with  the  director.  With  its  beak  the  surgeon  pushes  the 
median  nerve  forwards  and  outwards;  he  then  directs  it  behind  the  artery  in 
order  to  separate  it  from  the  ulnar  and  radial  nerves,  and  raises  it  a  little  in 
order  to  pass  between  it  and  the  vein,  which  latter  he  tries  with  the  nail  of 
the  index,  or  of  the  thumb  of  the  other  hand,  to  push  backwards  and  inwards. 

The  patient  spoken  of  by  J.  Bell  had  received  a  stroke  from  a  scythe,  and 
had  fallen  into  a  state  of  syncope.  Hall  consequently  found  it  sufficient  to 
tie  the  upper  portion  of  tne  artery.  M.  Maunoir's  patient  had  received  a 
sabre-stroke  5  the  wound  was  simply  enlarged.  M.  M.  applied  a  thread  above 
and  below  the  wound  in  the  vessel.  It  is  evident  that  in  actual  aneurism,  the 
opening  of  the  sac  would  here  be  very  dangerous  ;  too  dangerous  in  fact  to  be 
preferred  in  any  case.    When  it  is  not  possible  to  adopt  the  mode  of  pro- 


OPERATIVE    SURGERY*  109 

cedure  above  mentioned,  should  we  penetrate  by  the  front  of  the  arm-pit? 
Would  it  not  be  better,  more  prudent,  to  proceed  to  search  for  the  subclavian 
behind  the  clavicle,  as  was  practised  with  success  by  Mr.  Gibbs,  or,  according 
to  the  method  of  Brasdor,  to  apply  the  ligature  below  the  tumor  ?  Time  and 
experience  will  doubtless  solve  these  questions.  I  shall  only  say,  in  the 
meantime,  that  if  the  cyst  is  small  enough  and  high  enough  to  permit  the  ap- 
plication of  the  ligature  between  its  inferior  extremity  and  the  origin  of  the 
circumflex  and  subscapular  arteries,  the  operator  will  have  every  possible 
chance  of  success  in  conforming  to  the  method  of  Brasdor;  and  that  in 
contrary  cases,  it  is  much  to  be  feared  that  the  morbid  affection  of  the  arterial 
coats  will  be  prolonged  to  the  clavicle,  in  such  a  manner  as  to  render  the  liga- 
ture useless  upon  any  point  of  the  axillary  trunk.  Should  the  surgeon,  how- 
ever, notwithstanding  the  advice  here  given,  resolve  upon  practising  the  liga- 
ture through  the  front  wall  of  the  axilla,  he  will  find  processes  enough  by  which 
to  effect  his  purpose. 

2.  Process  of  Desault. — M.  Roux,  after  Desault,  recommends  to  incise  the 
soft  parts  on  the  inside  of  the  coraco  deltoid  line ;  afterwards  to  divide  the 
pectoralis  major  upon  the  grooved  director,  also  the  pectoralis  minor  if  neces- 
sary, to  expose  the  whole  of  the  brachial  plexus,  and  to  take  it  up  between 
the  thumb  and  fore-finger  of  the  left  hand,  in  order  carefully  to  isolate  it  from 
the  artery  as  low  down  as  possible.  It  is  not  absolutely  indispensable  to 
resort  to  this  mode  of  procedure,  except  in  operating  by  opening  the  aneurismal 
sac,  and  it  is  probably  by  inadvertence  that  it  has  recently  obtained  the  credit 
of  being  the  best  method  in  other  cases.  If  it  were  indeed  prudent  or  pos- 
sible to  tie  the  axillary  artery  above  the  tumor  at  this  height,  it  ought  to  be 
done  from  the  hollow  of  the  arm-pit,  and  not  through  the  pectoralis  muscle. 
Although  adopted  by  M.  Delpech,  in  1814,  and  since  practised  by  M.  Roux, 
I  cannot  consider  this  method  otherwise  than  as  a  last  resource. 

3.  Process  of  Mr.  Keate. — The  incision  of  Mr.  Keate  was  oblique  down- 
wards and  outwards.  It  comprised  a  part  of  the  pectoralis  major  without 
dividing  it  entirely,  but  a  first  ligature  was  applied  too  low ;  it  was  necessary 
to  place  a  second  very  near  the  clavicle.  This  would  probably  not  have 
happened  if,  previously  to  passing  a  curved  needle  into  the  bottom  of  the 
wound,  Mr.  Keate  had  taken  the  precaution  to  isolate  the  artery  with  the 
grooved  probe. 

4.  Process  of  Mr.  Chamberlayne. -r-The  conduct  of  Mr.  Chamberlayne  was 
more  regular  and  rational.  He  thought  proper  at  first  to  make  a  transverse 
incision  of  three  inches  in  length  in  front  of  the  clavicle ;  he  afterwards  made 
a  second  of  the  same  extent  parallel  to  the  cellular  line  which  separates  the 
pectoralis  major  from  the  deltoid,  turned  down  the  triangular  flap  formed  by 
that  complex  incision,  and  the  artery,  which  he  recognized  by  its  pulsations, 
was  then  exposed :  an  eyed  probe  served  to  pass  the  ligature.  This  operation 
was  performed  on  the  1 7th  of  January,  and  by  the  22d  of  February  the  cure 
was  complete. 

5.  Process  of  Mr.  Hodgson. — Mr.  Hodgson  rejects  the  double  incision. 
According  to  him  and  Mr.  S.  Cooper,  the  best  metliod  is  to  describe  a  semi- 
lunar flap  with  its  convexity  downwards,  the  extremities  of  which,  separated 
by  an  interval  of  three  inches,  correspond,  the  one  with  the  clavicle  near  the 
sternum,  and  the  other  with  the  acromion  process.  After  having  raised  this 
flap,  which  comprises  the  whole  thickness  of  the  pectoralis  major,  the  upper 
triangle  of  the  arm-pit  will  be  found  exposed,  and  the  artery  may  be  easily 
isolated  and  taken  up  between  the  clavicle  and  pectoralis  minor.  Messrs. 
Hodgson  and  Chamberlayne,  however,  may  be  reproached  with  having  sacri- 


no  NEW  ELEMENTS  OF 

ficed  to  no  purpose,  a  great  portion  of  the  pectoral  and  deltoid  muscles.  So 
that  in  France,  a  mode  of  procedure  is  now  particularly  recommended,  which 
is  very  similar  to  that  described  by  Mr.  C.  Bell,  and  difters  very  little  from 
that  of  Mr.  Keate. 

6.  Ordinary  Method. — The  member  is  at  first  slightly  removed  from  the 
trunk,  the  shoulder  depressed  a  little  backwards.  The  surgeon,  then  standing 
between  the  breast  and  the  arm,  begins  his  incision  at  two  fingers'  breadth  to 
the  outside  of  the  sterno  clavicular  articulation,,  and  prolongs  it  to  a  point  be- 
neath the  coracoid  process,  in  the  direction  of  the  fibres  of  the  pectoralis 
major,  taking  care  to  stop  at  the  distance  of  some  lines  from  the  interstice 
between  the  pectoralis  and  the  deltoides.  If  any  little  artery  present  itself 
under  the  skin,  the  ligature  is  immediately  applied  to  it ;  the  fleshy  fibres  are 
gradually  separated  rather  than  divided  with  the  bistoury,  a  very  distinct 
yellow  stratum  indicates  that  the  operator  has  passed  through  the  muscle,  the 
fibres  of  which  are  then  relaxed  by  lowering  the  member  a  little,  in  order 
more  easily  to  separate  or  cause  to  be  separated  tlie  lips  of  the  wound.  If 
there  be  the  slightest  danger  of  wounding  the  vessels,  the  director  or  probe 
should  here  be  substituted  for  the  cutting  instrument ;  the  operator  tears  witli 
its  beak  the  adipose  and  cellular  stratum  and  the  coraco-clavrcular  aponeu- 
rosis, whilst  the  left  index  finger,  bent  into  a  hook,  depresses  with  consider- 
able force  the  upper  edge  of  the  pectoralis  minor.  The  operator  will  soon 
distinguish  the  vein,  which  may  be  known  by  its  size  and  bluish  color,  or  the 
first  division  of  the  brachial  plexus  of  nerves.  In  seeking  for  the  artery  be- 
tween and  behind  these  two  cords,  the  director  is  guided  upon  the  external  side 
of  the  vein,  which  it  is  necessary  to  push  a  little  towards  the  thorax.  The 
instrument  is  then  made  to  penetrate  by  a  to  and  fro  movement  to  a  depth  of 
from  four  to  six  lines,  in  such  a  way  that  in  raising  it  again  from  rear  to  front 
and  from  within  outwards,  it  may  not  fail  to  bring  up  the  arterial  trunk,  from 
which  the  operator  removes  the  nerve  either  with  the  finger  nail  or  the^beafc 
of  another  director. 

By  these  precautions,  the  secondary  vessels  and  the  nervous  cords  upon  a 
dead  subject  at  least,  are  easily  avoided,  and  the  artery  with  certainty  ex- 
posed. By  placing  the  ligature  immediately  under  the  cephalic  vein,  the 
operator  is  almost  sure  to  embrace  the  axillary  between  the  acromials,  which 
are  left  above,  and  the  external  thoracics  which  pass  below.  The  supple- 
mentary branches  which  maintain  the  circulation  in  the  member  after  this 
operation,  are  the  acromial,  the  subscapular,  the  transverse  cervical,  the  in- 
ternal mammary,  and  some  others  of  minor  importance,  all  of  which  form 
anastomoses  with  the  circumflex,  the  common  scapular,  and  the  external 
mammary. 

F.  Subclavian. 

Art,  1.— Anatomical  Remarks. 

Several  authors  have  described  the  axillary  artery  as  formed  of  two  portions; 
one,  that  which  I  have  just  examined,  situated  below  the  clavicle,  the  other 
placed  between  that  bone  and  the  scaleni  muscles.  Nothing  can  justify  such 
an  abuse  of  anatomical  language ;  the  brachial  trunk  ought  not  to  take  the 
name  of  axillary  until  it  enters  the  arm-pit ;  until  then  it  is  the  subclavian 
artery. 

1st.  On  the  inside  of  the  scalenus,  the  subclavian  extremely  short  on  the 
right  hand,  on  account  of  its  origin  from  the  innominata,  lies  by  its  posterior 


OPlfiRATIVE    SURGERY.  Ill 

surface  in  contact  with  some  filaments  of  the  great  sympathetic ;  furnishes  the 
vertebral,  and  is  separated  from  the  triangular  space  between  the  longus  colli 
and  the  anterior  scalenus  only  by  cellular  tissue,  some  lymphatic  ganglions, 
and  the  beginning  of  the  recurrent  nerve.  The  pneumo-gastric,  the  phrenic, 
and  that  branch  of  the  trisplanchnic  which  connects  the  second  witli  the 
third  cervical  ganglion,  cross  its  anterior  surface,  which  is  afterwards  covered 
by  the  sterno-thyroideus  and  sterno-hyoideus  muscles,  several  cellural  lami- 
nae, the  internal  edge  of  the  sterno-mastoideus,  the  aponeurotical  strata  of 
the  neck,  and,  lastly,  by  the  common  integument.  Below  it  is  embraced 
by  the  recurrent  nerve,  and  its  concavity  is  only  removed  from  the  lungs  by 
the  pleura,  or  a  little  cellular  tissue.  In  this  short  passage  it  gives  off  the  in- 
ternal mammary,  the  thyroid,  the  transverse  cervical,  the  ascending  cervical, 
the  pj'ofound  cervical,  and  the  superior  intercostal.  On  the  left  side  it  ex- 
tends almost  vertically  from  the  arch  of  the  aorta  to  the  edge  of  the  first  rib, 
receding  by  degrees  from  the  corresponding  carotid.  The  pneumo-gastric 
nerve  descends  upon  its  internal  side ;  the  recurrent  does  not  cross  it  behind, 
because  it  is  not  until  after  that  nerve  has  turned  around  the  arch  of  the  aorta 
that  it  reascends  towards  the  trachea.  The  thoracic  duct  approaches  very 
near  its  posterior  surface,  and  commonly  hooks  around  it  above  to  empty 
into  the  subclavian  vein.  This  vein,  which  is  separated  from  the  artery  by 
a  considerable  interval,  crosses  it  at  some  distance,  whilst  on  the  right  "it  is 
principally  covered  by  the  termination  of  the  internal  jugular. 

2d.  After  it  has  become  horizontal,  the  subclavian  holds  the  same  relations 
on  either  side,  and  lies  immediately  on  the  first  rib.  The  inferior  attachment 
of  the  anterior  scalenus  separates  it  from  the  vein,  and  this  from  the  sternal 
portion  of  the  sterno-mastoideus  muscle ;  all  the  nerves  of  the  brachial  plexus 
are  above  and  behind,  so  as  to  form,  by  prolonging  themselves  upon  the  an- 
terior surface  of  the  posterior  scalenus^  a  sort  of  lattice-work,  of  which  the  ar- 
tery is  the  lowest  bar. 

3d.  On  the  outside  of  the  scalenus  it  corresponds  to  the  hollow  above  the 
clavicle,  rests  upon  the  first  intercostal  space,  the  second  rib,  and  the  first 
fasciculus  of  the  serratus  magnus  muscle.  The  vein  approaches  and  covers 
it,  descending  a  little  towards  the  clavicle;  receives  there  the  subscapular, 
the  external  jugular,  and  sometimes  the  acromial  vein,  from  which  results 
in  certain  cases  a  somewhat  complicated  plexus.  Its  superior  side  is  accom- 
panied by  the  united  cords  of  the  last  cervical  pair  and  the  first  dorsal ;  a 
little  farther  off  by  the  other  branches  of  the  brachial  plexus,  which  soon  pass 
behind,  so  that  it  is  found  constantly  in  the  triangular  space,  bounded  by  the 
omo-hyoideus  on  the  outside,  the  clavicle  below,  and  the  anterior  scalenus 
muscle  on  the  inside.  In  returning  towards  the  skin,  the  operator  will 
meet  with  lamellar  and  adipose  and  filamentous  masses,  with  lympathatic  gang- 
lions, small  veins,  the  supra-scapular  and  posterior  cervical  arteries,  many 
nervous  branches  of  the  cervical  plexus,  a  very  irregular  aponeurosis,  and, 
near  the  sternum,  the  external  root  of  the  sterno-mastoideus  muscle,  the  su- 
perficial veins,  and  some  scattered  fibres  of  the  platysma  myoides. 

Anomaly. — ^I  shall  add  to  the  above  details,  already  perhaps  too  minute, 
that  the  vein  has  been  seen  with  the  artery  between  the  scaleni  muscles ; 
and  again,  that  the  artery  has  passed  to  the  place  of  the  vein,  and  that  I  have 
myself  witnessed  both  these  anomalies.  When  the  small  scalenus  muscle 
exists,  it  may,  as  has  been  remarked  by  M.  Robert,  in  attaching  itself  to  the 
rib,  separate  the  two  inferior  cervical  nerves  from  the  superior  branches,  and 
incline  them  forwards  and  towards  the  vessels ;  at  other  times  the  artery 
may  be  completely  isolated  by  it  froni  all  the  nerves.     It  is  possible,  also, 


112  NEW   ELEMENTS   OF 

that  the  vein  may  be  more  than  usually  high  above  the  clavicle — may  be  di- 
vided into  two  trunks,  as  observed  by  Morgagni,  and  may  entirely  hide  the 
artery,  which  is  sometimes,  though  rarely,  environed  on  all  sides  by  the  bra- 
chial nerves.  The  occasional  presence  of  a  small  muscle  fixed  by  its  two 
extremities  upon  the  clavicle,  the  attachment  of  the  sterno-hyoideus  to  the 
inside  of  the  sterno-mastoideus,  the  insertion  of  a  second  root  or  the  inferior 
border  of  the  omo-hyoideus  muscle  in  the  clavicle,  are  also  anomalies  of 
which  the  surgeon  ought  not  to  be  unapprised. 

Art.  2. — Surgical  Remarks, 

The  subclavian,  sheltered  as  it  is  by  the  clavicle,  partly  enclosed  within 
the  breast,  protected  at  least  by  the  sides  of  this  cavity,  is  but  little  exposed 
to  the  influence  of  external  agents;  removed  also  from  the  alternations  of 
flexion  and  extension  to  which  the  axillary  and  popliteal  arteries  are  sub- 
jected, it  is  thus  free  from  one  of  the  most  frequent  causes  of  spontaneous 
aneurism.  Nevertheless,  it  is  not  entirely  exempt,  but  is  sometimes  affected 
by  the  maladies  to  which  the  other  arteries  are  subject.  M.  Larrey  relates 
two  examples  of  its  being  wounded  by  sharp  weapons.  In  a  third  case  the 
wound  was  followed  by  a  varicose  aneurism. 

In  all  cases,  it  is  less  for  lesions  of  itself  than  for  those  of  the  axillary,  that 
ligature  is  applied  upon  the  subclavian  artery.  When  an  aneurismal  tumor 
in  fact  develops  itself  in  the  supra-clavicular  hollow,  however  small  may  be 
its  volume,  it  soon  becomes  impossible  to  place  a  thread  between  it  and  the 
heart,  upon  the  trunk  which  it  affects.  If  an  aneurism  at  the  hollow  of  the 
arm-pit,  on  the  contrary,  enlarge  so  as  to  raise  the  shoulder,  the  ligature  is 
applied  above  the  clavicle.  Aneurisms  which  might  be  cured  by  the  ligature 
of  the  subclavian,  sometimes  disappear  spontaneously,  as  in  the  case  published 
by  M.  Bernardin.  The  method  of  Valsalva,  refrigerants,  &c.,  would  also, 
without  doubt,  occasionally  arrest  the  progress  of  the  malady.  M.  Richarme, 
in  his  thesis,  cites  an  example  of  cure  obtained  by  such  means.  As  it  is  dan- 
gerous, however,  to  permit  the  tumor  to  increase  in  size,  and  as  the  results  of 
the  above  resources  are  always  problematical,  it  is  most  advisable  to  operate 
as  speedily  as  possible. 

The  ancient  method  is  not  here  applicable.  If  it  is  not  possible  to  apply 
the  method  of  Anel,  that  of  Brasdor  is  the  only  one  which  can  supply  its  place; 
and  the  operation  is  then  not  ligature  of  the  subclavian,  but  ligature  of  the 
axillary  for  aneurism  of  the  subclavian. 

M.  Dupuytren  was  the  first  who  performed  this  operation  upon  a  living 
subject.  The  patient  it  is  true  died  at  the  expiration  of  nine  days  (20th  July, 
1822),  but  instead  of  increasing  as  might  have  been  feared,  the  tumor  was 
sensibly  diminished  in  size,  and  lost  in  a  great  measure  its  pulsation;  in 
short,  numerous  bleedings  and  a  hemorrhage  by  a  supplementary  branch 
(which  was  at  first  supposed  to  proceed  from  a  wound  of  the  principal  artery^^ 
seem  much  more  than  the  operation  itself  to  have  been  the  cause  of  deatn* 
It  must  be  confessed  however,  that  the  axillary  offers  fewer  facilities  than 
any  other  artery  for  the  practice  of  the  method  m  question.  The  numerous 
branches  which  arise  from  it  are  so  many  channels  by  which  the  blood  will 
continue  to  circulate,  and  will  hinder  the  resolution  of  the  aneurism,  unless 
they  have  been  previously  obliterated  by  the  accumulation  of  fibrin  or  by 
the  progress  of  the  tumor.  Tiie  branches  also  which  are  given  oft'  by  the  sub- 
clavian artery  to  the  inside  of  the  scalenus,  will,  wherever  the  malady  reaches, 
thus  far  constitute  an  equally  powerful  obstacle  to  the  success  of  tliis  mode  of 


OPERATIVE    SURGERY.  113 

operation.  Yet  as  it  is  possible  to  apply  the  ligature  very  near  the  cyst, 
and  internal  concretions  may  have  diminished,  or  even  completely  obstructed 
the  calibre  of  these  arteries,  and  as  the  last  resistance  to  the  course  of  the 
blood  suffices  to  determine  its  coagulation  in  the  morbid  sac,  I  believe  that 
it  would  be  perfectly  justifiable  to  repeat  the  operation  performed  by  M. 
Dupuytren. 

Art,  S. — Manual. 

Ligature  of  i}\e  subclavian  artery,  according  to  the  principles  of  Anel,  has 
been  practised  upon  three  different  points  of  its  length,  viz.  within  the  sca- 
leni,  between  the  scaleni,  and  without  those  muscles. 

1.  Process  of  Mr.  Colles. — CoUes  is  the  only  individual  to  my  knowledge 
who  has  ventured  to  expose  and  tie  this  artery  between  the  trachea  and 
the  anterior  scalenus  muscle.  Great  difficulty  was  experienced  in  passing 
the  thread  round  the  artery,  and  it  was  thought  that  the  pleura  had  been 
slightly  wounded.  Before  fastening  the  thread  the  respiration  became  very 
laborious,  and  the  patient  complained  of  a  sense  of  oppression  at  the  heart. 
These  symptoms  became  so  serious  that  it  was  not  deemed  advisable  to 
tighten  the  ligature  until  the  fourth  day.  The  patient  found  himself  very 
well  until  the  ninth  dsij,  when  he  again  experienced  a  feeling  of  strangulation 
and  great  pain  in  the  cardiac  region ;  he  then  became  delirious,  and  expired  in 
about  nine  hours  from  the  commencement  of  these  symptoms.  On  opening 
the  body,  the  aorta  was  found  to  be  diseased  as  well  as  the  whole  extent  of 
the  subclavian  artery. 

2.  Another  Process. — In  order  to  reach  this  point  of  the  arterial  trunk,  (if  it 
is  not  thought  advisable  to  imitate  the  process  of  Mr.  King*),  the  operator 
should  cut  across  upon  the  director  the  clavicular  portion  of  the  sterno-mas- 
toideus  muscle,  depress  the  internal  jugular  vein  towards  the  trachea,  the 
subclavian  vein  downwards  and  forwards  upon  the  clavicle,  and  push  aside 
the  carotid  artery,  and  the  phrenic  and  pnemuo-gastric  nerves.  On  the  left 
the  operation  is  rendered  more  formidable  by  apprehensions  of  injury 
to  the  thoracic  duct,  as  well  as  by  the  necessity  of  penetrating  much  more 
deeply. 

But  it  is  not  impossible  to  place  the  ligature  between  the  origins,  of  the 
mammary  and  vertebral  arteries,  &c.,  and  the  heart;  whilst  on  the  right,  the 
neighbourhood  of  the  innominataswould  render  such  an  attempt  very  dan- 
gerous. In  every  way,  ligature  of  the  subclavian  artery  between  the  scaleni 
and  the  trachea  must  prove  difficult  and  formidable.  It  ought  not  even  to 
be  practised  between  these  muscles,  unless  the  state  of  the  parts  should  be 
such  as  to  render  it  impossible  to  operate  on  the  outside.  Not  that  it  is  ex- 
tremely difficult,  or  that  it  would  be  surely  unsuccessful,  but  because  the  ad- 
vantages which  it  promises  may  be  otherwise  and  more  easily  obtained,  and 
because  the  section  of  the  scalenus,  which  is  in  itself  a  disadvantage,  also 
exposes  the  operator  to  the  danger  of  wounding  the  internal  jugular  vein,  or 
the  subclavian  itself,  as  well  as  the  two  respiratory  ner\'es. 

3.  Process  of  M.  Dupuytren. — The  following  is  the  method  recommended 
by  M.  Dupuytren,  who  is  said  to  have  practised  it  several  times  with  success, 
particularly  in  1819 : — A  transverse  incision  is  made  at  the  base  of  the  neck, 
from  the  anterior  edge  of  the  trapezius  muscle  to  the  external  edge  of  the 
sterno-mastoideus,  and  is  even  a  little  prolonged  upon  the  external  surface  of 
the  latter.    Having  found  the  anterior  scalenus,  the  operator  directs  between 

*  See  further  on  Innominata. 
15 


114  NEW   ELEMENTS   OF 

its  posterior  side  and  the  arterj  the  extremity  of  a  grooved  director,  upon 
which  he  divides  its  fibres.  By  the  performance  of  this  single  section,  the 
vessel  is  exposed  and  completely  isolated*  The  posterior  scalenus  muscle 
serves  as  a  guide  to  the  needle-probe  which  bears  the  ligature. 

4.  Process  of  Mr,  jRawisden.— The  subclavian  artery  ought  to  be,  and  most 
commonly  has.  been  tied  in  the  omo-clavicular  triangle,  or  on  the  outside  of 
the  scaleni  muscles.  Mr.  Ramsden,  who  was  the  first  to  perform  the  ope- 
ration in  a  regular  manner,  proceeded  as  follows : — He  in  the  first  place 
made  a  horizontal  incision  an  inch  and  a  half  long,  just  above  the  clavicle; 
then  another  incision  two  inches  in  length,  parallel  with  the  external  edge  of 
the  sterno-mastoideus  muscle,  and  meeting  the  extremity  of  the  first.  After 
having  lowered  the  shoulder,  Mr.  Ramsden  continued  the  dissection  of  the 
tissues  so  as  to  expose  the  edge  of  the  anterior  scalenus.  The  artery  was 
then  easily  found  ;  having  isolated  it  with  the  nail,  he  endeavored  to  pass  the 
ligature  around  it.  Numerous  difficulties  presented  themselves.  It  became 
necessary  to  make  use. of  several  instruments,  and  it  was  not  until  after  mul- 
tiplied attempts,  that  he  was  at  last  able  to  finish  the  operation.  The  patient 
died  on  the  sixth  day  (9th  or  10th  November).  Some  time  previously,  Sir  A. 
Cooper  had  attempted,  but  in  vain,  to  take  up  the  artery ;  he  took  up  a  nerve 
instead  of  it,  and  the  patient  died  shortly  afterwards  of  hemorrhage.  In  the 
month  of  April  or  May,  a  woman  of  about  sixty  years  of  age  was  admitted 
into  the  Hotel  Dieu,  at  Paris,  with  an  enormous  aneurism  in  the  axilla.  One 
of  the  surgeons  of  the  establishment  was  of  opinion  that  ligature  of  the  sub- 
clavian ought  to  be,  and  miglit  be  practised ;  the  other  was  of  the  opposite 
opinion,  and  the  patient  died  in  a  few  days  without  having  undergone  an  ope- 
ration. This  circumstance  however  occurred  some  time  after  the  attempt  of 
Messrs.  Cooper  and  Ramsden,  so  that  the  merit  of  priority  in  this  idea  re* 
mains  with  the  English  practitioners. 

A  patient,  very  aged  and  feeble,  operated  upon  by  Mr.  W.  Blizard,  in  1811, 
died  on  the  fourth  or  fifth  day.  A  similar  result  was  experienced  by  M.  Galtie, 
at  Montpeliers,  in  1814.  Messrs.  T.  Blizard  and  Colles  were  equally  un- 
successful in  1815;  but  complete  success  crowned  the  efforts  of  Mr.  Post,  in 
1817,  and  afterwards  those  of  Messrs.  Dupuytren,  Liston,  Bullen,  Green, 
Gibbs,  Key,  Roux,  Langenbeck,  Mott,  Porter,  &c. 

5.  Process  of  Mr.  T.  Blizard. — The  modes  of  operation  adopted  by  the 
above  gentlemen,  differed  very  little  from  each  other.  Mr.  T.  Blizard  made 
an  incision  three  inches  in  length,  parallel  with  the  external  jugular  vein  at 
the  bottom  of  the  neck,  and  towards  the  acromion.  Mr.  Post  divided  the 
tissues  in  the  direction  of  a  line  slightly  oblique  in  reference  to  the  clavicle, 
and  beginning  at  the  external  edge  of  the  sterno-mastoideus.  Mr.  Porter 
made  a  horizontal  incision  above  the  clavicle,  then  a  vertical  incision  on  the 
outside  of  the  sterno-mastoideus  muscle,  and  turned  backwards  the  triangular 
flap  thus  formed.  M.  Dubled,  on  the  contrary,  recommends  that  the  incision 
be  made  in  an  oblique  direction  downwards  and  inwards,  so  that  it  may  fall 
near  the  sterno- clavicular  articulation.  According  to  Mr.  Hodgson  the  inci- 
sion should  be  exactly  transverse ;  and  his  method  certainly  offers  more 
advantages  than  any  other.  I  do  not  think  that  the  proposal  of  a  member  of 
the  Surgical  Academy,  to  include  in  the  same  ligature  both  the  artery  and 
the  clavicle,  has  ever  been  renewed ;  and  I  am  at  a  loss  to  conceive  what 
reasons  could  induce  M.Cruveilhier  to  say,  in  his  course  of  anatomical  studies, 
that  it  would  be  useful  to  saw  that  bone  in  order  with  greater  security  to  tie 
the  subclavian. 

6.  Ordinary  Process. — The  patient  should  be  placed  upon  his  back  with 


OPERATIVE   SURGERY.  115 

the  breast  a  little  elevated ;  he  is  made  to  turn  the  head  and  neck  towards  the 
sound  side,  while  an  assistant  depresses  the  shoulder  as  far  as  the  aneurism 
will  permit,  removing  at  the  same  time  the  arm  from  the  trunk.    The  integu- 
ments are  then  cut  in  a  transverse  direction,  at  an  inch  above  the  clavicle, 
from  the  external  edge  of  the  sterno-mastoid  muscle  to  the  inner  border  of  the 
trapezius.     The  operator   then  divides  in  the  same  direction   the  cellular 
tissue,  the  fibres  of  the  platysma  myoides,  and  the  external  jugular  itself 
(after  having  tied  it  above  and  below  the  point  of  division),  if  there  be  no  pos- 
sibility of  avoiding  it  by  holding  it  aside  by  means  of  a  blunt  hook ;  he  after- 
wards divides  the  aponeurosis,  and  with  the  fore-finger  will  then  be  able  to 
distinguish  the  edge  of  the  scalenus  immediately  beneath,  and  within  the 
sterno-mastoideus.     After  having  removed  the  cellular  tissue,  the  lamellae, 
the  filaments,  and  the  ganglions,  from  the  bottom  of  the  wound,  with  the  end 
of  the  director  or  a  good  dissecting  forceps,  the  finger  is  carried  towards  the 
root  of  the  scalenus  to  find  the  tubercle  of  tha first  rib.    This  tubercle  is  here 
a  sure  guide ;  so  much  so,  that  if  without  leaving  it  the  pulp  of  the  fore-finger 
is  turned  a  little  outwards  and  backwards,  it  will  almost  invariably  feel  the 
vessel.   AYhen  the  vessel  has  once  been  found,  the  eye  is  no  longer  necessary. 
The  nail  applied  against  its  posterior  and  external  side,  serves  as  a  conductor 
to  the  bent  probe  or  needle.     By  directing  the  beak  of  one  of  these  instru- 
ments backwards  and  a  little  outwards,  it  is  soon  properly  placed  under  the 
artery.     The  operator  then,  in  order  to  hold  the  artery  and  prevent  it  from 
altering  its  position,  places  his  finger  between  it  and  the  first  division  of  the 
brachial  plexus  of  nerves. 

When  the  shoulder  is  not  too  much  deformed  or  elevated  by  the  tumor,  or 
can  be  depressed  without  inconvenience,  any  surgeon  who  has  a  little  prac- 
tical knowledge  of  anatomy  may  apply  the  ligature  without  the  difficulty 
which  is  generally  supposed  to  attend  the  operation.  The  section  of  the 
omo-hyoid  muscle,  proposed  by  some  surgeons,  and  that  of  the  sterno-mastoid, 
still  practised  by  Mr.  Mayo,  are  utterly  useless.  The  action  of  the  director, 
which  ought  to  be  preferred  after  the  division  of  the  aponeurosis,  enables  the 
operator  to  avoid  injuring  the  plexus  formed  by  the  confluence  of  the  little 
veins  of  tlie  shoulder  and  the  neck  when  they  arrive  at  the  subclavian. 
To  avoid  injuring  the  latter  it  is  sufficient  to  carry  the  extremity  of  the  con- 
ductor beneath  it  and  next  the  scalenus,  before  bringing  the  instrument  back- 
wards to  hook  up  the  artery.  Finally,  as  this  vessel  in  the  normal  conform- 
ation is  invariably  the  first  movable  cord  which  presents  itself  under  the 
finger  after  leaving  the  tubercle  of  the  first  rib,  and  as  the  nerves  are  distin- 
guished from  it  by  their  roundness  and  firmness,  it  is  almost  impossible  that 
the  operator  can  commit  an  error. 

Results  of  the  Operation. — Mortification  of  the  member,  which  appears  so 
much  to  be  apprehended  after  the  obliteration  of  the  subclavian,  seldom 
takes  place.  A  sense  of  suffocation,  delirium,  and  symptoms  of  affection  of 
the  cerebrum,,  of  the  heart,  and  its  envelope,  were  observed  in  the  patients  of 
Messrs.  Ramsden,  CoUes,  Blizard,  Mayo,  Gibbs,  &c.  After  death  traces  of 
pericarditis  were  discovered  5  the  aorta  and  the  heart  w^ere  also  diseased, 
but  there  was  no  appearance  of  gangrene.  In  some  cases  the  circulation  re- 
establishes itself  with  remarkable  rapidity ;  pulsation  reappeared  in  the  radial 
md  cubital  arteries  of  Mr.  Roux's  patient  the  morning  after  the  operation. 
The  blood  is  brought  back  into  the  axillary  or  the  brachial  by  the  anastomoses 
of  the  internal  mammary  with  the  thoracics,  and  of  the  acromial  and  the  com- 
mon scapular  with  the  posterior  cervical  and  the  supra-scapular.  If  the 
ligature  is  applied  to  the  inside  of  the  scaleni,  above  the  vertebral  and  mam- 


116  NEW  ELEMENTS   OF 

mary  arteries,  the  fluids  can  only  reach  the  limb  of  the  diseased  side  by  the 
communication  of  its  vessels  with  those  of  the  healthy  side. 

Wardrop  tied  the  subclavian  artery  upon  the  plan  of  Brasdor,  for  an  aneu- 
rism of  the  innominata.  The  corresponding  carotid  artery,  which  had  been 
previously  obliterated  by  the  tumor,  soon  became  pervious  again.  The  ope- 
ration appeared  at  first  to  be  completely  successful  5  but  after  a  few  days  the 
aneurism  made  renewed  advances,  and  the  patient  (Madame  Desmarest)  sank 
on  the  13th  Sept.  1829.  I  shall  revert  to  this  fact  in  another  place,  and  shall 
content  myself  at  present  with  remarking,  that  the  best  method  of  treating  an 
injury  or  disease  of  the  subclavian  is  to  place  a  ligature  upon  the  artery 
immediately  below  rather  than  above  the  clavicle. 


SECTION    III. 
ARTERIES    OF   THE    HEAD. 

There  is  hardly  a  branch  of  any  importance,  whether  upon  the  face  or  upon 
the  cranium,  but  is  subject  to  injury  by  external  agents,  or  may  become  the 
seat  of  one  of  these  spontaneous  aneurisms  which  are  characterised  as  mixed 
or  true.  Paletta  cites  one  example,  and  Scarpa  two,  of  aneurism  of  the  tem- 
poral artery.  Mr.  Green  has  lately  made  known  a  fourth.  Klaving  speaks 
of  one  which  occupied  the  left  posterior  auricular.  The  subject  was  a  young 
man,  twenty-five  years  of  age.  Dehaen  witnessed  a  similar  aneurism  upon 
the  dorsal  artery  of  the  nose.  M.  Godichon,  of  Versailles,  saw  a  pediculated 
aneurismal  tumor  upon  the  forehead,  more  than  an  inch  in  thickness ;  he  also 
observed  another  in  front  of  the  right  tuber-parietale.  The  Leipsic  trans- 
actions contain  an  observation  of  aneurism  of  the  frontal  artery.  M.  Gaste 
and  M.  Merat,  speak  of  aneurism  at  the  temple.  M.  Gama  cured  one  which 
was  seated  near  the  commissure  of  the  lips.  M.  Begin  cites  another  which 
was  seated  upon  the  middle  meningeal,  and  which  caused  the  death  of  the 
patient  after  having  perforated  the  temporal  fossa.  M.  Krimer  reports  a 
similar  fact.  Pelletan  mentions  an  aneurismal  or  erectile  tumor  on  the  eye- 
lid— the  patient  a  boy;  also  another  upon  the  conjunctiva  of  a  second  subject; 
and  a  third  upon  the  upper  part  of  the  forehead.  He  has  seen  also,  in  two 
different  cases,  almost  all  the  branches  of  the  occipital  or  temporal,  and  even 
the  external  carotid,  dilated  and  in  a  state  of  hypertrophia,  as  in  varicose 
aneurism.  The  palatine  artery  itself  is  not  exempt  from  these  aneurismal 
dilatations,  as  has  been  proved  by  an  observation  of  M.  Delabarre.  As  to  the 
arteries  within  the  cranium,  they  are,  though  less  frequently,  subject  to  the 
same  maladies  as  those  of  the  exterior.  Examples  of  varicose  aneurism,  or 
of  aneurism  by  anastomosis,  occurring  about  the  globe  of  the  eye,  have  been 
published  by  Messrs.  Wardrop,  Travers,  Arendt,  &c.  Sir  A.  Cooper  observed 
a  small  aneurismal  tumor  upon  the  central  artery  of  the  retina.  M.  Serres 
describes  another,  as  large  as  a  nut,  which  was  attached  to  the  basilary,  and 
Mr.  Hodgson  reports  a  case  in  which  a  small  sac,  formed  by  the  anterior  cere- 
bral artery,  was  completely  filled  with  a  solid  coagulum,  which  did  not  extend 
into  the  cavity  of  the  vessel.  But  in  cases  of  this  kind  one  of  two  things  is 
always  true  5  either  the  aneurism  is  completely  enclosed  in  the  cranium  so 
that  nothing  can  indicate  its  presence  and  the  resources  of  surgical  skill  are 
of  course  ot  no  avail,  or  the  malady  displays  itself  upon  the  exteiior ;  and  if 
compression  is  not  found  to  be  sufficient,  and  the  opening  of  the  sac  is  not  to 
be  attempted,  although  once  successfully  performed  by  M.  Cisset,  upon  the 


OPERATIVE   SURGERY.  117 

occipital  artery,  ligature  of  the  carotid  is  ordinarily  preferred  to  that  of  the 
artery  which  is  more  particularly  affected.  There  is  scarcely  any  exception  at 
the  present  day  in  this  respect,  unless  it  be  for  the  trunk  of  the  facial  and  tem- 
poral, or  unless  it  should  be  possible  to  act  upon  the  injured  part  itself. 

A.  Temporal. 

The  temporal  artery  is  easily  found  at  three  lines  in  front  of  the  ear,  a  little 
above  and  upon  a  level  with  the  zygomatic  arch.  An  incision  of  an  inch  in 
length  is  enough  to  conduct  to  it,  and  it  is  found  enveloped  in  the  deep  laminae 
of  the  subcutaneous  cellular  stratum. 


B.  Facial. 

It  would  not  be  difficult  to  expose  the  facial  at  the  place  where  it  begins 
its  course  over  the  inferior  maxilla.  By  cutting  the  skm  with  caution,  upon 
the  edge  of  that  bone  and  in  a  horizontal  direction,  from  the  anterior  edg3  of 
the  masseter  to  the  edge  of  the  depressor  anguli  oris,  it  is  immediately  exposed. 
It  may  also  be  reached  by  dividing  the  parts  which  cover  it,  to  the  extent  of 
an  inch  or  an  inch  and  a  half,  obliquely  from  above  downwards  and  back- 
wards, close  to  the  masseter  muscle ;  its  satellite  vein  is  the  only  organ  which 
requires  care,  and  even  this  might  be  wounded  or  compressed  in  the  ligature 
without  producing  any  serious  inconvenience. 

The  occipital  should  be  sought  for  in  the  neck. 

SECTION  IV. 

ARTERIES  OF  THE  NECK. 

A.  Primitive  Carotid. 

Art.  1. — Anatomical  Remarks. 

After  leaving  the  breast,  the  carotid  artery  soon  places  itself  upon  the  side 
of  the  passages  of  respiration  and  deglutition,  where  it  remains  until  its  bifur- 
cation, whicn  generally  occurs  opposite  the  thyro-hyoidean  interstice.  The 
internal  jugular  vein  is  joined  to  its  external  face,  and  in  the  living  subject 
even  partly  hides  its  anterior  surface.  On  the  inside,  some  elastic  and  resist* 
ing  cellular  tissue  and  branches  of  the  recurrent  nerve  and  of  the  inferior 
thyroid  artery,  separate  it  from  the  larynx,  from  the  trachea,  and  from  the 
oesophagus.  The  thyroid  artery  below  the  cardiac  branches  of  the  pneumo- 
gastric  nerve,  and  the  internal  divisions  of  the  great  sympathetic,  cross  more 
or  less  obliquely  its  posterior  surface,  the  external  side  of  which  is  also  accom- 
panied throughout  its  whole  extent  by  the  trisplanchnic  and  pneumo -gastric 
trunks.  A  yellow  sheath,  very  solid  and  difficult  to  tear,  incloses  it  with  the 
vein,  the  nervous  cords,  and  the  descending  branch  of  the  hypoglossal  nerve, 
which  usually  follows  down  its  anterior  and  external  face.  This  artery  lies 
upon  the  forepart  of  the  cervical  vertebrae,  from  which  it  is  separated  by  the 
longus  colli  and  the  rectus  anticus  major,  and  it  is  covered  on  the  outside  and 
near  its  root  by  the  sterno -mastoid  muscle,  which  soon  removes  from  it  so  as 
to  leave  it  uncovered  on  its  internal  side  ;  and  on  the  inside  by  the  external 
edge  of  the  sterno-hyoid  and  sterno -thyroid  muscles,  then  by  the  correspond- 
ing lobe  of  the  thyroid  gland  and  the  veins  (sometimes  of  considerable  size), 
which  come  from  tlie  face  and  neck  to  pour  their  contents  into  the  internal 


118  NEW  ELEMENTS  OF 

jugular.  It  is,  moreover,  divided  as  it  were  into  two  portions  by  the  omo- 
hyoid muscle,  towards  the  middle  of  the  sub-hyoid  region.  This  small  mus- 
cle, in  fact,  forms  of  the  side  of  the  neck  two  very  regular  triangular  spaces, 
by  its  passage  from  the  posterior  surface  of  the  sterno -mastoid  to  the  os-hyoides. 
In  the  inferior,  or  omo-tracheal,  limited  by  the  trachea,  the  clavicle,  and  the 
muscle  in  question,  the  artery  hidden  by  the  internal  root  of  the  sterno-mas- 
toidean  has  no  very  complex  relations,  although  it  is  very  deeply  situated  ; 
in  the  other,  which  is  bounded  by  the  edge  of  the  sterno-mastoid  on  the  out- 
side, the  transverse  line  which  limits  the  sub-hyoid  region  above  and  the  omo- 
hyoid muscle  below,  it  is  much  more  superficial.  But  there  a  plexus  of  veins 
frequently  covers  its  anterior  surface.  The  right  carotid,  which  is  shorter  as 
is  well  known  than  the  left,  on  account  of  its  origin  from  the  innominata,  and 
which  is  also  sensibly  nearer  the  median  line  and  more  superficial  because 
of  the  trachea  which  pushes  it  forwards  near  the  sternum,  is  almost  as  easy  to 
reach  in  the  omo-tracheal  space  as  in  the  omo-hyoid  triangle. 

Anomalies. — Among  the  varieties  presented  by  the  carotid  arteries,  are 
some,  the  possibility  of  which  ought  never  to  be  lost  sight  of  by  the  surgeon. 
That  of  the  right  side  many  come  directly  from  the  aorta.  At  other  times, 
the  innominata  rises  higher  than  usual,  of  which  Mr.  Harrison  cites  an  in- 
stance ;  and  it  is  sometimes  as  much  abridged  in  length.  Zagorsky  has  seen 
the  left  carotid  and  subclavian  originating  by  a  common  trunk  ;  at  the  right 
they  arose  separately  from  the  aorta.  I  have  myself  seen,  as  well  as  Messrs. 
A.  Monro,  Scarpa,  A.  Burns,  Goodman,  Meckel,  &c.,  both  carotids  proceed 
from  the  innominata,  and  in  other  cases  given  off  by  a  common  trunk  which 
came  from  the  aorta  distinct  from  the  subclavian  arteries.  But  it  is  rare  to 
see  them  separate  into  the  internal  and  external  carotids  in  the  inferior  part 
of  the  neck,  as  has  been  observed  by  Burns  and  others.  An  instance  of  this 
variety  was  observed  last  winter,  in  the  anatomical  rooms  of  the  Jefferson 
Medical  College  in  Philadelphia.  M.  Lan^enbeck  saw  the  primitive  carotid 
divided  into  the  internal  carotid  and  superior  thyroid,  without  furnishing  an 
external  carotid  ;  and  Burns  cites  examples  of  the  carotid  trunk  bifurcating 
on  a  level  with  the  angle  of  the  jaw. 

Art.  2. — Surgical  and  Historical  Remarks. 

Aneurisms. — The  primitive  carotid  has  presented  examples  of  every  species 
of  aneurism.  It  is  but  too  common  to  see  it  injured  by  penetrating  or  cutting 
instruments,  and  giving  passage  to  hemorrhage  which  promptly  becomes  mor- 
tal. Sometimes,  however,  the  wound  merely  occasions  an  aneurism  at  first 
diffused,  but  afterwards  circumscribed.  Harder  relates  a  case  of  this  kind 
where  the  carotid  had  been  wounded  by  the  point  of  a  sword  !  at  other  times 
aneurism  is  produced  by  violent  motions  of  the  head.  Rumler  saw  this  occur 
upon  a  man,  who  in  attempting  to  lift  a  heavy  burden,  forcibly  held  back  his 
head.  Scarpa  speaks  of  a  similiar  fact;  the  subject,  who  was  a  soldier,  had 
been  precipitated  from  the  walls  of  Mantua,  and  experienced  a  violent  twisting 
of  the  neck.  Aneurism  of  the  carotid  may  also  develop  itself  without  any 
apparent  cause,  as  it  has  been  observed  by  Scarpa,  and  proved  by  numerous 
modern  examples.  Messrs. Larrey  and  Desparanches,  of  Blois,  have  witnessed 
varicose  aneurism  at  the  carotid.  Lesions  of  arteries  so  voluminous,  the  only 
ones  which  supply  the  exterior  of  the  head  and  the  greater  part  of  the  ence- 
phalon,  naturally  produced  considerable  alarm  in  the  minds  of  surgeons  from 
tlie  time  when  it  became  known  that,  in  order  to  effect  a  cure,  it  was  neces- 
sary to  obliterate  the  injured  vessel. 


OPERATIVE    SURGERY.  119 

Galen  and  Valsalva,  it  is  true,  had  previously  ascertained  that  ligature 
of  the  carotid  arteries  of  dogs  was  not  dangerous;  but  they  Avere  far  from 
thinking  of  the  performance  of  such  an  operation  upon  a  human  subject.  To 
dissipate  the  doubts  of  the  faculty  upon  this  point,  other  facts  were  neces- 
sary. In  the  case  of  a  man,  who  died  seven  years  after  the  cure  of  an 
aneurism  of  the  neck,  M.  Petit  found  the  right  carotid  completely  obliterated ; 
Haller,  in  dissecting  the  body  of  a  female,  observed  a  similar  state  of  the  left 
carotid  ;  Baillie  found  one  of  the  carotids  entirely  closed,  and  the  other  con- 
siderably contracted.  Pelletan  and  Sir  A.  Cooper  relate  each  a  similiar 
case ;  and  if  Koberwin  may  be  believed,  M.  Jadelot  saw  both  arteries  oblite- 
rated on  the  same  subject.  These  examples,  added  to  those  which  have  been 
observed  of  late  years,  particularly  one  which  came  under  my  own  observa- 
tion last  winter  at  the  dissections  of  the  practical  school,  prove  two  things: 
first,  that  one  of  the  carotid  arteries,  and  even  both,  may  be  completely 
closed  without  producing  death,  and  without  cutting  oif  the  supply  of  blood 
from  the  brain  :  secondly,  that  aneurism  of  the  carotids  is  not  always  be- 
yond the  resources  of  the  organism,  but  that  if  abandoned  to  itself,  it  will  in 
certain  cases  spontaneously  disappear.  But  it  is  absurd  to  attempt  the  cure 
of  aneurism  of  these  arteries  (excepting  by  the  method  of  "Valsalva  or  refri- 
gerants, as  used  with  some  success  in  our  own  time,  by  M.  Larrey),  without 
renouncing  the  old  method.  It  seems  to  be  impossible  to  establish  at  the 
neck  a  sufficient  degree  of  compression  to  allow  the  opening  of  the  sac  with 
perfect  safety.  The  surgeons  of  La  Charite,  who,  according  to  Harder,  had 
the  temerity  to  adopt  this  method,  saw  their  patient  die  under  their  hands. 
According  to  Hebeinstreet,  cited  by  S.  Cooper,  the  carotid  had  already  been 
tied  with  success  for  a  wound  which  had  occurred  during  the  extirpation  of 
a  scirrhous  tumor  from  the  neck ;  also  by  Abernethy,  with  equal  success,  for  a 
traumatic  lesion  of  the  external  and  internal  carotids.  In  1803,  Mr.  Fleming 
was  equally  fortunate  with  a  mariner  who  had  attempted  suicide.  The 
journal  of  Sedillot  contains  a  fourth  example  of  this  operation  performed  for 
a  wound  in  the  neck :  the  patient  died  on  the  9th  day.  Mr.  Brown  makes 
known  a  fifth,  which  was  followed  by  cure.  Mr.  Collier  furnishes  a  sixth, 
authenticated  by  Mr.  S.  Cooper ;  and  the  treatise  of  Mr.  Hodgson  contains  a 
seventh.  Anel,  V.  Home,  and  M.  Larrey,  also  each  cite  an  example  of  wounds 
of  the  carotid,  cured  by  simple  compression.*  In  November,  1805,  an 
aneurism  of  the  carotid  was  treated  for  the  first  time  by  the  method  of  Anel. 
The  patient  died  on  the  twentieth  day.  Sir  A.  Cooper  again  had  recourse 
to  this  method  in  the  month  of  June  1808,  and  on  that  occasion  with  complete 
success.  In  the  September  following,  a  patient  operated  upon  in  the  same 
way  by  Mr.  Cline,  at  St.  Thomas's  Hospital,  died  on  the  fourth  day.  It 
was  not  until  this  time  that  the  surgeons  of  Paris  became  acquainted  with 
the  attempts  which  had  been  made  in  London,  and  learned  that  in  the  year 
1804  M.  Dubois  had  prepared  every  thing  for  a  similiar  attempt,  which, 
however,  could  not  be  made,  in  consequence  of  the  patient  having  expired 
the  evening  preceding  the  day  appointed  for  the  operation.  In  our  own 
time  it  has  been  practised  by  a  great  number  of  surgeons,  sometimes  with 
and  sometimes  without  success,  either  for  the  purpose  of  permitting  the 
amputation  of  the  maxilla,  or  the  extirpation  of  the  parotid  or  of  cancerous 
or  fungous  tumors,  as  in  the  cases  of  Messrs.  Lisfranc,  Gensoul,  Walther, 
Fricke,  M'Clellan,  &c.;  to  cure  erectile  tumors,  or  fungous  hematodes  of  the 
eye,  as  it  has  been  successfully  done  by  Messrs.  Travers,  Dalrymple,  Arendt, 
&c.  5   for  simple  wounds  of  the  face  or  neck,  as  by  Messrs.  Langenbeck» 

•  Was  the  carotid  really  the  seat  of  the  disease  ? 


120  NEW   ELEMENTS    OF 

Baffin,  Lisco,  &c. ;  or  finally,  for  aneurisms,  properly  so  called,  of  the  carotid 
or  its  branches.  Mr.  Pattison  practised  it  with  complete  success  in  1821, 
for  an  aneurism  by  anastomosis,  or  an  erectile  tumor  of  the  zygomatic 
fossa,  upon  a  subject  of  about  nineteen  years  of  age.  The  infant  aged  six 
weeks,  upon  whom  Mr.  Wardrop -performed  the  operation  for  a  fungous  ulcer 
of  the  cheek  died  on  the  fourteenth  day.  In'Mr.  Roux's  patient,  the  fungus  was 
considerably  diminished  in  the  orbit,  and  reduced  to  the  part  which  existed  in 
the  temporal  fossa.  M.  Dupuytren's  patient  derived  no  benefit  from  this 
operation,  which  was  performed  for  an  erectile  tumor  in  the  concha.  M.  Wil- 
laume  was  equally  unsuccessful  with  a  subject  afiiicted  with  fungous  hematodes 
of  the  left  temple.  Mr.  Massey,  who  tied  successively  the  two  primitive 
carotids  for  an  enormous  bloody  tumor  of  the  vertex,  obtained  only  an 
incomplete  reduction  of  the  fungus,  and  was  obliged  eventually  to  have 
recourse  to  extii'pation.  In  the  case  of  an  infant  laboring  under  a  similar 
aftection  of  the  face,  Dr.  M'Clellan,  who  is  said  to  have  performed  the  opera- 
tion four  times  in  one  year,  obtained  some  advantage.  Ligature  of  the  carotid 
has  been  successful  in  forty  out  of  sixty  cases  which  have  been  published. 
It  ought,  therefore,  to  be  admitted  among  the  number  of  the  most  important 
acquisitions  to  the  surgery  of  the  present  age.  It  has  even  been  practised  for 
mere  pains  in  the  face,  but  the  operator  in  this  case  acknowledges,  in  the 
supplementary  journal,  that  the  sufferings  of  his  patient  were  not  alleviated 
by  the  operation. 

Art.  3. — Manual. 

Ligature  of  the  carotid  trunk  is  usually  an  easy  operation,  but  practitioners 
differ  a  little  as  to  the  best  manner  of  performing  it. 

1.  Ordinary  Process. — The  patient  should  be  placed  upon  his  back,  with 
the  breast  a  little  elevated,  the  neck  moderately  extended,  and  the  face  in- 
clined towards  the  unaffected  side.  Standing  on  the  same  side  with  the 
aneurism,  the  surgeon  seeks  the  anterior  edge  of  the  sterno-mastoid  muscle, 
which  is  indicated  by  a  slight  depression.  He  then,  in  order  to  discover  the 
artery  in  the  omo-tracheal  triangle,  makes  an  incision  in  the  direction  of  this 
edge  of  about  three  inches  in  length,  commencing  at  the  level  of  the  cricoid  car- 
tilage, and  terminating  near  the  sternum ;  but  he  makes  the  incision  higher  up, 
though  in  the  same  direction  and  with  the  same  ffuide,  whenever  the  malady 
permits  the  ligature  of  the  artery  in  the  omo-hyoid  triangle.  A  second  stroke 
of  the  bistoury  divides  the  platysma  and  the  cervical  aponeurosis,  and  exposes 
the  fibres  of  the  sterno-mastoid  muscle.  The  assistant  draws  the  internal 
lip  of  the  wound  towards  the  median  line.  The  operator  holds  the  external 
and  muscular  lip  outwards  by  means  of  the  index  and  middle  finger  of  the 
left  hand,  restores  the  head  to  its  natural  position,  and  afterwards  incises  the 
fibro-cellular  stratum,  which  extends  from  the  sterno-hyoid  and  sterno-thyroid 
muscles  to  the  posterior  face  of  the  sterno-mastoid,  and  passes  over  the  front 
of  the  vessels.  The  omo-hyoid  muscle  then  presents  itself  in  the  shape  of, 
a  narrow  reddish  band  ;  if  it  be  much  in  the  way  it  is  divided  upon  the  di- 
rector, but  it  is  generally  easy  to  preserve  it  by  drawing  it  to  either  side  with 
the  finger,  a  blunt  hook,  or  with  the  extremity  of  the  probe.  Above  and 
below  are  seen  the  vein  and  artery  enveloped  in  their  common  sheath,  the 
anterior  wall  of  which  incloses  the  descending  branch  of  the  ninth  pair. 
This  sheath  should  be  at  first  perforated  opposite  to  the  artery,  and  not  the  vein, 
with  the  beak  of  the  director ;  it  should  then  be  divided  upon  the  same  in- 
strument with  the  bistoury,  to  the  extent  of  an  inch  or  two.  When  the  jugular 


OPERATIVE   SURGERY.  121 

becomes  so  much  distended,  during  inspiration,  as  to  conceal  a  part  of  the 
carotid  and  embarrass  the  operator,  compression  applied  at  the  superior  angle 
of  the  wound  will  immediately  remove  this  difficulty.  The  probe,  held  like 
a  pen,  is  then  directed  between  the  two  vessels ;  one  or  two  fingers  of  the 
opposite  hand  fix  the  artery  and  prevent  it  from  slipping  towards  the  trachea, 
whilst  by  gentle  movements  to  and  fro  and  pressure  upon  the  point  of  the 
instrument,  the  operator  passes  it  along  the  posterior  surface  so  as  to  raise 
the  artery  without  violence,  and  without  touching  the  pneumo-gastric  or  sym- 
pathetic nerves  or  any  of  their  branches. 

Remarks. — In  falling  at  first  to  the  inside  of  the  sterno-mastoid  muscle, 
the  operator  incurs  the  risk  of  mistaking  its  fibres  for  those  of  the  sterno-hyoid 
and  thus  deceiving  himself;  it  is  better,  therefore,  to  commence  the  incision 
upon  its  external  surface,  some  lines  to  the  outside  of  its  edge:  it  may  after- 
wards be  easily  brought  back  to  the  ed»e  of  the  wound  in  the  integuments. 
As  the  coats  of  the  vein  are  extremely  thin  and  easily  torn  or  dividea,  and  as 
the  wound  of  such  a  vessel  is  extremely  dangerous,  it  is  of  the  highest  im- 
portance that  it  should  not  be  approached  by  the  bistoury.  For  the  rest  it  is 
easily  distinguished  by  its  black  or  bluish  color,  since  that  of  the  artery  is 
grey  or  yellow.  In  isolating  the  latter  there  are  two  dangers  to  be  avoided, 
viz.;  by  not  isolating  it  sufficiently  from  its  sheath,  the  operator  incurs  the 
risk  of  comprising  in  the  same  thread  either  the  cardiac  nerves  or  the  branch 
of  the  hypoglossal;  by  isolating  it  too  carefully,  on  the  other  hand,  it  is  pos- 
sible to  destroy  its  vasa  vasorum,  to  denude  it  of  its  cellular  tissue,  and  to 
render  it  liable  to  be  easily  cut  by  the  ligature.  It  is  scarcely  necessary  to 
observe,  that  the  vagus  nerve  is  between  the  posterior  laminae  of  this  sheath 
in  the  fossa  between  the  artery  and  the  vein.  To  recapitulate  all  the  dan- 
gers which  may  result  from  its  being  injured,  suffice  it  to  say,  that  the  parts 
should  be  sparingly  separated,  that  the  artery  should  be  tied  alone  but  with- 
out being  too  much  denuded,  and  above  all,  that  one  of  the  conditions  of  suc- 
cess in  this  operation  is  the  being  able  to  obtain  an  immediate  reunion. 

Should  the  jugular  vein  unfortunately  be  opened,  I  do  not  know  that  it 
would  be  better  to  tie  it  than  to  stop  the  hemorrhage  by  thrusting  pieces  of 
lint  into  the  wound.  Mr.  Simmons,  of  Manchester,  applied  the  ligature 
without  inconvenience  it  is  true,  and  stoppage  of  the  hemorrhage  as  above 
mentioned,  would  produce  irritation  and  render  it  necessary  to  have  the 
wound  open ;  yet  to  say  nothing  of  phlebitis,  which  is  there  the  most  to  be 
apprehended,  what  consequences  miglit  not  result  from  the  obliteration  of  so 
'voluminous  a  vein  at  the  same  time  with  the  principal  artery  of  the  head  ?  If 
the  lesion  were  trifling  it  would  be  better  to  pinch  together  the  lips,  and  en- 
-circle  them  with  a  thread  in  such  a  way  as  not  to  close  the  calibre  of  the  vessel. 
The  patient  thus  treated  by  Mr.  Guthrie  did  not  die  until  after  another  ope- 
ration, which  was  practised  some  time  after  the  first. 

2.  Process  of  M.  Sedillot. — In  order  to  fall  perpendicularly  upon  the  ar- 
tery, to  have  a  neater  incision  of  less  depth,  and  which  would  allow  an  easier 
issue  to  the  fluids,  M.  Sedillot  has  recently  invented  a  new  mode  of  tying 
the  carotid  at  the  inferior  part  of  the  neck.  His  incision,  directed  much  more 
outwards  than  in  the  ordinary  process,  falls  upon  the  external  surface  of  the 
sterno-mastoid  muscle,  of  which  he  passes  through  the  whole  thickness  be  - 
tween  the  two  points  of  origin.  The  lips  of  this  wound  being  separated  by 
an  intelligent  assistant  by  means  of  the  fingers  or  of  hooks,  the  operator  will 
find  himself  immediately  above  the  vein  and  the  artery,  and  has  nothing  to 
do  but  to  separate  them.  This  method  is  feasible  and  ingenious;  but  upon  a 
living  subject,  on  account  of  the  jugular  vein,  and  the  contractions  of  the 
16 


122  .   NEW    ELEMENTS    OF 

divided  muscle,  it  would  be,  I  apprehend,  less  easy  and  less  sure" than  the  me- 
thod before  described.  Consequently  I  am  of  opinion  that  it  ought  not  to  be 
adopted,  particularly  as  the  inconvenience  which  M.  Sedillot  desires  to  evade, 
is  scarcely  to  be  apprehended  if  the  operation  be  well  performed. 

Results  of  the  Operation* — When  the  carotid  is  obliterated,  the  circulation 
soon  completely  re-establishes  itself  in  the  corresponding  side  of  the  neck 
and  head;  the  voluminous  and  almost  innumerable  anastomoses  which  it 
forms  in  the  brain  with  the  vertebral  and  internal  carotid  of  the  opposite 
side;  those  whicLare  formed  by  the  temporal,  the  occipital s,  the  supra- 
orbitals, the  facials,  the  Unguals,  the  thyroids  both  superior  and  inferior,  and 
in  short  all  tlie  branches  of  the  external  carotid,  form  so  large  a  net- work  that 
the  operator  need  not  entertain  the  least  inquietude  on  this  point;  it  is  rather 
to  be  feared,  in  fact,  that  these  resources,  so  precious  and  so  long  neglected, 
may  Compromise  success,  by  conveying  too  great  a  quantity  of  blood  into  the 
tumors  after  the  operation.  This  is  an  inconvenience  which  actually  occurs  ; 
the  pulsations  of  the  aneurism  have  been  remarked  to  diminish  at  first,  but 
have  afterwards  returned,  and  continued  for  several  weeks.  In  the  case  of 
the  patient  operated  upon  by  Mr.  Walther,  for  an  aneurism  of  the  external 
carotid,  they  continued  two  months.  It  would  be  difficult  to  comprehend, 
if  observation  had  not  demonstrated  that  the  ligature  of  the  primitive  carotid 
should  be  able  to  eifect  the  cure  of  aneurismal  affections  of  arteries  so  remote 
as  those  for  example,  of  the  orbit,  or  of  the  face,  or  of  the  outside  of  the  cra- 
nium ;  but  it  has  been  proved  in  our  day  that  this  reflux  does  not  always 
prevent  the  resolution  of  the  morbid  tumor,  and  that  topical  refrigerants  and 
compression  suffice  to  determine  that  resolution,  or  at  least  to  hasten  it.  The 
success  obtained  by  Mr.  Mayo  by  the  aid  of  this  operation,  in  a  case  of  hemor- 
rhage by  an  ulcer  of  the  pharynx,  another  mentioned  by  Mr.  Lucke,  occasioned 
by  a  pharyngeal  or  laryngeal  hemorrhage,  the  source  of  which  could  not  be 
precisely  ascertained,  offer  still  further  proofs  of  the  correctness  of  this 
doctrine. 

B.  Internal  and  External  Cai'otids. 

Neither  the  internal  nor  the  external  carotid  is  ever  tied,  nor  tbe  occipital, 
below  the  head,  unless  they  present  themselves  in  a  wound  5  not  that  such  an 
operation  is  impracticable,  or  even  difficult,  but  because  it  i&  seldom  possible 
to  decide  whetner  the  aneurism  belongs  to  this  or  to  that  branch,  and  because 
the  same  result  may  be  obtained,  with  greater  certainty  and  less  danger,  by 
applyiuj^  the  thread  upon  the  primitive  trunk  itself.  Still  the  neck  presents 
some  other  branches  which  it  may  become  necessary  to  tie ;  the  external  max- 
illary and  the  lingual  for  example,  in  operations  upon  the  maxilla  or  the 
tongue ;  the  superior  and  inferior  thyroids  in  various  maladies  of  the  gland 
from  which  they  take  their  name ;  and  even  the  vertebral,  when  it  does  not 
enter  its  canal  until  it  arrives  at  the  fifth,  fourth,  or  third  vertebra. 

C.  Facial  or  External  Maxillary. 

To  expose  the  facial  artery  an  incision  should  be  made  of  two  inches  in 
length,  parallel  to  the  inner  edge  of  the  sterno-mastoid  muscle,  its  middle 
point  corresponding  with  the  greater  horn  of  the  thyroid  cartilage.  After 
having  divided  the  skin,  the  platysma  myoides  and  the  cervical  aponeurosis, 
removed  the  muscle,  and  exposedi  the  carotid  itself,  the  sheath  of  that  vessel 
should  be  divided  with  the  channeled  probe  on  its  anterior  side,  ascend- 


OPERATIVE   SURGERYr  123 

ing  towards  the  os-hyoides.  The  operator  will  there  find  the  origin  of 
the  external  artery  of  the  face,  which  passes  obliquely  inwards  and  upwards, 
so  as  to  gain  the  submaxillary  gland  and  the  inferior  border  of  the  jaw. 
The  same  process  is  applicable  to  the  lingual  artery,  which  is  a  little  more 
deeply  situated,  and  which  begins  by  running  horizontally  before  it  takes 
a  vertical  direction  between  the  hyoid  bone  and  the  muscles  of  the  tongue. 

D.  Thyroids. 

The  thyroid  arteries  have  been  tied  by  several  practitioners,  particularly 
Messrs.  Walther,  Heden,  Coates,  and  Langenbeck,  in  order  to  permit  the 
extirpation  of  the  thyroid,  or  to  produce  atrophy  of  that  body,  in  cases  of 
scirrhus  or  of  goitre. 

Operation. — Superior  Thyroid. — An  incision  is  made  as  above  ;  and  as 
soon  as  the  sterno-mastoid  muscle  is  withdrawn  from  the  larynx,  the  operator 
will  see,  in  the  omo-hyoid  space,  the  jugular  vein  and  the  primitive  carotid  ; 
after  having  divided  the  fibro-cellular  lamellas  which  cover  and  connect  these 
vessels,  the  thyroid  artery,  although  deeply  situated,  is  seen  exposed  between 
them  and  the  corresponding  lobe  of  the  thyroid  gland.  It  is  occasionally 
hidden  by  some  small  veins,  from  which,  however,  it  may  be  always  isolated 
with  the  channeled  sound,* and  the  more  easily  as  the  operator  approaches 
more  nearly  the  trunk  where  it  originates. 

Inferior  Thyroid. — The  incision  ought  here  to  be  made  in  the  same  way  as 
for  ligature  of  the  carotid  at  the  bottom  of  the  neck.  The  thyroid  artery, 
coming  from  the  subclavian,  passes  behind  the  internal  jugular  vein,  the 
pneumo-gastric  nerve,  and  the  carotid  artery,  ascending  afterwards  obliquely 
to  the  posterior  face  of  the  corresponding  lobe  of  the  thyroid  gland.  It  is 
commonly  concealed  by  the  superior  portion  of  the  omo-hyoid  muscle.  It  is 
necessary  then  to  divide  or  depress  that  muscle,  in  order  to  reach  the  artery 
which  is  behind  it,  between  the  trachea  or  the  oesophagus  and  the  trunk  of  the 
carotid,  taking  good  care  to  avoid  the  recurrent  nerve  and  the  descending 
branch  of  the  great  hypoglossal.  As  to  the  vertebral,  that  is  found  between  the 
longus  colli  and  the  anterior  scalenus,  outside  of  the  jugular  vein,  and  accom- 
panied by  the  phrenic  nerve  ;  it  may  consequently  be  discovered  by  the  pro- 
cess recommended  by  M.  Sedillot  for  the  ligature  of  the  carotid. 

Ligature  of  the  carotid  is  practised,  not  only  when  it  is  possible  to  apply  it 
below  the  malady,  but  sometimes  also  according  to  the  method  of  Brasdor.  It 
is  in  the  latter  case  in  fact  that  its  advantages  are  more  peculiarly  manifest, 
as  will  be  explained  in  treating  of  the  arteria  innominata. 

E.  Innominata, 

Art,  1. — Anatomical  Remarks, 

The  brachio-cephalic  trunk  is  about  two  inches  in  length,  extending  from 
the  anterior  superior  part  of  the  aortic  arch  near  its  right  extremity  to  the 
level  of  the  sterno-clavicular  articulation,  where  it  divides  into  the  subclavian 
and  the  right  carotid.  It  affects  a  slightly  oblique  direction  upwards,  and 
outwards  and  backwards.  The  pleura  lines  its  external  face;  behind,  it  rests 
upon  the  front  and  ri^ht  side  of  the  trachea ;  and  its  anterior  surface  is  crossed 
at  its  upper  part  by  the  left  subclavian  vein,  and  lower  down  by  the  descend- 
ing cava  which  runs  in  a  plane  parallel  to  it,  and  which  removes  from  it  by 


124  NEW   ELEMENTS   Of 

degrees  as  it  approaches  the  right  auricle  of  the  heart.  It  is  covered,  besides, 
only  by  the  cellular  tissue,  the  root  of  the  sterno-hyoid,  and  sterno -thyroid 
muscles,  the  superior  and  right  portion  of  the  sternum,  and  slightly  by  the 
sterno-clavicular  articulation  of  the  same  side. 

Anomaly. — This  remarkable  artery  presents  numerous  varieties ;  it  may  be 
wanting,  or  it  may  be  found  on  the  left  side;  it  may  be  longer  or  shorter,  and 
may  furnish  at  the  same  time  the  right  and  the  left  carotid,  of  which  Walther, 
Malacarne,  Scarpa,  and  others,  cite  examples.  It  may  proceed  from  the  left 
side  of  the  aorta — cross  the  whole  extent  of  the  trachea,  and  yet  be  eventually 
found  at  the  right.  In  one  instance  I  saw  it  (and  my  attention  has  been  since 
called  to  two  similar  cases  at  the  practical  school),  passed  to  the  left,  cover 
the  trachea,  make  the  circuit  of  that  canal  from  front  to  rear,  and  return, 
crossing  between  the  posterior  face  of  the  oesophagus  and  the  vertebral  column, 
to  the  level  of  the  first  rib,  there  to  be  distributed  as  usual. 

Art.  2. — Surgical  and  Historical  Remarks, 

Aneurisms  of  the  brachio-cephalic  trunk  have  been  very  frequently  observed. 
Sharp,  A.  Burns,  Messrs.  Mott,  Grsefe,  Wardrop,  Devergie,  Vosseur,  &c. 
have  made  known  several  examples.  But  spontaneous  aneurism,  either  by 
dilatation  or  by  rupture  of  the  internal  or  middle  coat,  is  nevertheless  almost 
the  only  kind  to  which  it  is  subject. 

A  case  which  came  under  the  observation  of  Pelletan,  in  wliich  the  subcla- 
vian, the  right  carotid,  and  the  extremity  of  the  innominata,  were  obliterated 
during  ife  without  producing  any  serious  inconveniences,  and  another  of  the 
same  kind  related  by  Mr.  W.  Darrah,  in  which  the  brachio-cephalic  trunk 
and  the  left  carotid  were  completely  closed,  prove  that  the  circulation  may 
be  maintained  in  the  superior  extremity,  although  the  arteria  innominata 
may  have  ceased  to  give  passage  to  the  blood.  Some  surgeons  therefore  have 
had  the  boldness  to  apply  the  ligature  upon  it  for  aneurisms  of  the  neck,  which 
were  situated  too  low  to  permit  the  tying  of  the  carotid  itself.  Dr.  Mott 
practised  it  for  the  first  time  on  the  11th  May,  1818,  upon  a  young  man 
twenty-seven  years  of  age,  and  had  at  one  time  every  reason  to  believe  that 
the  operation  would  prove  successful.  The  death  of  the  patient  did  not  take 
place  until  the  twenty -sixth  day;  the  circulation  had  been  re-established  in 
the  member,  and  on  the  twentieth  day  the  patient  was  so  far  recovered  as  to 
be  able  to  walk  about  in  the  court  of  the  hospital ;  but  at  the  commencement 
of  the  twenty-third  day  several  hemorrhages  occurred,  and  the  patient  ex- 
pired in  a  state  of  extreme  exhaustion.  There  was  no  inflammation  either  of 
the  aorta,  the  lun^s,  or  the  pleura ;  a  firm  and  adhesive  clot  filled  a  part  of 
the  innominata  below  the  ligature,  but  an  ulceration  occupying  the  other  side 
of  the  artery  had  given  rise  to  the  hemorrhages.  In  1822,  M.  Grasfe  repeated 
the  operation  of  the  professor;  of  New  York ;  his  patient  lived  fifty-eight  days, 
and  expired  in  consequence  of  having  made  some  violent  movements  which 
occasioned  profuse  hemorrhage,  and  perhaps,  as  M.  Graefe  himself  observes, 
because  it  had  been  thought  best  to  leave  a  presse-artere  in  the  wound  until 
that  time.  These  two  cases  demonstrate  that  ligature  of  this  trunk  presents 
some  chances  of  success,  and  that  it  ought  to  be  practised  when  the  art  offers 
no  other  resources,  and  when  the  death  of  the  ^'atient  appears  other  vise  in- 
evitable. We  are  now  happily  permitted  to  hope,  that  in  future  the  (  perator 
will  not  be  reduced  to  this  painful  alternative.  Ligature  between  the  tumor 
and  the  branches  of  this  artery  will  probably  henceforth  be  practised,  although, 
out  of  four  examples  which  we  possess  of  this  mode  of  procedure,  only  one 


OPERATIVE    SURGERY.  125 

can  be  said  to  have  been  decidedly  successful  in  aneurism  of  the  trachio- 
cephalic  trunk  itself.  In  following  this  mode  it  is  necessary  to  tie  at  the  same 
time  both  the  carotid  and  the  subclavian ;  this,  however,  has  never  yet  been 
done.  Mr.  Wardrop  upon  one  occasion,  when  unable  to  discover  any  pulsa- 
tion in  the  carotid,  tied  the  subclanian;  the  tumor  became  much  diminished  in 
size,  but  after  death  it  was  discovered  that  the  carotid  trunk  was  not  affected. 
Taken  together,  the  cases  of  aneurism,  whether  of  the  innominal  trunk  or 
of  the  cephalic  artery,  which  have  been  subjected  to  the  method  of  Brasdor, 
are  nine  in  number:  three  out  of  these  were  successfully  treated.  Two  other 
subjects  who  were  believed  to  have  been  cured,  eventually  died.  The  patient 
under  the  care  of  Mr.  Evans  ran  the  greatest  risk.  The  female  operated 
upon  by  Mr.  Key  died  the  same  day.  It  is  doubtful,  therefore,  whether  this 
method  will  actually  afford,  even  upon  the  carotids,  the  success  which  it  at 
first  sight  seems  to  promise.  However,  as  it  is  possible  that  an  aneurismal 
tumor  of  the  neck  may  be  so  placed  as  to  prevent  the  operator  from  acting 
upon  the  carotid  low  down,  and  there  may  be  reason  to  believe  that  the  arteria 
innominata  preserves  its  attributes  of  the  normal  state,  I  proceed  to  explain 
the  method  of  subjecting  it  to  the  ligature. 

Art.  S. — Modes  of  Operation. 

1st.  Method  of  Dr.  Mott. — Dr.  Mott  made  an  incision  of  about  three  inches 
in  length  above  the  clavicle,  extending  from  the  outer  part  of  the  sterno-mastoid 
to  the  front  of  the  trachea;  he  then  made  another  incision  of  the  same  length 
along  the  internal  edge  of  the  sterno-mastoid  muscle,  causing  it  to  fall  upon 
the  internal  extremity  of  the  first.  He  afterwards  divided  the  whole  sternal 
portion  and  a  great  part  of  the  clavicular  origin  of  the  same  muscle,  so  as  to 
turn  it  outwards  and  upwards.  After  having  pushed  aside  the  jugular  vein, 
the  subclavian,  and  some  little  veins  and  the  surrounding  nerves  with  the 
handle  of  the  scalpel,  he  discovered  the  carotid.  Seeing  that  it  appeared  dis- 
eased, he  proceeded  to  the  brachio-cephalic  trunk,  around  which  he  passed 
and  tied  a  simple  ligature  of  silk. 

2d.  M.  Graefe  performed  the  operation  in  a  similar  manner,  leaving,  how- 
ever, an  instrument  in  the  wound,  by  which  pressure  might  be  suddenly  applied 
to  the  artery  in  case  of  hemorrhage.  Mr.  Porter,  also,  in  1 829,  tied  the  carotid 
in  the  same  way,  very  low  down ;  his  patient  perfectly  recovered. 

3d.  Others  have  been  of  opinion,  I  know  not  from  what  cause,  that  it  would 
be  better  to  trepan  the  sternum ;  but  the  best  operation,  that  which  is  executed 
with  the  greatest  facility  upon  a  dead  subject,  is  the  following,  which  differs 
very  little  from  that  which  was  devised  by  Mr.  O'Connell,  of  Liverpool,  and 
which  Mr.  King  has  described  in  his  thesis : — 

4th.  The  operator,  placed  on  the  left  side,  makes  an  incision  in  the  supra 
sternal  hollow  of  the  necTt,  of  about  two  inches  in  length,  upon  the  internal 
ed^e  of  the  left  sterno-mastoid  muscle,  obliquely,  from  the  outside  to  the 
inside,  or  from  left  to  right ;  divides  successively  the  skin  and  the  subcuta- 
neous stratum,  the  superficial  layer  of  the /ascia  cervicalis,  the  adipose  cellular 
tissue  (more  abundant  below  than  above),  and  a  second  fibrous  lamina ;  af- 
terwards encounters,  behind  the  sterno-thyroid  muscle,  the  thyroideal  plexus, 
and,  when  it  exists,  the  thyroid  artery  of  Neubauer  5  removes,  or  causes  to  be 
removed  by  an  assistant,  the  last  mentioned  vessels,  or  ties  them  when  it  is 
not  possible  to  avoid  them,  and  then  arrives  at  the  trachea.  Here  the  left 
subclavian  vein  and  the  internal  jugular  of  the  opposite  side  present  themselves ; 
these  it  is  necessary  to  detach  and  push  with  caution  to  the  right  and  upwards, 


1^6  New  elements  ot 

by  means  of  the  probe.  The  operator  then  slightly  flexes  the  head  of  the 
patient,  and  endeavors,  by  directing  the  fore-finger  between  the  trachea  and 
the  right  sterno-hyoid  muscle,  to  feel  the  artery ;  having  discovered  it,  he 
first  isolates  its  concavity,  by  passing  from  front  to  rear,  between  it  and  the 
superior  cava  vein,  with  all  possible  care,  the  extremity  of  a  probe  very  slightly 
curved.  He  then  passes  this  instrument  in  the  same  manner  on  the  side 
towards  the  trachea,  in  order  to  denude  its  posterior  surface,  and  to  raise  it; 
slightly  augments  the  curvature  of  the  probe,  which  serves  to  direct  the  eyed 
stylet,  whether  directed  from  front  to  rear  and  from  right  to  left,  or  from 
rear  to  front  and  from  left  to  right,  taking  care  also  during  the  whole  of 
tiiis  procedure,  to  avoid  tearing  the  pleura,  touching  the  vagus  nerve  which 
is  left  on  the  right,  and  using  too  roughly  the  subclavian  vein  :  it  would 
perhaps  be  better,  in  fact,  upon  a  living  subject,  to  raise  or  depress  this  vein 
so  as  to  pass  the  sound  between  it  and  the  trachea,  than  to  withdraw  it  as  I 
have  above  directed.  This  process,  undeniably  more  simple,  more  rational, 
and  less  dangerous  than  any  other,  has  also  this  advantage,  that  the  same  in- 
cision would  serve  equally  well  for  the  ligature  of  either  of  the  subclavian 
arteries  within  the  scalenus,  and  of  either  of  the  carotids  at  their  origin. 

Results  of  the  Operation. — -After  the  obliteration  of  the  brachio-cephalic  trunk, 
the  blood  is  brought  back  by  the  branches  of  the  carotids  and  the  left  subcla- 
vian, which  convey  it  into  the  analogous  canals  of  the  right  side;  afterwards 
these  latter,  that  is  to  say,  the  thyroids,  the  cervicals,  &c.,  transmit  it  to  the 
supra-scapulars,  the  external  thoracics,  the  acromial,  the  common  scapular, 
the  circumflexes,- and  so  on  to  the  whole  of  the  superior  member,  which  is 
also  additionally  supplied  through  the  medium  of  the  intercostals  and  of  the 
internal  mammary.  It  is  not,  therefore,  any  deficiency  in  the  circulation  that 
is  to  be  apprehended  after  an  operation  of  this  kind,  but  rather  the  division  or 
ulceration  of  the  artery,  rendered  almost  inevitable  by  the  proximity  of  the 
heart  and  the  volume  of  the  vessel,  together  wdth  effusion  into  the  pleura,  and 
inflaiiimation  of  the  aorta,  of  the  pericardium,  and  even  of  the  cavities  of  the 
heart. 

Method  of  Brasdor. — The  application  of  the  method  of  Brasdor  in  the 
neck,  off*ers  nothing  peculiar.  If  the  aneurism  be  of  the  cephalic  artery,  that 
trunk  is  tied  in  the  omo-hyoid  triangle.  If  it  occupy  the  root  of  the  sub^ 
clavian  it  is  equally  requisite  to  tie  this  trunk,  and  necessarily  on  the  outside 
of  the  scalenic.  Supposing  the  brachio-cephalic  itself  to  be  affected,  the  ope- 
ration beyond  the  tumor  is  the  only  resource ;  and  when  the  malady  limits 
itself  to  the  carotid,  however  low  it  may  be,  this  operation  ought  to  suffice. 
Consequently,  I  see  only  two  circumstances  capable  of  rendering  the  ligature 
of  the  brachio-cephalic  trunk  necessary.  1st.  When  an  aneurismal  tumor, 
sufficiently  developed  to  reach  to  the  origin  of  the  secondar^^  carotids,  yet 
leaves  sufficient  space  above  the  sternum  to  admit  of  an  operation,  but  wlien 
the  trunk  without,  being  dilated,  is  found  diseased  to  its  origin.  2d.  When, 
the  subclavian  only  being  affected,  the  alteration  of  its  coats  is  prolonged  too 
far  towards  its  root  to  allow  of  its  being  tied,  and  when  it  is  not  certain  that 
the  method  of  Brasdor  would  be  successful.  It  is,  therefore,  an  operation 
v/hich  ought  seldom  to  be  performed,  and  which  is  rarely,  if  ever,  indispens- 
able. 

Aneurisms  have  also  been  seen  to  develop  themselves  upon  other  parts  of 
the  body.  Pelletan  saw  upon  the  summit  of  the  shoulder  a  pulsatile  tumor, 
which  he  took  for  an  aneurism  of  the  acromial  artery.  Ruysch  and  A.  Petit, 
Weltin  and  M.  Briot,  saw  each  an  example  on  the  chest,  in  the  passage  of 
the  intercostals.     Thinking  to  open  an  abscess,  Desault  plunged  his  bistoury 


OPERATIVE   SURGERY.  127 

mto  an  aneurism  of  one  of  the  thoracic  arteries,  and  M.  Floret,  in  his  thesis, 
speaks  of  a  case  in  which  the  first  four  intercostals  offered,  from  space  to  space, 
a  great  number  of  true  aneurisms.  Supposing  these  facts  not  to  belong  to 
other  maladies,  they  are  involved  in  what  has  been  already  said  of  the  axillary 
artery,  and  in  the  discussion  of  the  ligature  of  the  intercostal  artery,  which  will 
be  taken  up  under  the  article  empyema* 


CHAPTER   III. 


NiEVI    MATERNI. 


Erectile  Tumors. — Left  to  themselves,  the  sanguineous  tumors,  which  have 
their  origin  in  a  connatural  blemish,  and  the  nature  of  which  modern  practi- 
tioners have  caused  to  be  better  understood  than  formerly,  sometimes  acquire 
considerable  volume.  Lassus  met  with  one  which  was  as  large  as  the  head 
of  an  adult,  and  M.  Latta  extirpated  another  which  did  not  weigh  less  than 
fourteen  ounces,  although  it  occurred  upon  an  infant  of  two  years.  As  the 
organization  is  not  able  to  effect  the  removal  of  these  aneurisms,  prudence 
dictates  that  they  should  never  be  neglected  when  they  begin  to  increase  with 
any  degree  of  rapidity,  or  when  they  have  already  attained  a  considerable 
size.  The  same  remarks  apply  to  accidental  erectile  tumors  of  every  species, 
which  have  their  seat  either  in  the  venous  or  arterial  system,  and  which  may 
manifest  themselves  at  any  period  of  life. 

1st.  Astringent  Remedies^  styptics,  or  refrigerants,  although  frequently 
employed  by  the  ancients,  and  recommended  by  Abernethy,  who  by  these 
means  in  the  course  of  some  months  caused  the  disappearance  of  an  erectile 
tumor  of  the  orbit,  are  yet  seldom  alone  found  sufficient,  and  ought  never  to  be 
tried  but  in  cases  where  the  tumor  is  too  small  to  excite  much  apprehension. 

2d.  Compression. — Although  it  is  not  a  resource  upon  which  the  operator  can 
place  much  reliance,  compression  has  jet  succeeded  often  enough  to  justify 
its  use  whenever  the  volume  and  situation  of  the  tumor  permit.  Batteman,  it 
is  true,  speaks  unfavorably  of  it,  and  says  that  it  exasperates  the  malady; 
but  it  has  been  used  with  incontestable  success  by  Burns,  Abernethy,  and  Mr. 
Randolph.  M.  Roux  cured  one  of  his  children  by  these  means,  and  M.  Boyer, 
who  hardly  dared  to  recommend  it,  cites  a  case  of  naevus  of  the  lip  cured 
by  the  tenderness  of  the  mother,  who  had  the  constancy  to  press  her  finger 
seven  or  ei^ht  hours  a  day  for  several  months  below  the  nose  and  across  the 
lip  of  her  cnild.  In  the  case  of  a  child  a  few  months  old,  troubled  with  a 
small  erectile  tumor  in  front  of  the  breast,  M.  Roux,  after  having  renounced 
compression,  saw  the  swelling  decrease  and  eventually  disappear.  Styptics 
and  astringents  may  be  also  very  advantageously  associated  with  compres- 
sion. 

3d.  Caustics. — Caustic  plasters,  or  simple  escharotics,  vaunted  by  Callisen, 
Wardrop,  &c. ;  nitric  acid,  still  used  in  England;  nitrate  of  silver,  recom- 
mended by  Mr.  Guthrie  when  the  najvus  is  small  or  not  very  thick  ;  and  the 
multiplied  vaccine  punctures  praised  by  M.  Cumin,  are^evidently  insufficient, 


1^8  NEW   ELEMENTS   OF 

except  in  a  very  limited  number  of  cases.  The  hot  iron  which  was  success- 
fully used  by  M.  Maunoir,  and  all  active  caustics,  when  they  do  not  com- 
pletely extirpate  the  evil,  are  sometimes  attended  v/ith  the  most  serious 
consequences,  such  as  consecutive  hemorrhage,  and  acceleration  of  the 
progress  of  the  tumor.  The  loss  of  substance,  the  suffering,  and  the  deformed 
cicatrices  which  follow  the  employment  of  these  means,  are  enough  in  feet 
to  prevent  every  prudent  and  humane  practitioner  from  having  recourse  to 
such  means  when  any  other  aflford  a  chance  of  relief. 

4th.  Ligature  of  the  Tumor. — It  is  not  so  with  the  ligature,  which  may 
be  employed  in  several  different  ways.  In  one,  that  of  Mr.  White,  the 
operator  draws  the  tumor  towards  himself  with  one  hand  in  order  to  re- 
move it  from  the  subjacent  tissues,  while  with  the  other,^he  passes  a  needle 
with  a  double  thread  through  the  skin  behind  the  fungus,  which  latter  may 
afterwards  be  easily  compressed  or  strand-ed  by  bringing  the  extremities  of 
the  ligatures  together,  and  tying  them,  nie  one  above  and  the  other  ])elow. 
Mr.  Itawrence,  who  is  from  experience  opposed  to  cauterization,  has  pub- 
lished three  observations,  sufficiently  conclusive,  in  favor  of  the  practice  of 
Mr.  White,  which  practice  has  also  been  adopted  by  Messrs,  Lyne,  Carlisle, 
Guthrie,  and  for  a  long  time,  says  the  latter,  by  the  surgeons  of  the  Westmin- 
ster Hospital,  Bv  another  mode  of  operation  no  tissue  is  pierced,  but  the 
operatorcontentshimself  with  embracing  circularly  and  with  a  strong  ligature 
the  base  of  the  naevus.  This  method  is  not  confined  to  pediculated  tumors.. 
M.  Gensoul,  of  Lyons,  according  to  M.  Penod,  still  uses  it  with  success 
whenever  the  base  of  the  tumor  is  not  immoderately  large,  and  the  skin  which 
surrounds  it  is  sufficiently  flexible  and  movable  to  yield  without  difficulty 
to  the  action  of  the  ligature.  But  there  are  many  cases  in  which  tlie  ligature 
is  totally  inapplicable  by  either  method.  Finally,  Mr.  Keate,  and  after  him 
Messrs.  Lawrence  and  Brodie,  adopted  a  third  mode  of  procedure,  which 
consists  in  passing  a  single  straight  needle,  if  the  ncevus  is  small,  or  two  needles 
crossed  under  the  tumor  if  it  is  large ;  the  tissues  are  afterwards  strangulated 
by  mean?  of  a  circular  ligature,  sufficiently  tight,  placed  between  the  needles 
and  the  healthy  skin. 

6th.  Ligature  of  the  Arteries. — Comparing  erectile  tumors  to  aneurisms,  it 
was  natural  to  seek  a  cure  by  ligature  of  the  arteries  upon  which  they  were 
seated.  Pelletan  was  the  first  to  try  this  method  in  a  case  of  varicose  tumor^ 
which  occupied  the  lateral  and  rather  posterior  part  of  the  cranium;  he  was 
not  able  however  to  discover  the  occipital,  and  his  operation  was  consequently 
incomplete.  I  have  already  stated  that  Messrs.  Travers,  Dalrymple,  and 
Arendt,  each  cured  an  erectile  tumor  of  the  eye  by  tying  the  carotid  of  the 
same  side,  and  that  Dr.  Pattison  was  equally  successful  in  the  case  of  a  young 
man  affected  with  a  similar  malady  behind  the  cheek.  M.  Roux  also  derived 
some  advantage  from  tying  one  of  the  facial  arteries  for  a  fungus  of  the  lips. 
Other  practitioners,  on  the  contrary,  have  been  completely  unsuccessful  in 
their  operations  by  this  method.  Hodgson  was  unable,  even  by  tying  both  ar- 
teries of  the  fore-arm,  to  arrest  the  progress  of  a  tumor  of  this  kind  upon  the 
thumb.  It  was  in  vain  also  that  M.  Dupuytren  tied  the  carotid  for  an  erec- 
tile mass  of  the  concha  of  the  right  ear.  For  some  days  appearances  pro- 
mised success ;  but  the  tumor  soon  returned  to  its  former  state.  It  would  be 
wrong  therefore  to  consider  this  method  as  an  unfailing  resource. 

6th.  Okcular  incision  of  the  base  of  the  tumor. — Dr.  Physick  adopted  a  dif- 
ferent process,  and  in  some  cases  followed  it  with  complete  success.  Instead 
of  successively  exposing  all  the  arterial  branches  which  supply  an  erectil« 
tumor,  he  made  an  incision  round  the  base  or  root,  and  thus  in  some  degree 


aPERAxfVE    SURaERY/  129 

isolated  it  from  the  living  tissues  and  the  canal,  which  supplied  it  with  the 
fluids.  By  imitating  this  method,  Mr.  Lawrence  cured  the  sanguine  tumor 
of  the  thumb,  which  has  been  mentioned  as  resisting  the  efforts  of  Mr.  Hodg- 
son. In  following  this  mode  of  treatment  it  is  necessary  that  the  incision  be 
made  upon  healthy  tissues,  and  that  it  should  comprehend  the  whole  thickness 
of  the  skin,  the  cellular  stratum,  the  arteries,  and  the  veins,  without  being  ar- 
rested by  the  nervous  twigs,  unless  they  have  some  important  duty  to  fulfil,  in 
the  part.  Each  arterial  branch  is  tied  as  it  is  divided ;  and  to  prevent  immediate 
reunion,  lint  or  small  pieces  of  linen  are  placed  between  the  lips  of  the  wound. 

6th.  Extirpati&n  is  unquestionably  the  most  efficacious  resource,  but  it  can- 
not be  always  called  in.  It  is  practised  in  three  different  ways:  1st.  By 
conforming  to  the  rules  laid  down  for  the  extirpation  of  all  other  kinds  of 
tumor.  2d.  By  removing  at  the  same  time  the  morbid  tumor  and  the  part 
which  supports  it.     3d.  At  two,  three,  or  a  greater  number  of  operations. 

The  first  method,  which  is  most  generally  adopted,  which  is  so  strenuously 
insisted  upon  by  J.  L.  Petit,  and  which  Messrs.  J.  Bell,  Wardrop,  Boyer, 
Roux,  Dupuytren,  Maunoir,  and  Dorsey,  follow  from  preference,  requires  that 
the  operator  should  encroach  a  little  upon  the  healthy  parts,  if  he  would  pre- 
vent the  reproduction  of  the  malady.  In  order  as  much  as  possible  to  avoid 
hemorrhage,  the  arteries  should  be  carefully  tied  as  they  are  opened  during 
the  operation;  by  neglecting  this  precaution,  or  availing  himself  of  it  too  tar- 
dily, Mr.  Wardrop  had  the  misfortune  to  see  an  infant  expire  under  his  bands. 
A  little  girl  also,  operated  upon  by  M.  Roux,  fell  immediately  afterwards  into 
a  syncope  which  lasted  four  hours.  The  second  mode  of  extirpation  never 
is  and  never  ought  to  be  employed,  excepting  when  it  is  impossible  to  make 
use  of  the  others,  or  when  the  tumor  is  seated  upon  a  small  and  unimportant 
part  of  the  body,  a  finger  or  toe  for  example.  The  merit  of  the  third, 
described  in  the  work  of  Dr.  Dorsey,  is  due  to  Professor  Gibson,  of  Philadel- 
phia. Fearing  the  loss  of  too  much  blood  in  the  case  of  a  woman  aged 
twenty-five,  and  in  whose  person  almost  the  whole  of  the  right  side  of  the 
head  was  involved  in  the  disease,  this  gentleman  resolved  upon  performing 
the  operation  at  three  several  times.  On  the  first  occasion  he  incised  exactly 
a  third  of  the  tumor,  promptly  secured  the  vessels,  and  kept  the  wound  open. 
At  the  expiration  of  a  few  days,  a  second  incision,  made  with  the  same  pre- 
cautions as  the  first,  circumscribed  another  third  of  the  fungous  mass,  and  a 
week  afterwards  the  extirpation  of  the  whole  was  effected.  The  patient  found 
herself  completely  recovered  at  the  end  of  thirteen  or  fourteen  days. 


CHAPTER  IV. 

OF    VARIX. 


Historical. — Although  varices  do  not  constitute  a  malady  essentially  dan 
gerous,  they  are  yet  sufficiently  so  to  demand  the  aid  of  surgery.     The  pain, 
the  deformity,  and  the  ulcers  which  they  cause  or  maintain,  together  with 
17 


130  NEW   ELEMftNTg  OF 

the  hemorrhages  which  they  sometimes  originate,  sufficiently  explain  the  soli- 
citude of  which  they  have  always  been  the  subject.  The  ancients,  who  em- 
ployed against  them  topical  remedies,  astringents,  desiccatives,  and  resolv- 
ents, used  also  the  compressive  bandage,  which  they  applied  upon  the  whole 
extent  of  the  member,  pretending  also  to  forward  its  action  by  means  of  in^ 
ternal  medications.  Then^  as  now,  those  different  modes  of  treatment  were 
mereljr  palliatives.  To  obtain  a  radical  cure  it  was  necessary  to  perform  an 
operation.  Sometimes,  however,  they  contented  themselves,  like  Hippocrates, 
and  as  it  was  recommended  even  by  Pare  and  Dionis,  with  puncturing  the 
varix,  and  incising  it  length-wise  (more  extensively  than  in  phlebotomy),  in 
order  to  empty  it  of  the  fluid  and  coagulated  blood.  According  to  Avicenna, 
the  vein  should  be  taken  up  with  hooks  upon  two  points  distant,  three  fingers' 
breadth  from  each  other,  then  tied  with  a  good  silk  thread,  and  cut  across  in 
the  interval ;  after  which  the  ligature  should  be  removed  from  the  inferior 
end,  and  the  blood  forced  out  as  much  as  possible  with  the  hand  :  the  superior 
extremity  of  the  vessel,  and  the  whole  extent  of  the  wound  is  then  cauterized 
with  arsenics  or  a  red  hot  iron. 

Albucasis  recommends  that  a  bandage  should  be  placed  upon  the  thigh 
as  far  as  the  knee,  and  that  the  vein  should  be  opened  and  cut  in  two  or  three 
places,  in  order  that  as  much  blood  may  be  forced  out  as  possible. 

Others  extirpated  the  varices  after  having  incised  them ;  this  mode  of  pro- 
cedure, at  least,  seems  to  have  been  counselled  by  Ali  Abbas.  Celsus  speaks 
of  cauterization  and  extirpation  ;  and  every  one  who  has  read  Plutarch,  knows 
that  the  stoic  Marius,  who  had  been  treated  in  this  way,  after  having  been 
relieved  of  varices  which  had  covered  the  whole  of  one  leg,  refused  to  present 
the  other  to  the  surgeon,  which  was  in  the  same  condition,  saying  that  the 
remedy  was  worse  than  the  disease.  Dionis  is  astonished  tliat  the  ancients  did 
not  make  use  of  the  heated  iron  to  extirpate  varicose  veins,  as  upon  horses,  and 
that  they  should  have  contented  themselves  with  the  potential  cautery.  Ac- 
cording to  this  author,  the  rolled  bandage  applied  in  the  form  of  buskins  is 
preferable  to  all  other  means.  It  was  also  the  advice  of  a  great  many  surgeons 
of  our  own  day,  when  an  attempt  was  made  some  years  ago  to  simplify  the 
operations  of  the  Greeks  and  Arabs. 

1st.  Excision  is  rarely  necessary,  and  ought  never  to  be  practised,  as  has  been 
justly  remarked  by  Boyer,  excepting  in  cases  of  those  large  tumors  or  varicose 
lumps  which  are  sometimes  seen  on  the  leg,  and  even  then  it  is  not  certain, 
that  it  might  not  be  beneficially  replaced  by  other  and  simpler  means. 

2d.  Ligature,  so  clearly  and  carefully  described  by  Dionis,  has  been  frequent 
Ij^'  practised  by  Sir  Ev.  Home,  in  England,  and  by  Beclard,  in  France.  A  lon- 
gitudinal fold,  says  M.  Briquet,  who  reports  the  results  obtained  by  Beclard, 
IS  made  in  the  skin,  and  divided  to  its  base  upon  a  point  of  the  member  where 
the  vein  is  single  and  most  superficial.  The  operator  then  passes  beneath 
the  vein  a  needle  stylet  carrying  a  thread,  and  after  having  tied  the  ligature 
divides  the  vessel  immediately  above.  He  may  also  divide  the  skin  and  the 
vein  at  a  single  stroke,  and  afterwards  tie  the  inferior  extremity  of  the  venous 
canal,  by  seizing  it  with  pincers.  The  lips  of  the  wound  are  closed  by  means 
of  bands  or  fillets,  and  the  patient  should  be  kept  in  a  state  of  perfect  rest. 
Messrs.  Smith,  Travers,  and  Oulknow,  have  imitated  the  treatment  of  Mr. 
Home,  but  not  with  such  constant  success.  Dr.  Physick  is  said  to  have  had 
reason  to  praise  it,  and  Dr.  Dorsey,  by  whom  it  was  frequently  tried,  aflirms 
that  he  never  saw  it  produce  any  serious  or  dangerous  results.  Out  of  sixty 
operations  performed  by  Beclard,  at  La  Pitie,  only  two,  says  M.  Briquet, 
were  attended  with  a  single  unfavorable  symptom.    It  is  diflicult,  in  fact,  to 


OPERATIVE   SURGERt.  131 

comprehend  how  this  ligature,  properly  applied,  can  be  attended  with  great 
pain,  and  followed,  as  has  been  pretended,  by  tetanus;  or  why  inflammation  of 
the  vein  towards  the  heart  should  be  produced  by  this  any  more  than  by  any 
other  method  which  requires  the  obliteration  of  the  vessel.  The  process  of 
M.  Gagneles,  cited  by  M.  Marchal,  and  which  consists  in  passing  a  ligature 
round  the  vein  by  a  simple  puncture  of  the  skin,  would  only  render  the  ope- 
ration more  difficult  without  avoiding  any  thing  that  could  be  apprehended. 

3d.  Incision. — Not  wishing  to  confine  himself  to  simple  incision,  M.  Riche- 
rand  thought  that  by  incising  parallel  with  the  member,  and  to  a  great  extent 
the  tortuosities  or  varicose  knots,  he  should  more  certainly  succeed.  I  have 
seen  this  method  followed  several  times  at  St.  Louis's  hospital  with  perfect 
success,  and  I  have  myself  applied  it  with  advantage  on  different  occasions  j 
but  the  only  patient  upon  whom  I  practised  it  at  La  Pitie,  died  on  the 
ninth  day.  The  operator  should  choose  that  part  of  the  member  where  the 
varices  are  most  numerous,  and  should  incise  them  deeply,  and  to  the  extent 
of  four,  five,  six,  and  even  eight  inches.  After  having  forced  out  the  clotted 
blood  by  pressure,  he  should  fill  the  wound  with  lint  smeared  with  cerate. 
The  first  dressing  takes  place  at  the  expiration  of  three  or  four  days.  After 
that  time  the  venous  orifices  are  closed,  and  the  wound  may  be  smoothly 
dressed,  like  all  other  simple  solutions  of  continuit3^  Beclard  practised  this 
method  upon  some  occasions,  and  as  successfully  as  M.  Richerand.  These 
long  incisions,  however,  create  great  alarm  in  the  mind  of  the  patient,  and 
upon  mature  reflection  there  appears  to  be  little  necessity  for  them. 

4th.  Would  not  the  division  of  a  single  and  selected  point,  or  of  different 
branches,  when  it  is  not  desirable  to  act  upon  the  principal  trunk  of  the  vein, 
be  evidently  preferable.  I  have  practised  it  thirty-seven  times  at  the  hospital 
St.  Antoine,  and  at  La  Pitie.  One  of  the  patients  it  is  true  died  on  the 
twelfth  day,  but  he  evinced  the  most  extraordinary  ataxic  symptoms,  which 
could  only  be  attributed  to  the  state  of  fear  and  inconceivable  moral  con- 
straint to  which  he  had  brought  himself  before  the  operation.  We  did  not 
meet  with  any  traces  of  phlebitis  above  the  wound,  aiid  that  which  existed 
below  bore  no  proportion  to  the  progress  of  the  fatal  symptoms.  Nothing  can 
be  more  simple  than  such  an  operation.  The  vein  is  at  first  taken  up  in  a 
fold  of  the  skin,  and  a  straight  bistoury,  very  sharp,  passed  across  the  base 
of  this  fold  then  divides  it  at  a  single  stroke.  The  operator  thus  successively 
incises  (when  it  is  not  thought  necessary  to  divide  the  trunk  of  the  saphena 
itself  near  the  knee)  all  those  veins  which  are  at  all  voluminous,  and  which 
seem  to  take  their  root  in  the  middle  of  every  knot  of  varices.  The  blood 
immediately  issues  in  abundance,  and  is  suffered  to  flow  for  a  longer  or 
shorter  time,  according  to  the  strength  of  the  patient,  after  which  the  wound 
is  filled  with  balls  of  lint,  and  covered  with  a  cerated  pledget,  and  with  soft 
and  flexible  compresses.  The  whole  oudit  afterwards  to  be  kept  in  place  by 
a  rolled  bandage  moderately  tight.  If  immediate  union  should  take  place, 
the  continuity  of  the  vein  might  re-establish  itself,  and  thus  cause  the  failure 
of  the  operation. 

Hoping  to  avoid  phlebitis  with  greater  certainty,  Mr.  Brodie  contented  him- 
self with  dividing  the  veins  transversely,  making  only  a  simple  puncture 
through  the  skin.  He  used  a  bistoury  with  a  narrow  blade,  and  a  little  con- 
cave on  its  edge.  The  point  of  the  instrument  is  at  first  passed  through  the 
integuments  on  one  side  of  the  vein  ;  it  is  then  directed  flatly  between  that 
vessel  and  the  skin ;  and  when  it  reaches  the  opposite  side  the  edge  is  turned 
backward  and  the  wrist  of  the  operator  is  raised  in  such  a  way  as  in  drawing 
back  the  bistoury  completely  to  divide  the  vein.    Mr.  Carmichael  and  other 


132  NEW    ELEMENTS   OF 

practitioners,  have  highly  praised  this  process;  a  patient,  also  treated  in  this 
way  in  my  presence  by  M.  Bougon,  found  himself  perfectly  relieved ;  but 
Beclard,  who  practised  it  at  La  Pitie,  says  that  it  does  not  offer  any  greater 
security  against  phlebitis  or  phlegmonous  erysipelas  than  the  ordinary  incision, 
and  besides,  that  it  sometimes  fails  to  obliterate  the  vein. 

5th.  Resection^  which  was  practised  so  early  as  the  times  of  Ali  Abbas, 
Avicenna,  Albu-Kasem,  &c.  have  given  to  M.  Lisfranc  more  satisfactory 
results  than  the  simple  incision.  By  retracting  under  the  lips  of  the  wound, 
the  two  extremities  of  the  vein  immediately  cease  to  be  subject  to  the  influ- 
ence of  the  external  air,  the  action  of  which,  according  to  Mr.  Brodie  and 
Lisfranc,  is  a  powerful  cause  of  phlebitis. 

Comparison. — To  obliterate  veins  which  have  become  varicose,  is  the  avowed 
and  incontestable  aim  of  the  operator;  yet  it  cannot  be  denied  that  the  liga- 
ture, with  or  without  division,  the  section  transverse  or  longitudinal,  exposed 
or  under  the  skin,  that  even  extirpation  itself,  as  well  as  cauterization  with 
potash  or  the  red  hot  iron,  are  insufficient  to  effect  this  result. 

It  only  remains,  therefore,  to  decide  which  of  these  means  may  be  most 
easily  executed,  involves  the  least  danger,  and  causes  the  least  pain.  In  my 
opinion  the  transverse  incision  of  the  vein  comprehending  the  skin,  promises 
all  the  advantages  of  the  other  modes,  together  with  all  desirable  simplicity. 
It  is  performed  in  the  twinkling  of  an  eye ;  the  youngest  student  may  per- 
form it  with  ease ;  the  pain  is  trifling,  and  the  whole  operation  differs  very 
little  from  an  ordinary  bleeding.  The  ligature,  so  much  vaunted  by  Hone 
and  Beclard,  is  only  calculated  to  render  the  operation  more  difficult  and 
dangerous.  And  why  should  the  practitioner  expose  himself,  by  imitating 
Mr.  Brodie,  to  the  probability  of  leaving  the  vein  partially  divided,  and 
seeing  the  blood  effused  into  the  subcutaneous  stratum,  forming  the  point  of 
departure,  the  nucleus  of  a  phlegmon  or  an  abscess  ?  Ought  the  division  of  the 
skin  ever  to  cause  uneasiness  after  such  an  operation  ?  And  who  does  not  now 
know,  that  the  action  of  the  air  upon  the  veins  is  incapable  of  producing  any 
of  those  terrible  effects  which  have  been  so  gratuitously  ascribed  to  it?  As 
to  the  long  and  deep  incisions  recommended  by  M.  Richerand  and  formerly 
by  J.  L.  Petit,  and  the  excision  of  Celsus  as  practised  by  M.  Boyer,  they 
ought  not  to  be  thought  of,  excepting  in  cases  where  varices  form  painful 
masses,  and  have  degenerated  into  tumors  which  will  yield  to  nothing  but 
extirpation. 

But  after  all,  is  it  right  to  resort  to  the  most  easy  and  least  painful  of 
these  operations  ?  Does  not  humanity  revolt  at  the  idea  of  phlegmons,  ery- 
sipelas, purulent  collections,  phlebitis,  and  all  the  other  accidents  which 
have  more  than  once  resulted  from  them,  in  cases  where  the  varices  did  not 
at  all  endanger  the  lives  of  the  patient?  Why  should  not  the  operator  con- 
tent himself  with  a  laced  stocking  or  rolled  bandage,  which  would  maintain 
the  parts  in  a  proper  position  without  any  risk  to  the  patient?  These  objec- 
tions appear  to  me  more  specious  than  solid.  It  is  not  perfectly  correct  to 
say  that  varices  are  unattended  with  danger.  Chaussier  cites  an  example  of 
a  ruptured  varicose  vein  in  the  case  of  a  pregnant  female,  which  quickly 
produced  death.  Similar  instances  have  been  mentioned  by  Murat,  Gri- 
maud,  Amussat,  Rees,  La  Croix  and  Lebrun;  and  one  case  fell  under  my 
own  observation.  The  death  of  Copernicus  is  attributed  to  such  an  accident. 
The  bandages  or  gaiters  which  are  so  earnestly  recommended,  require  care 
and  precaution  in  their  use,  and  often  cause  excoriations  upon  different  points 
of  the  member,  so  that  they  are  not  entirely  without  their  inconveniences. 
Finally,  those  ulcers  which  it  is  so  difficult  to  cure,  and  which  almost  always 


OPERATIVE    SURGERY.  133 

return  when  the  patients  make  the  least  eieertion — which  are  the  despair  of 
the  surgeon  and  the  misery  of  those  who  are  so  unfortunate  as  to  be  afflicted 
with  them*^will  any  one  say  that  they  never  produce  death,  that  they  are 
never  the  cause  of  any  serious  maladies,  and  that  they  never  make  it  neces- 
sary to  amputate  the  limb  ? 

On  the  other  side,  if  it  be  true  that  after  the  incision  of  the  veins  phlegmo- 
nous inflammations  and  engorgements  of  various  kinds  sometimes  take  place, 
that  even  phlebitis  may  manifest  itself,  it  is  not  less  true  that  all  these  ac- 
cidents are  very  rare,  that  they  are  generally  easily  remedied,  and  that  above 
all,  they  may  be  almost  always  prevented,  if,  after  a  simple  incision  such  as 
I  have  (described,  the  operator  takes  the  precaution,  when  there  is  reason  to 
fear  inflammation,  to  envelop  the  member  from  its  extremity  to  its  root  with 
a  compressive  bandage.  It  should  always  be  remembered,  however,  that 
these  operations  cannot  be  counted  upon  as  infallible,  and  that  they  ought  not 
to  be  practised  excepting  in  cases  where  the  deep-seated  veins  are  in  their 
natural  state,  at  the  demand  of  the  patient,  and  when  the  varices  have  proved 
capable  of  impeding  the  functions  of  the  injured  part,  or  of  compromising  the 
general  health. 


TITLE  II.— OF  AMPUTATIONS. 
CHAPTER   I. 

AMPUTATIONS  IN  GENERAL. 

Amputation,  the  last  resource  and  extreme  eflTort  of  surgery,  ought  never 
to  be  practised  but  in  despair  of  other  remedies.  It  is  of  a  doubly  serious 
nature,  inasmuch  as  it  endangers  life  and  mutilates  the  body.  Even  when 
amputation  seems  necessary,  the  skillful  practitioner  will  never  forget  that 
the  end  of  surgery  is  to  preserve,  not  to  destroy ;  and  that  he  will  be  entitled 
to  greater  credit  for  preserving  one  limb,  than  he  would  for  making  with  all 
imaginable  address  a  great  number  of  amputations  :  on  the  other  hand,  it  is 
better  to  sacrifice  one  part  than  to  lose  the  whole — to  live  with  three  mem- 
bet;s,  than  to  die  with  four. 

The  painful  necessity  of  cutting  away  the  whole  or  a  portion  of  one" of  the  ap- 
pendages of  the  trunk,  has  been  felt  and  acknowledged  from  the  earliest  years 
of  surgical  experience.,  The  mortification  and  natural  and  accidental  dropping 
off  of  the  members,  which  must  have  been  observed  among  the  ancients,  as  well 
as  among  ourselves,  doubtless  suggested  the  first  idea  of  amputation.  It  was 
rarely,  however,  that  they  decided  upon  its  execution.  The  Hippocratists 
give  very  few  details  upon  this  subject.  Galen  himself,  elsewhere  so  prolix, 
scarcely  mentions  it,  and  it  is  not  until  we  come  to  Celsus  that  we  find  a 
description  of  the  operation  somewhat  more  at  length.  This  negligence  on 
the  part  of  the  ancient  authors,  is,  however,  easy  to  be  understood.  Know- 
ing little  of  the  circulation  of  the  blood,  they  were  unable  to  guard  against  he-» 


*1S4  NEW   ELEMENTS   OF 

morrhages,  and  were  constantly  impeded  by  their  fear  that  death  would  result 
from  the  cutting  away  of  a  living  portion  of  the  body.  Again,  before  the  dis- 
covery of  gunpowder,  wars  were  less  murderous  in  their  nature,  and  rendered 
amputation  also  less  frequently  indispensable. 

In  the  beginning  they  were  obliged  to  content  themselves,  as  is  recom- 
mended by  Paulus  jEgineta,  with  cutting  off'  the  dead  parts  without  touching 
the  living  tissues,  and  this  practice,  which  was  continued  by  the  surgeons  of 
the  middle  age,  is  still  recommended  by  Fabricius  de  Aquapendente.  Although 
the  old  surgeons  scarcely  speak  of  amputation  excepting  in  cases  of  gangrene 
or  erosive  ulcers,  it  is  nevertheless  certain  that  they  early  admitted  the  ne- 
cessity of  dividing  the  tissues  above  the  mortified  parts.  Celsus  fomaally 
prescribes  it,  and  Achigenes,  of  Apamea,  appears  frequently  to  have  executed 
it.  Always  terrified  at  the  hemorrhages  which  ensued,  they  imagined  a  thou- 
sand means  (now  forgotten)  of  preventing  it,  and  the  operation  became 
eventually  so  terrible  to  them,  that  many,  rather  than  practise  it,  preferred 
leaving  the  patient  to  certain  death.  In  performing  amputation,  some  com- 
menced by  tying  the  vessels  by  means  of  a  ligature  passed  through  the  whole 
thickness  of  the  limb,  or  by  compressing  the  limb  itself,  and  afterwards 
sprinkling  it  with  cold  water.  The  operation  being  terminated,  the  surface 
of  the  stump  was  burnt  with  a  red-hot  iron.  Others,  after  the  manner  of  Al- 
bucasis,  incised  the  soft  part  with  a  knife  heated  to  whiteness,  and  afterwards 
cauterized  with  boiling  oil.  This  latter  author,  less  timid  than  is  generally 
believed,  says :  *'  When  it  is  not  possible  to  preserve  the  limb,  it  should  be 
cut  away  up  to  the  healthy  part,  since  the  loss  of  one  member  is  better  than 
the  death  of  the  whole  body."  Avicenna,  according  to  the  celebrated  Guy, 
recommends  that  amputation  should  be  performed  a  little  above  the  diseased 
tissues,  **  at  the  place  to  which  hardness  and  pain  are  discovered  on  the  in- 
troduction of  the  tent."  In  practising  this  operation,  the  member  is  at  first 
firmly  held  by  the  assistants ;  the  soft  parts  are  then  divided  to  the  bone  with 
a  razor,  and  the  surface  of  the  wound  is  covered  with  a  compress  in  order 
that  it  may  not  be  lacerated  by  the  saw;  the  surface  of  the  stump  is  after- 
wards cauterized  with  a  hot  iron  or  boiling  oil.  *'  As  to  myself,"  says  Guy, 
of  Chauliac,  "  I  envelope  the  whole  of  the  mortified  member  in  a  plaster,  and 
suffer  it  to  remain  in  this  state  until  it  falls  of  itself.  This  is  more  honor- 
able to  the  surgeon  than  amputation ;  for  if  the  limb  be  taken  off",  tliere  always 
rankles  in  the  heart  of  the  patient  a  belief  that  it  might  perhaps,  have  been 
preserved."  In  despite  the  efforts  of  Pare  to  introduce  the  practice  of  tying 
the  vessels  after  amputation,  Pisray,  Dionis,  and  Rossi,  still  preferred  the  ac- 
tual cautery.  But  surgery  has  long  since  done  justice  to  this  barbarous  prac- 
tice. It  appears  that  from  the  time  of  Hippocrates  and  Galen  amputation 
was  admitted  as  a  surgical  resource,  although  Heliodorus,  who  lived  between 
those  two  authors,  endeavored  to  proscribe  it. 

Amputation  was  also  practised  by  the  Arabs  ;  for  it  is  said  in  their  books, 
that  if  the  corruption  extends  to  the  joint,  it  will  be  necessary  to  cut  into  the 
articulation  itself  with  the  razor  or  other  instmments,  without  using  the  saw. 
The  method  of  Celsus,  although  defended  by  Gersdorf  of  Strasbourg,  by 
Cervia  a  long  time  before,  by  Maggi  and  some  others  afterwards,  was,  not- 
withstanding, abandoned  by  the  greater  part  of  practitioners ;  so  that  in  the 
seventeenth  century  Botal  was  not  ashamed  to  perform  amputation  by  means 
of  two  hatchets,  one  placed  immediately  below  the  member  and  the  other, 
loadeil  with  lead,  let  fall  upon  it.  Finally,  from  the  time  of  Ambrose  Pare 
and  Wiseman,  the  mode  of  practice  became  materially  changed,  and  the  ope- 
^ -ration  is  now  performed  witli  much  less  danger. 


OPERATIVE    SURGERY.  135 


SECTION   I. 


INDICATIONS. 

Cases  which  require  amputation  merit  particular  attention,  and  will  become 
it  is  to  be  hoped,  less  and  less  numerous  as  medical  knowledge  advances,  and 
as  the  just  treatment  of  diseases  comes  to  be  more  generally  understood. 

Art.  1. — Gangrene, 

Mortification.^— The  only  circumstance  which  was  formerly  supposed  to  jus- 
tify the  amputation  of  a  limb,  is  not  now  the  cause  whicli  most  frequently 
renders  the  operation  requisite,  although  it  must  be  confessed  that  it  forms 
one  of  the  most  positive  indications.  Amputation  in  this  case  is  only  warranted 
when  the  mortification  has  invaded  the  whole  thickness  of  the  part,  or  at 
least  when  it  is  sufficiently  deep  to  leave  no  hope  of  preserving  its  principal 
elements.  With  regard  to  amputation,  gangrene  involves  a  question  which 
some  moderns  have  attempted  to  solve  differently  from  the  ancients.  Pott, 
and  before  him,  Sharp,  strenuously  maintained  the  necessity  of  waiting  until 
the  organization  had  arrested  the  progress  of  mortification  and  established  its 
limits,  before  thinking  of  amputation  ;  without  attention  to  this  particular  say 
they  (and  the  majority  of  surgeons  agree  with  them  in  opinion),  the  mortifi- 
cation will  affect  the  stump,  continue  to  propagate  itself  in  the  direction  of 
the  trunk,  and  will  only  be  aiTCsted  by  the  death  of  the  patient,  while  the 
surgeon  will  have  performed  to  no  purpose  a  most  painful  operation.  This 
manner  of  viewing  the  matter,  founded  upon  an  exact  observation  of  facts, 
ought  to  be  adopted  as  a  general  but  not  as  an  absolute  rule.  Messrs.  Larrey, 
Yvan,  Lawrence,  Dupuytren,  Gouraud,  Guthrie,  and  Chaussier,  who,  while 
justifying  the  conduct  of  M.  Labesse  of  Nancy,  in  a  case  of  this  kind  have 
admirably  established  the  distinction  necessary  to  be  made.  Messrs.  Mac- 
dermott  and  Busch,  who  have  recently  reported  several  observations  on  this 
point,  and  many  other  modern  surgeons,  have  proved  that  it  is  sometimes  pru- 
dent to  pursue  an  opposite  course  of  conduct,  and  to  practice  amputation 
before  the  gangrene  has  become  limited.  For  example,  when  a  traumatic 
injury  is  the  cause  of  mortification ;  when  it  proceeds  from  the  rupture  of  an 
artery  or  the  division  of  the  vein  or  principal  nerves  of  the  member,  or  from 
the  mechanical  compression  of  the  part ;  when  in  fact  it  does  not  seem  to  result 
from  a  constitutional  affection,  from  any  external  or  hidden  cause ;  it  is  diffi- 
cult to  see  what  real  advantages  can  result  from  temporizing.  Gangrene  ought 
here  to  be  considered  as  a  cause  of  gangrene,  and  as  soon  as  that  is  well  esta- 
blished the  patient  cannot  but  be  a  gainer  in  being  relieved  as  speedily  as  pos- 
sible from  the  presence  of  the  mortified  parts. 

If  gangrene  on  the  contrary,  proceeds  from  the  spontaneous  obliteration  of 
the  artery  or  principal  vein  of  the  member,  as  is  frequently  the  case,  then, 
indeed,  it  is  evident  that  amputation  will  not  prevent  it  from  spreading.  The 
success  of  the  operation  would  then  still  be  a  matter  of  chance.  The  object 
of  the  practitioner  might  be  accomplished  if  the  knife  fell  above  the  oblite- 
rated part,  but  the  reverse  would  be  the  case  if  it  did  not.  In  such  a  con- 
juncture, prudence  requires  one  to  pause.  So  that  senile  gangrene,  which 
comes  under  this  head,  will  not,  even  if  the  general  state  of  the  patient  do  not 
exclude  the  idea  of  amputation,  permit  us  to  resort  to  it  until  the  disease  have 


156  NEW   ELEMENTS  OF 

paused  in  its  ravRges,  and  its  limits  have  been  marked  by  an  inflammatory 
fine.     The  point,  then,  is  to  distinguish  these  two  cases  from  each  other. 

Art.  9>.^—Fructures, 

Complicated  fracture  is .  one  of  the  causes  which  most  frequently  render 
amputation  necessary.  But  to  do  this  it  is  necessary  that  the  fracture  have 
been  attended  with  serious  injury  of  the  soft  parts.  When  the  artery,  the 
vein,  or  the  principal  nerves  remain  unbroken;  when  the  muscles  preserve  a 
partial  continuity  ;  when,  in  short,  gangrene  does  not  appear  inevitable,  it  is 
always  prudent  to  wait  a  little  and  to  try  in  every  way  to  obtain  a  cure  with- 
out mutilating  the  patient.  If  fragments  of  bone  or  splinters,  are  free  or  buried 
in  the  flesh,  they  are  to  be  extracted  ;  but  if  the  extremities  of  either  portion 
of  the  fractured  bone  appear  without  and  cannot  be  reduced  by  deep  incisions 
t)r  other  justifiable  means,  it  is  thought  good  to  remove  them  with  the  saw. 
Even  when  the  muscles  are  so  bruised  as  to  be  reduced  to  a  sort  of  jelly,  it 
does  not  follow  (if  any  of  them  remain  entire,  and  there  is  a  possibility  of  the 
circulation  of  the  fluids  below  the  fracture),  particularly  if  the  thoracic  limb 
is  concerned,  that  the  member  should  of  course  be  sacrificed.  Three  male 
adults  who  had  experienced  fractures  of  this  nature  in  the  leg,  were  cured 
witliout  amputation  at  the  hospital  of  St.  Anthony,  in  1829  and  1830,  although 
two  of  them,  becoming  suddenly  delirious  on  the  sixteenth  or  eighteenth  day, 
got  up  with  their  dressings  on,  and  walked  about  the  hall  of  the  hospital.  I 
saw  at  VHopital  de  Perfectionnement,  a  case  in  which  all  the  muscles  of  the 
internal  and  anterior  region  of  the  fore-arm  had  been  lacerated  and  beaten 
almost  to  a  jelly  by  a  spinning  machine.  The  skin  was  also  injured,  and  the 
radius  and  ulna  fractured  in  two  or  three  places.  The  patient,  a  young  man, 
having  several  times  refused  amputation,  eventually  recovered  without  an 
operation  and  preserved  the  limb.  In  civil  practice  the  surgeon  should  never 
lose  sight  of  the  following  remark,  viz :  that  with  care,  proper  regimen,  and 
all  the  resources  of  a  scientific  treatment,  it  should  be  rare  to  find  complicated 
fractures  immediately  demand  amputation.  It  is,  however,  sometimes  indis- 
pensable, particularly  when  the  fracture  reaches  so  far  as  the  next  articula- 
tion. Out  of  three  subjects  who  presented  themselves  in  this  state,  at  St. 
Anthony's  hospital,  and  whose  legs  I  tried  to  preserve,  two  died  in  a  few  days, 
and  the  life  of  the  third  was  only  preserved  by  amputation,  which  was  prac- 
tised on  the  fourteenth  day  in  consequence  of  gangrene.  It  is  true  that  a 
iburth  upon  whom  the  operation  had  been  performed  immediately,  died,  not- 
withstanding, on  the  seventh  day ;  but  in  that  case  the  sources  of  vitality  were 
«o  nearly  dried  up  at  the  time  of  the  operation  that  the  patient  scarcely  knew 
what  was  done  to  him.  To  the  numerous  facts  brought  forward  by  M.  Bardy 
in  1803,  for  the  purpose  of  demonstrating  that  in  these  cases  removal  of  the 
limb  is  scarcely  ever  necessary,  M.  Bintot  has  opposed  others  not  less  conclu- 
sive, in  support  of  the  contrary  opinion. 

Art*  3. — Lutations. 

Luxations  with  laceration  of  the  soft  parts  are  sometimes  followed  by  symp- 
toms so  formidable,  so  torrifying,  that  they  were  at  an  early  period  classed 
with  those  cases  which  most  imperiously  call  for  amputetion.  The  opinion 
expressed  by  a  military  surgeon,  and  which  made  so  lively  an  impression 
upon  tlie  mind  of  J.  L.  Petit,  viz.  that  all  luxations  of  the  foot,  with  laceration 
of  the  integuments  and  cutting  out  of  the  bone,  would  prove  mortal,  unless 


OPERATIVE    SURGERY.  137 

amputation  were  immediately  practised,  has  been  but  too  often  verified.  The 
dreadful  pain  which  follows  their  inflammation;  the  gangrene  which  fre- 
quently results  from  them,  and  which  nothing  can  arrest ;  and  death,  pre- 
ceded by  the  most  lively  agonies,  which  alone  seems  capable  of  terminating 
so  many  evils,  appear  sufficient  to  justify  the  surgical  rule  established  upon 
this  subject. 

Yet  experience  has  proved  that  there  may  be  many  exceptions  to  this  rule ; 
J.  L.  Petit  himself  has  been  very  careful  to  remark  this,  and  M.  Laugier,  M. 
Arnel,  &c.,  have  very  recently  given  new  proofs  of  the  fact.  If  the  laceration 
is  not  very  extensive,  if  the  bones  are  simply  luxed  without  being  broken,  if 
the  nerves  and  principal  vessels  are  not  divided,  and  if  gangrene  does  not 
appear  inevitable,  the  surgeon  should  replace  the  parts,  have  recourse  imme- 
diately to  scarifications,  antiphlogistics,  and  anodynes  of  every  kind ;  should 
combat  w'ith  energy  any  unexpected  or  unpleasant  symptoms  which  may  make 
their  appearance,  and  should  never  resort  immediately  to  amputation,  unless 
the  integuments,  tendons,  ligaments,  and  articular  capsules  are  extensively 
lacerated,  the  bones  and  soft  parts  torn  and  violently  contused,  or  the  joint 
too  complicated  or  too  unimportant  to  justify  an  attempt  at  its  preservation. 
By  proceeding  thus,  some  patients  whose  lives  might  have  been  saved  by  am- 
putation, will  perhaps  be  lost,  but  a  far  greater  number  will  be  curea,  and 
preserve  their  limbs. 

Art,  4. —  Caries,  Necrosis. 

The  last  remedy  of  caries  and  necrosis,  whether  of  the  middle  part  or  of 
the  articular  extremities  of  the  bones,  is  also  amputation.  To  justify  its  use, 
however,  the  disease  should  be  extensive ;  have  existed  for  a  considerable 
time ;  have  caused  great  suffering  or  an  exhausting  suppuration ;  should 
occupy  an  articulation  and  an  extended  surface,  or  be  surrounded  by  fistu- 
lous ulcers  and  deep  degeneration  of  the  soft  parts ;  the  bone  should  be 
affected  throughout  its  whole  thickness,  if  in  the  continuity  of  tlie  limbs ;  and 
reproduction  through  the  vessels  of  the  periosteum  cannot  be  counted  on.  It 
should  also  in  such  cases  be  remembered  that  the  organization  is  very  pow- 
erful, and  that  the  surgical  art  actually  possesses  the  means  of  partially 
removing  the  bone  without  removing  the  limb,  when  the  soft  parts  are  in  a 
staCe  to  be  preserved. 

Art.  5. — Cancerous  Affections. 

Spina  vcntosa,  osteosarcoma,  the  colloid,  hydatoid,  and  erectile  degenera- 
tions, give  less  latitude,  and  demand  much  more  positively  a  resort  to  ampu- 
tation. These  affections  are  of  so  malignant  a  character,  that  the  practitioner, 
even  of  the  present  day,  may  consider  himself  fortunate  if  he  is  able  to  destroy 
them  finally  by  sacrificing  the  part  upon  which  they  are  situated.  Unless 
they  occupy  a  very  superficial,  long,  and  slender  bone,  it  is  wrong  to  hesitate 
an  instant.  However  little  the  soft  parts  may  participate  in  the  disease,  am- 
putation cannot  be  dispensed  with.  The  same  observation  applies  to  the 
fungus  hematodes,  from  the  moment  that  it  becomes  impossible  wholly  to 
extirpate  it  without  affecting  the  continuity  of  the  bone  or  bones  of  some  im- 
portant parts  of  the  limb.  M.  Hervez,  of  Chegoin,  has  perfectly  established 
the  point,  that  extirpation  or  amputation,  when  practicable,  is  the  only  effica- 
cious remedy  for  sanguineous  fungous  tumors,  with  a  mixed  mass  of  hetero- 
geneous tissues,  brainiike  matter  for  instance,  as  soon  as  they  have  invaded  to 
18 


If^S  NEW    ELEMENTS    OF 

a  certain  extent  the  thickness  of  the  organ.  But  we  should  be  cautious  not 
to  confound  the  above  with  simple  erectile  tumofs,  which  at  the  present  day 
are  often  cured  by  gentler  and  less  painful  metliods.  As  to  cancers,  properly 
so  called,  there  is  no  necessity  for  waiting  until  they  penetrate  to  the  bone 
before  amputating.  If  they  are  large,  immovable,  and  extend  beyond  the 
integuments,  comprising  the  aponeurosis,  the  muscles,  and  the  vessels  or  the 
nerves,  the  safety  of  the  patient  would  be  compromised  by  any  attempt  to  pre- 
serve the  limb. 

Art.  6. — Aneurisms. 

For  the  cure  of  aneurisms  and  simple  wounds  of  the  great  vessels,  other 
and  more  simple  means  are  now  adopted.  The  ideas  of  Petit  and  Pott  upon 
this  subject  are  rarely  applicable  at  the  present  day,  and  can  only  be  adopted 
in  cases  where  gangrene  threatens,  or  already  exists;  when  the  aneurism  is 
too  voluminous,  and  the  surrounding  parts  too  deeply  affected  for  the  ligature 
to  afford  the  least  probability  of  success ;  or  when,  after  the  ligature,  second- 
ary hemorrhages,  caused  by  the  ossification  of  the  artery  or  by  mortificatioii, 
unexpectedly  ensue ;  when  the  principal  nervous  trunks  are  divided,  or  the 
vein  has  been  enclosed  in  the  same  ligature  with  the  artery  ;  when  the  muscles 
have  been  reduced  to  a  soft  mass,  or  become  disorganized  in  any  way  what- 
ever ;  or  when  the  neighboring  bones  are  themselves  affected,  have  become 
brittle,  or  are  to  a  greater  or  less  extent  destroyed. 

When  a  coach-wheel,  a  machine^  or  any  exterior  agent  whatever,  has 
effected  amputation,  either  by  tearing  away  the  part  or  in  any  other  manner, 
the  member,  being  in  the  same  state  as  after  gangrene,  requires  amputation 
above  the  accidental  division  as  much  as  if  it  had  suffered  nothing  but  attri- 
tion and  contusion  of  the  tissues. 

Art.  7. — Suppurations. 

Suppurations,  either  of  recent  or  of  long  standing,  superficial  or  profound, 
however  large,  seldom  absolutely  require  amputation,  unless  they  have  their 
origin  in  a  disease  of  the  bones.  Regimen,  a  skillful  application  of  medi- 
cines, incisions,  and  convenient  dressings,  should  generally  suffice  in  the  early 
stages  of  the  disease.  Otherwise,  the  cause  should  be  sought  in  the  general 
state  of  the  patient,  or  may  be  traced  to  some  internal  affection,  and  then 
amputation  would  only  tend  to  hasten  the  progress  of  the  evil.  It  is  impos- 
sible to  shut  the  eyes  against  the  danger  to  which  the  patient  is  exposed  by 
those  suppurations  whicu  sometimes  invade  the  greater  part  of  a  limb,  and 
which  are  commonly  the  result  of  an  inflammation  of  the  synovial  and  tendi- 
nous laminae,  of  the  intermuscular  cellular  tissue,  &c.  As  these  dangers, 
however,  do  not  always  exist ;  as  death  is  not  always  the  inevitable  result ;  as 
it  is  possible  to  combat  them  advantageously,  or  what  is  better  still,  in  a  great 
number  of  cases  to  prevent  thejn ;  the  suppuration  of  the  parts,  without  alter- 
ation of  the  bones,  ought  not  to  be  classed  among  those  cases  which  reqiure 
amputation.  The  only  patients  (three  in  number)  who  ever  suffered  ampu- 
tation in  my  prcseiace,  died  as  soon  as  if  the  operation  had  not  been  performed 
upon  them.  In  the  case  of  the  first  two  a  suppuration,  which  the  most  nume- 
rous incisions  had  not  been  able  to  arrest,  occupied  the  whole  of  the  fore- 
arm ;  in  that  of  the  other,  the  malady  approached  the  wrist  and  extended 
nearly  to  the  elbow  :  all  three  lost  their  arms  and  died  before  the  fifteenth 
4ay,  having  purulent  depots  in  the  bowels. 


OPERATIVE   SURGERY.  ISS 

These  remarks  apply  also  to  exostosis,  and  to  fibrous  or  other  tumors ;  unless 
they  are  very  voluminous,  compromise  the  general  health,  or  destroy  the 
nat-uralitises  of  the  parts,  and  absolutely  cannot  be  separately  removed  or  de- 
tached from  the  bones,  or  the  neighboring  organs  most  essential  to  the  main- 
tenance of  life  in  the  rest  of  the  limbs. 

Art.  S. — White  Swellings. 

The  numerous  observations  published  of  late  years  by  Messrs.  Larrey, 
Brodie,  and  Lisfranc,  prove  that  white  tumors  will  also  yield  more  readily 
than  is  generally  supposed  to  the  rational  use,  therapeutic  means,  and  that  it 
would  be  unworthy  an  honest  man  to  amputate  the  affected  member,  until  the 
caries  or  suppuration  of  the  articular  surfaces  became  evident,  and  before 
having  exhausted  every  resource  that  prudence  permits  to  be  employed.  If 
tlie  capsule  on  the  contrary  has  been  long  filled  with  pus,  if  there  be  fistu- 
lous sores  about  the  joints  and  rubbing  over  the  parts,  or  the  introduction  of 
the  probe  leaves  no  doubt  as  to  the  extent  of  the  caries  or  the  necrosis ;  if 
the  ligaments  and  the  surrounding  fibrous  strata  are  destroyed  ;  if  an  ichorous 
and  abundant  liquid  escapes  from  them  ;  if  the  fungous  or  fatty  alteration  has 
seized  upon  the  synovial  membrane  and  the  soft  parts  generally ;  if  the 
member  is  in  a  state  of  atrophy  above  and  below,  is  luxed  or  has  a  tendency 
to  become  so  ;  if,  in  a  word,  it  is  demonstrated  that  the  bones  or  cartilages 
liave  been  for  a  long  time  the  seat  of  a  deep  morbid  action,  the  necessity  of 
amputation  may  then  be  said  to  be  formally  indicated. 

Art.  9. — Tetanus,  Bites  of  Rabid  Animals. 

Erosive  ulcers  of  the  legs,  which  formerly  were  considered  as  particularly 
demanding  amputation,  do  not  really  require  it,  and  can  only  justify  its  use  in 
very  few  cases:  when,  for  example,  the  skin  is  destroyed,  or  the  muscles 
separated  round  the  greater  part  of  the  limb ;  and  even  in  these  cases,  the 
consent  of  the  patient  should  be  obtained,  and  he  should  be  convinced,  before 
submitting  to  the  operation,  that  there  is  no  possibility  by  any  other  means  of 
effecting  a  cure.  Did  M.  Larrey,  M.  del  Signore,  and  some  others,  derive  any 
benefit  from  the  amputations  which  they  had  the  courage  to  practice  in  certain 
cav<?e3  of  tetanus  ?  were  not  those  cases  on  the  contrary  rather  aggravated  than 
relieved  by  the  removal  of  a  limb  ?  I  remember,  it  is  true,  the  case  of  a  coun- 
tryman whose  life  was  thus  saved  some  years  ago  by  M.  Dubois,  and  I  am 
aware  that  our  medical  annals  present  here  and  there  some  instances  of  success 
obtained  by  the  same  means :  but  two  of  the  patients  upon  whom  M.  Larrey 
operated  died  notwithstanding  the  amputation,  and  the  case  of  the  third  was 
such  as  to  leave  great  doubt  in  the  mind  as  to  the  real  nature  of  the  disease 
with  which  he  was  affected.  If  the  wound  itself  which  has  occasioned  tetanus 
is  of  sufficient  importance  to  justify  an  extreme  resource,  the  appearance  of 
sucli  a  frightful  event  may  certainly  be  permitted  to  have  some  weight  as  a 
determining  motive.  There  is  less  room  for  hesitation  too  when  the  part  is 
of  small  importance  ;  but  in  other  cases  I  am  so  much  the  less  disposed  to  follow 
the  practice  of  our  celebrated  military  surgeon,  as  amputation  is  well  known 
to  be  a  powerful  cause  of  the  very  evil  v/hich  it  is  here  intended  to  cure.  The 
bite  of  rabid  animals  is  also  by  some  practitioners  considered  a  sufficient  cause 
for  amputation.  Very  recently,  at  a  London  hospital,  Mr.  Calloway  did  not 
hesitate  to  amputate  the  arm  of  an  individual  who  had  been  bitten  in  the 
hand;  and  who  (by  way  of  parenthesis)  died  shortly  afterwards  of  hydro- 


140  NEW  ELEMENTS  OF 

phobia.  What  could  such  an  operation'effect  against  an  infection  already  dis- 
seminated, against  symptoms  wiiich  evidently  have  their  immediate  source  in 
the  intestines,  or  some  general  organic  system,  which,  in  a  word,  are  alto- 
gether independent  of  the  primary  injury  ?  At  the  most,  amputation  can  only 
be  permitted  when  a  part  like  a  finger  has  beeii  bitten,  unless  the  wound  is 
so  extensive,  complicated,  or  deep,  as  to  forbid  cauterization,  or  prevent  a 
thorough  removal  of  the  sides  of  the  wound.  But  even  then,  amputation 
should  be  immediate;  for  when  once  an  absorption  of  the  virus  has  taken 
place,  what  can  we  hope  from  amputation  ? 

Art.  10. — Amputations  of  Convenience. 

Anchylosis,  complete  or  incomplete,  deformities  of  different  sorts,  old  and 
incurable  ulcers,  or  those  the  cure  of  which  is  never  durable,  affections  which 
hinder  the  use  of  some  of  the  limbs,  frequently  induce  patients  to  ask  us  to 
relieve  them  at  any  sacrifice,  although  neither  life  nor  health  is  compromised 
by  the  existence  of  the  malady.  As  a  general  rule,  a  prudent  surgeon  ought 
always  to  resist  the  solicitations  of  those  who  consult  him  on  this  point.  It  has 
been  observed,  in  fact,  that  these  operations  which  are  called  amputations  of 
complaisance,  usually  terminate  unsuccessfully.  In  the  year  1821,  a  robust 
man  in  ^ood  health  and  in  the  prime  of  life,  came  to  the  Hospital  of  St. 
Louis  with  the  fixed  determination  of  having  an  operation  performed  at  the 
thigh  for  an  anchylosis  of  the  knee,  which  obliged  him  to  use  a  crutch  in 
walking.  After  having  remonstrated  with  him  in  every  possible  way,  and 
represented  to  him  in  the  most  forcible  manner  the  dangers  to  which  he 
would  expose  himself,  M.  Richerand  at  last,  although  with  great  regret,  ac- 
ceded to  his  wishes.  Amputation  was  practised  in  the  most  simple  manner  ; 
no  local  accident  occurred,  but  a  low  fever,  which  speedily  developed  itself, 
brought  on  death  on  the  fifth  day  after  the  operation.  A  similar  fact  is  re- 
corded by  M.  Pelletan.  I  also  myself  witnessed  instances  equally  striking, 
at  the  Hospital  of  Tours,  in  the  years  1815  and  1820,  and  M.  Gouraud,  then 
surgeon-in -chief  to  that  establishment,  came  to  a  resolution  to  refuse  in  every 
such  instance.  In  1825,  a  countryman,  who  had  formerly  been  a  soldier, 
tired  of  carrying  a  dry  ulcer  behind  the  malleolus,  presented  himself  in  the 
hall  of  the  clinical  department  of  the  school  of  medicine,  with  the  intention 
of  having  the  limb  removed.  M.  Roux  in  vain  endeavored  to  alarm  him,  by 
representing  the  probable  consequences  of  such  an  operation :  the  patient 
was  not  to  be  shaken.  Amputation  was  accordingly  performed  ;  nothing  parti- 
cular occurred  at  the  time  of  the  operation,  but  in  a  few  days,  general  symptoms 
appeared,  and  the  subject  expired  in  about  a  week  from  the  time  of  ampu- 
tation. The  worst  of  these  cases  is,  that  amputations  the  least  important  in 
themselves,  those  of  a  finger  or  toe,  for  example,  are  often  followed  by 
equally  serious  results.  In  1829,  a  shoemaker  who  had  had  the  left  index 
finger  for  a  considerable  time  immovably  fixed  upon  the  palm  of  the  hand, 
came  to  me  at  the  hospital  St.  Antoine.  Prevailed  upon  by  his  solicitations,  I 
operated,  and  separated  the  finger  from  the  corresponding  metacarpal  bone. 
The  amputation  was  not  at  first  attended  with  any  disagreeable  consequences, 
and  the  patient  was  eventually  cured,  but  for  fifteen  days  he  was  so  seriously 
affected,  that  on  two  different  occasions  I  thought  him  beyond  recovery. 
Nothing  is  more  frequent  than  cases  of  this  description,  and  there  is  scarcely 
a  practitioner  who  has  not  observed  a  certain  number  of  them.  From  these 
circumstances  has  arisen  the  following  surgical  question  among  the  moderns, 
and  which  the  ancients  do  not  seem  to  have  thought  of: — ought  the  skillful 


%. 


OPFRATIVE    SURGERY,  141 

practitioneis  to  be  influenced  by  the  representations  of  the  patients  who  may 
apply  to  him  ?  ought  he  not  rather  flatly  to  refuse  the  performance  of  opera- 
tions which  are  not  indispensably  necessary  ?  On  the  other  hand,  does  hu- 
manity permit  us  to  condemn  a  patient  always  to  bear  an  infirmity  which 
renders  his  life  miserable,  simply  because,  in  relieving  him  from  it,  we  should 
expose  liim  te  dangers  more  or  less  serious  ?  By  this  rule  the  surgeon  ought 
never  to  touch  lupi,  or  tumors  of  any  species  which  may  develop  themselves 
upon  different  points  of  the  body,  for  they  are  rarely  dangerous  in  themselves, 
and  the  operations  which  it  is  necessary  to  perform  in  order  to  remove  them 
are  sometimes  attended  with  the  most  serious  results,  and  occasionally  produce 
the  death  of  individuals  the  most  robust,  and  apparently  of  the  best  consti- 
tution. I  am  far  from  wishing  to  justify  those  who  hastily  practise  amputation 
of  the  members  on  occasions  which  do  not  absolutely  demand  it,  for  mere 
inconveniences,  or  solely  because  it  is  desired  by  the  patient  5  but  I  ask  if  it 
is  not  conformable  to  the  rules  of  sound  surgery  to  have  recourse  to  it  for 
deformities  which  cannot  be  otherwise  removed,  and  which  are  of  such  a 
nature  as  to  destroy  the  natural  use  of  an  important  part  of  the  body,  to 
cause  pain,  and  to  be  a  source  of  constraint  and  continual  suffering  ;  when 
also  the  patient  is  in  favor  of  the  operation,  after  having  fully  reflected  upon 
the  consequences  which  may  result  from  his  determination  ? 

^  Art.  2. — Gun-shot  Wounds. 

'  f> —■ 

No  wounds  so  frequently  call  for  amputation  as  those  which  are  inflicted 
by  fire-arms.  Not  that  the  projectiles  impelled  by  gunpowder  have  in 
themselves  any  venomous  property,  as  has  been  believed  by  some  surgeons 
since  the  time  of  A.  Ferri,  and  as  is  still  imagined  by  the  vulgar,  but  because 
they  break,  tear,  and  bruise  the  tissues  which  they  penetrate  or  strike. 

A  bullet,  a  grenade,  or  a  portion  of  a  bomb,  which  carries  away  a  part  of 
the  thickness  of  a  limb  comprising  the  vessels,  demands  amputation  ;  while 
the  same  wound,  produced  by  a  cutting  instrument,  might  perhaps  be  cured 
without  thus  mutilating  the  patient. 

If  such  an  agent  strike  the  body  of  the  arm  or  thigh  in  such  a  manner  as  to 
reduce  the  muscles  to  a  jelly,  but  without  affecting  either  the  skin  or  the  bones, 
it  is  still  necessary  to  amputate,  excepting  in  cases  where  the  attrition  is  very 
limited,  and  the  vascular  and  nervous  trunks  have  escaped. 

Wounds  complicated  with  fracture  also  require  this  last  resource.  At  the 
articulations,  if  the  injury  is  considerable,  there  is  no  room  for  hesitation. 
There  is  no  disagreement  among  practitioners  upon  this  subject,  excepting 
when  the  articulation  is  not  too  extensively  opened,  and  the  osseous  extremi- 
ties have  simply  been  pierced  or  cracked  by  a  ball.  Here  the  surgeon  takes 
account  of  circumstances.  Is  the  patient  in  a  situation  to  receive  the  neces- 
sary attentions  ?  has  the  ball  merely  passed  through  the  wrist,  the  elbow,  the 
instep,  the  shoulder,  &c.,  shattering  the  articular  extremities  without  lacera- 
ting the  tendons  and  other  soft  parts  ?  The  preservation  of  the  limb  should  be 
attempted.  But  in  the  midst  of  camps  and  in  crowded  hospitals,  when  de- 
structive epidemics  are  prevailing,  and  when  the  patient  cannot  obtain  that 
calm  repose  and  those  assiduous  cares  which  are  indispensable,  and  if  the  frac- 
ture is  accompanied  by  a  splintering  of  the  bone,  if  the  ligaments,  the  synovial 
membranes,  or  the  tendons  are  bruised  and  torn,  amputation  will  be  found 
more  advantageous  to  the  patient  than  delay.  M.  Labestide,  it  is  true,  de- 
sirous of  sustaining  the  principles  of  Bilguer,  has  brought  together  in  his 
thesis,  a  number  of  examples  which  prove  that  wounds  of  this  kind,  at  the 


1,4^  NEW    ELEMENTS    OF 

wrist,  the  elbow,  the  foot,  or  the  knee,  have  been  cured  without  amputation. 
Several  observations  of  a  similar  description  have  also  been  collected  and  pub- 
lished by  M.  Arnel  from  the  practice  of  the  hospital  of  St.  Cloud,  during 
the  days  of  July.  Faure,  Percy,  and  Lombard,  had  previously  mentioned 
similar  facts.  But  how  many  cases  of  an  opposite  character  may  there  not 
be  opposed  to  these  instances  of  unhoped  for  success?  The  gardener  of  the 
director  of  one  of  the  theatres  of  the  capital  had  a  part  of  the  metacarpus, 
and  some  of  the  fingers  of  the  ri^ht  hand  carried  away  by  the  bursting  of  a 
gun  5  he  was  brought  to  the  Hospital  St.  Antoine,  where  he  earnestly  entreated 
me  not  to  sacrifice  the  remaining  tliumb  and  index  finger.  I  gave  way  to  his 
entreaties.  Serious  symptoms  shortly  appeared,  and  amputation  of  the  arm, 
performed  a  fortnight  after,  failed  to  preserve  his  life.  One  of  the  individuals 
wounded  in  Jul  j,  had  the  heel  pierced  by  a  ball  and  the  tibio-tarsal  articula- 
tion opened  behind  and  outwardly.  The  injury  not  being  of  any  great  extent, 
M.  Lisfranc  and  myself  were  desirous  of  preserving  the  member,  but  our 
patient  expired  on  the  eighteenth  day.  Another  person  who  had  received  an  ex- 
tensive wound,  with  fracture  of  the  elbow  and  opening  of  the  joint,  underwent 
no  operation,  and  died,  like  the  others,  under  the  influence  of  the  suppurative 
fever  Bud  phlebitis.  A  young  man  in  my  service  had  the  heads  of  the  bones 
and  the  articulation  of  the  knee  obliquely  traversed  by  a  ball,  at  the  taking 
of  the  Hotel  de  Ville.  There  was  no  splintering  nor  any  laceration  of  the  soft 
parts :  after  a  month's  care  it  became  necessary  to  amputate  the  thigh :  this 
was  done,  but  did  not  prevent  the  death  of  the  patient,  which  took  place  on 
the  thirteenth  day  after  the  operation.  It  is  at  least  probable  that  amputation, 
practised  at  firet,  would  have  sftved  the  lives  of  some  of  these  patients. 

It  is  not  only  about  the  complex  articulations  that  wounds  from  fire-arms, 
with  fracture  or  injury  of  the  synovial  cavities,  are  so  dangerous;  they  are 
scarcely  less  so  at  the  middle  part  of  the  long  bones,  particularly  of  the  in- 
ferior members.  Thus  a  simple  ball,  which  shatters  at  the  same  time  the  tibia 
and  iihe  fibula,  almost  always  calls  for  amputation.  For  one  person  who  re- 
covers without  submitting  to  the  operation  there  are  ten  who  die,  however 
trifling  in  extent  may  be  the  parts  which  have  been  injured  or  contused.  At 
the  femur,  amputation  is  still  more  formally  indicated.  Ravaton  says,  that  if 
amputation  be  neglected  this  fracture  is  almost  always  mortal.  Schmucker 
says  that  not  more  than  one  patient  out  of  seven  can  be  saved  by  any  other 
means.  Lombard  holds  the  same  language.  M.  Ribes,  who  never  saw  a  case 
of  this  kind  cured  otherwise  than  by  amputation,  gives  the  history  of  ten 
patients  who  died  notwithstanding  every  care,  and  says  that,  at  the  Hospital 
of  Invalids,  out  of  a  total  of  four  thousand  individuals'he  was  not  able  to  find 
one  who  had  been  cured  of  this  species  of  wounds.  M.  Yvan,  in  1815,  calls 
the  attention  of  M.  Ribes  to  two  cases  of  this  description ;  but  the  patients  re- 
tained fistulas,  and  eventually  died  in  consequence  of  the  fracture.  I  see 
that  M.  Gaulthier,  of  Claubry,  formerly  surgeon  of  the  Imperial  Guard,  is  of 
the  same  opinion  as  M.  Ribes  upon  this  subject;  and  says  that  those  soldiers 
of  the  Spanish  army,  whose  thighs  were  fractured  and  upon  whom  amputation 
■was  not  immediately  performed,  almost  invariably  died.  Out  of  eight  subjects 
treated  bv  Mr.  Samuel  Cooper,  after  the  battle  of  Ondenbosh,  only  one  sur- 
vived, and  even  he  was  not  able  afterwards  to  make  much  use  of  his  limb. 
Messrs.  Percy,  Tomson,  Larrey,  Guthrie,  and  J.  Hcnnen,  express  themselves 
nearly  in  the  "same  terms;  and"  the  events  of  July,  1830,  have  induced  almost 
all  the  surgeons  attached  to  the  hospitals  of  Paris  to  adopt  the  same  opinion. 
One  of  the  individuals,  however,  who  was  wounded  on  that  occasion,  re- 
covered under  the  treatment  of  M.  Lisfranc,  at  La  Pitie.   M.  Dupuytren  saved 


m 


OPERATIVE    SURGERY.  143 

a  second,  and  M.  Arnel  mentioned  three  others.  I  was  not  so  fortunate :  only 
one  case  of  the  kind  called  for  my  assistance ;  the  fracture  appeared  quite 
simple,  but  nothing  was  able  to  prevent  the  death  of  the  patient,  which  took 
place  on  the  thirty-eighth  day.  M.  Somme  cured  two  out  of  eight  without 
having  recourse  to  amputaiion,  during  tl:3  events  at  Antwerp  in  Oct.  1830. 
M.  Lassis,  and  other  practitioners  of  Paris  and  Belgium,  have  also  published 
several  other  successful  cases  5  but  it  ought  noL  to  be  forgotten  that  with  us, 
as  in  Belgium,  the  wounded  were  treated  with  all  that  care  which  is  usually 
experienced  by  patients  in  civil  practice ;  whilst  in  the  army  and  in  military 
hospitals,  they  are  necessarily  deprived  of  that  tender  treatment  which  in  the 
above-mentioned  cities  was  so  lavishly  bestowed. 

These  successes  besides  were  very  few  in  number,  and  the  member  pre- 
served generally  continued  in  a  deformed  state,  so  that  its  loss  could  scarcely 
have  been  more  disagreeable  to  the  patient.  It  is  necessary  here  to  remark, 
that  the  fracture  is  so  mucV  the  more  dangerous  as  it  approaches  the  middle 
of  the  bone,  whether  on  acceunt  of  the  splinters  which  more  frequently  result 
at  that  part,  or  from  the  number,  disposition,  and  force  of  the  muscles.  On 
the  whole,  amputation  is  the  vnost  frequently  indicated  in  cases  of  commi- 
nuted fracture  of  the  inferior  raembers.  Except  in  extreme  cases,  however, 
it  may  be  frequently  dispensed  vith  upon  the  upper  extremity.  To  distin- 
guish at  first  sight  the  circumstances  which  demand  amputation  and  those 
which  enable  the  operator  to  dispense  with  it,  is  absolutely  impossible.  From 
the  earliest  ages  wounds  extremely  trifling  in  appearance  have  been  seen  to 
become  very  serious,  whilst  on  the  other  hand  the  most  frightful  injuries 
have  sometimes  passed  away  without  any  particular  ill  consequence. 

It  is  doubtless  painful  to  be  obliged  to  mutilate  a  patient  who  desires  to 
preserve  his  limb ;  but  is  the  argument  drawn  from  certain  unexpected  cures 
of  subjects  who  have  refused  to  submit  to  amputation,  really  entitled  to  the 
value  which  has  been  so  generally  accorded  to  it  ?  Admitting  that  four  out 
of  ten  individuals  thus  treated  are  cured,  is  it  too  much  to  presume  that  if 
they  had  all  submitted  to  amputation,  two-thirds  of  them  would  have  re- 
covered ?  I  leave  conscientious  men  to  decide  whether  the  lives  of  two  or 
three  men  yet  in  the  prime  of  their  days,  ought  not  to  be  preferred  to  the 
preservation  of  a  deformed  member  to  four  persons  at  the  price  of  a  thousand 
dangers  ? 

Preliminary  Attentions. 

Art.  1. — Counter  Indications 

To  justify  an  amputation,  it  is  not  sufficient  that  the  disease  which  requires 
it  cannot  be  cured  by  any  other  means ;  it  is  also  necessary  that  the  ope- 
ration should  promise  entirely  to  remove  it,  and  leave  a  reasonable  chance  of 
preserving  the  life  of  the  subject.  When  the  operation  is  performed  for  a 
cancerous  affection,  the  operator  should  assure  himself  that  no  germ  of  the 
disease  exists  in  the  viscera.  If  degenerated  lymphatic  ganglions  are  re- 
marked at  the  root  of  the  limbs ;  if  the  color  of  the  skin,  the  state  of  the  re- 
spiration, or  of  the  digestion,  or  any,  the  least  symptom,  indicates  that  the 
affection  is  not  confined  to  the  exterior,  amputation  will  be  useless,  and  will 
only  tend  to  hasten  the  development  in  more  dangerous  situations  of  diseases 
analagous  to  those  which  it  is  intended  to  cure.  The  same  remarks  apply  to 
pulmonary  phthisis ;  to  the  necrosis  and  caries  of  the  vertebral  column;  to  ab- 
scesses by  congestion,  the  source  of  which  cannot  be  stopped  ;  to  any  organic 


144  NEW    ELEMENTS    Of 

injury  of  the  heart,  of  the  liver,  of  the  stomach,  of  the  genito-urinary  passage, 
&c.;  to  extreme  exhaustion ;  to  old  and  numerous  ulcerations  of  the  intestines, 
combined  or  not  with  a  colliquative  diarrhoea ;  in  fact,  to  all  those  occasions 
when,  after  the  removal  of  the  limb,  a  disorder  is  left  in  the  organization  suffi- 
ciently serious  to  produce  death.  In  rheumatic,  scrofulous  or  syphilitic 
affections,  it  is  much  to  be  feared  that  the  malady  would  speedily  reproduce 
itself  in  other  parts  of  the  members,  and  would  oblige  the  operator  if  he  would 
pursue  it  to  practice  successively  several  amputations.  It  is  necessary  there- 
fore in  these  cases  to  have  at  least  many  chances  of  being  able  to  limit  the 
progress  of  the  general  malady,  even  to  cause  it  to  retrograde,  and  at  last  to 
eradicate  it  entirely.  Prudence  does  not  permit  us,  for  example,  to  amputate 
a  member  affected  with  caries  or  necrosis,  scrofulous  or  syphilitic,  if  the  articu- 
lations of  any  of  the  other  parts  are  the  seat  of  swellings,  pain,  or  any  of  the 
first  symptoms  of  a  similar  affection.  In  cases  of  scrofula,  however,  it  has 
been  for  a  long  time  remarked  that  the  removal  of  an  important  member  is  fre- 
quently followed  by  an  advantageous  change  in  the  constitution  of  the  patient; 
that  weakness  is  sometimes  succeeded  by  appearances  of  strength  and  the  most 
flourishing  health.  This  effect  is  easily  accounted  for:  an  abundant  suppu- 
ration, continued  pain,  and  a  diseased  articulation,  form  a  cause  of  disease 
which  tends  continually  to  deteriorate  the  functions,  and  cannot  fail  to  keep 
up  such  a  state  of  the  economy  as  will  prevent  the  development  of  the  natural 
resources  of  the  organization.  By  removing  therefore  this  material  cause  of 
suffering  and  danger,  it  is  obvious  thai  the  general  health  will  be  re-esta- 
blished ;  that  ceasing  to  be  obstructed  or  embarrassed  in  her  efforts,  nature 
will  soon  cause  the  disappearance  of  the  lesser  evils,  and  triumph  over  a 
malady  the  principal  source  of  which  has  been  destroyed.  The  first  ques- 
tion to  be  decided  is,  whether  disease  really  exists  in  the  interior,  and  what 
is  its  nature  ?  because  if  it  be  incurable,  amputation  is  not  admissible.  The 
second  relates  to  the  source  of  the  disease ;  as  if  it  be  in  the  external  affection, 
amputation  is  formally  indicated;  if  elsewhere,  the  reverse.  Whenever  the 
local  affection  is  the  result  of  a  general  cause,  it  is  absolutely  requisite  to 
neutralize  the  first  before  proceeding  to  remove  the  second,  sound  practice 
not  permitting  amputation  until  this  has  been  done.  A  minute  examination 
of  the  patient  is  the  more  necessary  before  coming  to  a  full  decision,  as  the 
greater  part  of  the  diseases  which  require  amputation  rarely  fail  to  react 
upon  the  splanchnic  cavities,  and  to  cause  in  the  viscera  either  abscesses,  or 
tubercles,  or  ulcers,  or  indurations ;  together  with  a  thousand  other  morbid 
foci,  the  appreciation  or  discovery  of  which  is  far  from  being  always  easy. 

It  is  nevertheless  well  to  remark,  that  the  weakness  with  which  some 
patients  are  affected  does  not  absolutely  of  itself  forbid  the  operation.  All 
practitioners  know  that  it  is  not  always  with  the  strongest  patients,  or  those 
who  seem  to  have  the  best  constitutions,  that  amputation  most  frequently  suc- 
ceeds. In  fact,  a  certain  degree  of  exhaustion,  occasioned  by  long  continued 
pain  ;  even  diarrhcea  itself,  when  not  kept  up  by  any  internal  cause,  are  in 
general  rather  favorable  to  the  operation  than  otherwise.  It  seems  in  the  first 
case,  that  the  organization  enjoying  perfect  integrity  revolts  at  the  mutilation 
which  is  practised  upon  it;  whilst  in  the  second,  the  affection  against  which 
it  has  exhausted  all  its  resources  being  removed,  it  has  only  to  cause  the  dis- 
appearance of  the  secondary  disorders  which  it  had  not  been  able  to  prevent. 

Art,  % — Time  for  the  Operation^ 
During  the  last  century  the  question  was  much  dgit^ted,  whether,  after  se«- 


OPERATIVE    SURGERY.  145 

rious  wounds  by  fire-arms  or  otherwise,  it  were  best  to  amputate  immediately 
or  to  wait  for  reaction.  Faure,  Boucher,  Bilguer,  Comte,  and  more  par- 
ticularly Schmucker,  debated  this  point  with  great  interest,  on  account  of  the 
wars  which  were  about  to  take  place ;  and  although  since  that  time  it  has 
continually  occupied  the  attention  of  the  surgical  body,  the  problem  still 
remains  unsolved.  The  partisans  of  immediate  amputation  maintain  that  the 
subject  is  in  the  most  proper  state  for  the  operation,  immediately  after  having 
received  the  wound.  There  is  then,  say  they,  no  fever,  suppuration,  or  inflam- 
mation ;  the  affection  is  wholly  local,  whilst  at  a  later  period,  the  swelling  of 
the  member,  frequently  gangrene,  an  intense  reaction,  tetanus,  and  a  thou- 
sand other  accidents,  may  bring  on  death  before  a  proper  moment  can  be  found 
for  the  operation.  Even  v/hen  the  violence  of  this  reaction  is  calmed,  say 
they,  the  abundance  of  the  suppuration,  the  separation  of  the  muscles,  the 
fistulous  passages  which  are  formed,  the  induration  and  disorganization  of 
the  tissues,  render  the  operation  very  serious  and  difficult.  The  partisans  of 
consecutive  amputation  on  the  contrary,  in  order  to  justify  their  conduct, 
maintain  that  immediately  after  a  wound  the  organization  is  too  much  dis- 
turbed, is  under  the  influence  of  a  too  violent  commotion,  to  permit  the  per- 
formance of  any  operation  with  a  probability  of  success,  and  above  all,  that 
limbs  are  sometimes  sacrificed  which  might  otherwise  have  been  preserved  ; 
whereas,  after  having  combated  the  first  symptoms,  if  amputation  becomes 
inevitable,  the  surgeon  is  at  least  saved  from  reproach.  Taken  according  to 
the  letter,  both  these  opinions  appear  equally  contrary  to  sound  practice. 
When  amputation  becomes  absolutely  indispensable,  when  there  is  no  uncer- 
tainty upon  this  point,  there  can  be  no  doubt  that  it  is  better  to  operate  imme- 
diately than  to  make  any  delay  ;  and  Faure  himself,  who  defended  with  so 
much  ardor  the  cause  of  consecutive  amputation,  is  also  of  this  opinion.  When 
on  the  contrary,  there  remains  any  possibility  of  preserving  the  limb,  when 
its  loss  is  not  irrevocably  decreed,  the  operator  ought  to  temporize,  to  combat 
with  energy  the  general  symptoms,  and  also  to  decide  upon  amputation  when 
there  remains  no  hope  of  obtaining  a  cure  by  other  means. 

Upon  looking  closely  at  this  matter,  it  is  easy  to  discover  that  Faure  has 
not  placed  it  in  its  proper  light.  His  ten  wounded  patients,  it  is  true,  had 
all  fractures ;  the  first,  the  ninth,  and  the  tenth,  at  the  leg ;  the  second,  at  the 
femur;  the  third,  at  the  knee  ;  the  fourth  and  fifth,  at  the  fore-arm ;  the  sixth, 
at  the  humerus;  the  seventh,  at  the  metacarpus;  and  the  eighth,  at  the  heel: 
but  none  of  these  gun-shot  wounds  were  so  severe  as  to  remove  all  hope  of 
saving  the  part.  In  these  cases  the  question  might  have  been  whether  the 
operation  was  indispensable,  but  not  whether  it  should  have  been  performed 
sooner  or  later.  The  result  to  which  this  surgeon  has  given  so  much  import- 
ance, does  not  in  any  way  prove,  that  when  the  necessity  of  amputation  has 
become  apparent  it  would  be  less  dangerous  to  practice  it  after  than  before 
the  appearance  of  general  symptoms.  The  very  opposite  conclusion  might  in 
fact  be  drawn  from  it.  What  did  M.  Faure  gain  by  temporizing  ?  Nine  of 
his  patients  were  obliged  to  submit  to  amputation  after  having  endured  five  or 
six  weeks  of  the  most  anxious  uncertainty,  and  after  having  been  in  the  great- 
est danger  of  losing  their  lives.  To  say  that  these  patients  if  operated  upon 
immediately  ^vould  not  have  recovered,  is  to  make  a  supposition  wholly  gra- 
tuitous. Reason  tells  us  on  the  contrary,  that  these  men  who  were  able  to  resist 
so  many  causes  of  death,  would  have  experienced  a  more  perfect  cure,  and 
have  been  more  fully  restored  to  health,  if,  instead  of  being  subjected  to  the 
temporizing  practice  of  Faure,  they  had  undergone  immediate  amputation. 

In  admitting  that  secondary  amputations  succeed  better  than  those  which 
19 


146  NEW   ELEMENTS    OF 

are  practised  immediately,  the  surgical  academy  is  evidently  wrong.  To 
tlie  calculations  of  Faure,  which  go  to  prove  that  the  successes  are  as  three  to 
one,  may  be  now  opposed  the  experience  of  a  host  of  respectable  men  who 
have  observed  precisely  the  contrary.  M.  Dubor  affirms  that  during  the  Ame- 
rican war  in  1780,  the  French  surgeons  lost  almost  all  their  patients  by  defer- 
ring amputation,  whilst  the  American  practitioners,  who  performed  the 
operation  immediately,  were  successful  in  every  case  that  they  undertook. 
At  the  affair  of  Newburg,  Percy  was  successful  in  eighty -six  out  of  ninety- 
two  immediate  amputations.  Out  of  fourteen  M.  Larrey  saved  twelve.  Of 
sixty  patients  wounded  in  the  naval  engagement  of  1st  January,  1794,  and 
who  underwent  immediate  amputation,  only  eight  died.  After  the  battle  of 
Aboukir,  the  eleven  soldiers  mentioned  by  M.  Masclet,  who  were  operated 
upon  during  the  first  twenty-four  hours,  recovered,  whilst  three  others  upon 
whom  amputation  was  practised  eight  days  later,  died.  The  English  surgeons 
inform  us,  that  after  the  battle  of  Toulouse,  immediate  amputation  was  attend- 
ed with  success  in  thirty-seven  cases  out  of  forty-eight,  and  that  twenty-one 
out  of  fifty-one  died  under  a  contrary  practice.  At  the  attack  on  New  Orleans, 
the  proportion  was  still  more  favorable ;  for  out  of  forty-five  immediate  am- 
putations only  seven  were  unsuccessful,  whilst  by  the  other  method  only 
two  out  of  seven  were  saved.  It  appears  also,  that  M.  del  Signore,  surgeon 
of  the  Egyptian  army  at  the  battle  of  Navarino,  saved  the  whole  of  those 
patients  upon  whom  he  practised  immediate  amputation,  but  lost  twenty-five 
out  of  thirty-eight  of  those  upon  whom  the  operation  was  delayed.  Finally, 
the  events  of  1831  have  further  proved  the  advantages  of  immediate  ampu- 
tation. About  one  hundred  operations  were  practised  (thirty  at  the  Hotel  Dieu, 
fifteen  at  La  Charite,  twenty  at  the  Gros-Caillou,  thirteen  at  Beaujon,  six  or 
seven  at  St.  Louis,  four  or  five  at  the  Maison  de  Sante,  three  at  Necker,  one 
at  the  School  Hospital,  one  at  St.  Mery,  and  five  at  La  Pitie),  and  in  all  these 
cases,  the  superiority  of  immediate  over  consecutive  amputation  was  fully 
manifested. 

The  only  question  then  is,  whether  amputation  is  or  is  not  necessary  ;  and 
the  rules  for  deciding  this  point  in  each  case,  may  be  gathered  from  the 
chapter  on  the  diagnostic,  or  on  indications. 

Amputation  ought  to  be  practised  immediately,  that  is  to  say  within  the 
first  twenty-four  hours,  before  symptoms  of  reaction  are  developed ;  in  short, 
as  soon  as  possible,  whenever  there  appears  to  be  no  chance  of  saving  the 
patient  otherwise.  The  stupor  and  numbness  with  which  some  subjects  are 
aftected,  is  not  a  formal  counter-indication.  A  Swiss,  whose  thigh  had  been 
broken  by  a  bullet,  in  July,  and  in  whose  case  I  had  discountenanced  ampu- 
tation at  UHopital  de  Perfectionnement,  was  operated  upon  by  M.  Guer- 
sent,  jun.,  and  recovered.  Only  those  cases  should  be  abandoned  which 
appear  to  be  beyond  the  reach  of  art.  It  is  for  the  skillful  practitioner  to 
distinguish  the  circumstances  which  render  a  temporizing  practice  necessary. 
In  doubtful  cases  he  will  wait,  and  combat  or  endeavor  to  prevent  those 
symptoms  which  may  manifest  themselves.  If  afterwards  amputation  be- 
comes indispensable,  it  should  be  observed  that  it  will  rarely  be  successful  if 
practised  during  the  acute  stage  of  the  symptoms,  when  the  affection  has  not 
yet  become  wholly  local,  and  while  there  are  evident  signs  of  phlebitis  or  of 
resorption.  It  is  then  that  the  viscera  and  their  functions  should  be  examined 
with  the  minutest  care,  as  the  reaction,  which  may  appear  to  have  subsided, 
frequently  leaves  purulent  foci  somewhere  in  the  organization,  which  would 
not  fail  to  compromise  the  success  of  the  operation.  These  remarks  are  not 
confined  to  wounds  inflicted   by  fire-arms,  but  are  equally  applicable  to 


OPERATIVE    SURGERY.  147 

injuries  proceeding  from  other  causes.  Upon  all  points  connected  with  this 
subject,  I  recommend  to  practitioners  a  reference  to  the  excellent  work  of 
M.  Gouraud  (Principal  Operator,  Tours,  1815). 

Art,  3. — Point  of  Amputation. 

Amputations  have  been  divided  into  two  great  classes:  those  which  are 
practised  upon  the  body  of  the  limbs,  bear  the  name  of  amputations  in  conti- 
nuity; the  others,  which  are  only  disarticulations,  are  entitled  amputations  in 
contiguity.  Amputations  are  likewise  practised  at  the  point  of  election  or  at 
the  point  o( necessity,  according  as  the  practitioner  is  at  liberty,  or  is  influ- 
enced by  the  wound  or  disease,  to  act  upon  one  part  in  preference  to  another. 
Upon  this  subject  it  is  scarcely  possible  to  establish  other  than  very  vague 
rules ;  no  rule,  in  fact,  can  be  given  which  will  not  have  numerous  excep- 
tions. Tlius  it  would  not  be  always  correct  to  say  that  the  operation  should 
be  performed  as  far  as  possible  from  the. trunk,  or  that  the  most  slender  part 
of  the  member  should  be  chosen. 

The  same  remark  applies  to  the  rule  which  recommends  that  the  amputa- 
tion should  always  be  practised  above  the  injured  tissues.  The  lardaceous 
degeneration  does  not  in  any  way  demand  the  removal  of  the  affected  parts, 
as  It  is  sometimes  advantageous  to  preserve  them.  It  is  commonly  a  symp- 
tom of  an  alteration  of  the  hard  parts,  and  will  speedily  disappear,  the  same 
as  fistulous  passages  and  the  purulent  sinus,  when  the  cause  which  produced 
them  has  been  destroyed.  It  is  sufficient  in  such  cases  to  divide  the  bone 
above  its  diseased  parts,  without  being  concerned  at  the  state  of  the  soft 
parts. 

Art,  4, — Preparatives. 

1st.  The  attentions,  both  physical  and  moral,  which  ought  to  be  bestowed 
upon  a  patient;  the  preparations  to  which  it  is  necessary  to  subject  him 
before  an  amputation,  are  the  same  as  for  all  other  grave  operations  ;  the  same 
as  in  the  operation  for  aneurism,  for  example,  and  vary  according  to  an 
infinity  of  circumstances.  All  times,  all  seasons,  all  hours  of  the  day  or  night, 
may  he  adopted  for  the  practice  of  amputating,  as  well  as  for  all  urgent  ope- 
rations. The  morning,  however,  is  generally  preferred  when  a  choice  of  time 
is  given,  as  it  is  easier  to  watch  the  patient  during  the  rest  of  the  day,  than 
if  the  operation  were  performed  at  the  setting  in  of  the  night. 

2d,  A  method  of  amputating  without  pain,  has  long  been  thought  a  deside- 
ratum. Theodore,  and  many  others  after  him,  have  recommended  to  pass 
under  the  nose  a  sponge  steeped  in  opium,  water  of  nightshade,  henbane, 
mandrake,  lettuce,  &c.,  previously  prepared  and  dried  in  the  sun,  to  throw 
the  patient  into  a  profound  sleep;  afterwards  waking  him  by  using  in  the  same 
manner  a  sponge  dipped  in  vinegar,  or  by  putting  the  juice  of  fennel  or  rue 
into  the  nostrils  or  ears.  Others,  from  the  time  of  Guy  of  Chauliac,  con- 
tented themselves,  as  has  been  subsequently  practised,  with  administering 
opium  internally.  For  a  long  time  a  strap,  drawn  tightly  round  the  limb 
above  the  place  where  the  flesh  is  divided,  was  believed  to  be  the  best  means 
of  preventing  pain.  Very  recently  Mr.  Hirckmann,  of  London,  has  returned 
to  the  practice  of  the  ancients;  and  maintains  that  it  is  possible  to  perform 
the  most  serious  operations  without  pain,  if  the  patient  is  made  to  inspire,  or 
to  take  into  his  lungs  in  any  way  whatever  a  certain  quantity  of  stupifying 
gas.  Magnetism  has  not  been  forgotten ;  and  all  the  journals  of  the  day  con- 
tained an  account  of  an  amputation  of  the  breast,  which  had  been  performed 


148  NEW    ELEMENTS   OF 

by  M.  J.  Cloquet,  without  its  being  even  perceived  by  the  patient.  Unfortu- 
nately all  these  means  are  dangerous,  if  not  inefficacious.  It  is  only  by  his 
address,  his  knowledge,  and  the  skillful  choice  of  instrunients,  that  the  sur- 
geon ought  to  pretend  to  diminish  or  shorten  the  pair  of  amputation.  It  is 
much  to  be  feared  that  the  bistoury  heated  to  the  temperature  of  the  body,  as 
recommended  by  M.Guyot,  will  prove  equally  unsatisfactory  with  the  means 
which  have  just  been  described. 

S.  Apparatus. — The  instruments  necessary  for  practising  the  most  compli- 
cated amputations,  are  a  tourniquet,  a  garot,  a  cushion  with  a  handle,  or  other 
means  of  suspending  for  a  time  the  circulation  of  the  blood  in  the  limb. 
Knives  of  different  lengths,  a  straight  bistoury,  a  convex  bistoury,  a  saw  with 
a  change  of  blades,  a  dissecting  forceps,  scissors,  curved  or  straight  incisive 
nippers,  hooks,  suture  needles,  and  a  tenaculum.  For  the  dressing  are  re- 
quired single,  double,  triple,  and  quadruple  waxed  threads,  cut  into  ligatures 
of  different  sizes  and  lengths;  adhesive  straps;  lint  raw,  in  balls  and  in 
pledgets  ;  compresses,  oblong,  square,  and  of  other  shapes,  together  with  band- 
ages of  linen  and  sometimes  of  woollen  cloth.  It  is  also  necessary  to  have 
at  liand  agaric,  sponges,  warm  and  cold  water  in  different  vessels,  a  little 
wine,  vinegar,  and  cologne  water,  a  lighted  candle,  fire  in  a  chafing  dish,  and 
in  case  they  should  be  necessary,  some  cauterizing  irons. 

Among  these  instruments  there  are  some  that  demand  all  the  attention  of 
the  surgeon.  The  knives  for  example  ought  to  be  proportioned  in  length  to 
the  size  of  the  member  about  to  be  amputated.  Wiseman  recommended  that 
they  should  be  made  in  the  form  of  a  sickle,  in  order  to  divide  at  once  as 
much  of  the  soft  parts  as  possible.  This  description  of  instrument  was  gene- 
rally adopted  for  upwards  of  a  century,  but  has  been  completely  out  of  use 
since  the  time  of  Louis,  who  proved  its  uselessness  and  its  inconveniences. 
Tiiey  are  now  made  completely  straight,  terminating  in  a  broad  and  blunt 
point.  Others  on  the  contrary  are  round  at  the  extremity,  wlnlst  some  are 
narrow  and  very  pointed.  This  latter  sort  is  preferred  by  M.  Lisfranc.  The 
best  in  my  opinion,  are  those  the  edge  of  which  is  slightly  convex,  as  recom- 
mended by  Lassus.  With  regard  to  its  length,  it  is  between  the  knives 
adopted  by  the  members  or  pupils  of  the  old  academy  of  surgery  and  those 
of  M.  Lisfranc.  Without  being  too  sharp  their  point  is  yet  not  cut  square, 
and  the  heel  is  not  required  to  form  an  angular  projection  in  front  of  the  handle. 

The  saw  is  an  instrument  which  varies  in  shape  still  more  than  the  knife. 
It  should  be  so  heavy  as  to  require  only  to  be  drawn  across  the  bone  in  order 
to  its  immediate  action.  Its  blade  should  be  properly  set  immediately  before 
the  operation,  so  as  to  present  a  greater  degree  of  thickness  towards  the 
teeth,  than  towards  the  back  ;  a  width  of  cut  sufficient  to  enable  the  blade 
freely,  and  easily  to  follow  in  the  passage  made  by  the  teeth.  This  is  effected 
by  the  care  of  the  workman,  in  turning  the  teeth  alternately  to  the  right  and 
to  the  left.  Mr.  Guthrie  recommends  that  these  teeth  should  be  placed  in  two 
parallel  rows,  the  points  of  one  row  being  turned  backward  and  the  other 
forwards ;  by  which  means  says  he,  the  teeth  will  penetrate  equally  well,  going 
and  coming.  This  modification  has  not  been  adopted  among  us.  It  is  neces- 
sary always  to  have  one  or  two  spare  blades.  This  is  a  principle  which  F.  de 
Hilden  was  induced  to  establish,  in  consequence  of  having  been  obliged  upon 
one  occasion  to  leave  an  amputation  unfinished  until  he  had  procured  another 
saw  to  replace  one  which  had  broken  in  his  hand.  The  importance  of  this 
precaution  must  be  manifest  to  every  one.  I  shall  return  to  the  other  parts 
of  the  apparatus,  when  speaking  of  their  special  application  or  of  the  particular 
amputations. 


OPERATIVE    SURGERY.  149 

4th.  Position  of  the  Patient. — In  the  hospitals  the  patient  is  usually  placed 
in  the  amphitheatre,  or  in  a  chamber  particularly  devoted  to  amputations.  He 
is  there  laid  upon  a  table  more  or  less  elevated,  and  furnished  with  niatresses 
and  the  necessary  linen.  In  certain  cases  he  is  simph^  seated  in  a  chair, 
placed  in  a  convenient  position.  Out  of  the  public  establishments  a  par- 
ticular locality  may  be  chosen,  but  in  general  the  operation  is  performed  upon 
a  bed  or  ciiair  in  the  bed-chamber  of  the  patient. 

5th.  A  particular  duty  ought  to  be  carefully  assigned  to  each  of  the  assist- 
ants, before  the  operation.  One  of  them  is  charged  with  the  compression  of 
the  artery.  For  this  purpose  the  individual  who  possesses  the  greatest  strengtii, 
self-possession,  and  knowledge,  is  usually  selected.  A  second  embraces  the 
member  towards  its  root,  in  order  to  draw  up  the  flesh;  a  third  sustains  and 
fixes  the  part  which  is  to  be  removed  ;  and  a  fourth  is  charged  \yith  the  duty 
of  presenting  the  instruments  as  they  become  necessary.  Others  are  to  hold 
those  parts  of  the  body,  the  movements  of  which  might  be  injurious  during 
the  operation. 

6th.  To  suspend  the  Circulation  of  the  Blood. — Before  carrying  the  knife 
through  the  living  tissues,  it  is  necessary,  to  guard  against  hemorrhage,  to 
obstruct  in  some  way  the  passage  of  the  principal  artery  of  the  limb,  until  the 
amputation  will  permit  the  final  obliteration  of  the  vessels.  For  this  purpose 
recourse  was  for  a  long  time  had  to  circular  compression.  This  method  was 
adopted  by  Avicenna,  by  the  Greeks,  and  even  still  later  by  Pare.  Some  of 
the  ancients,  however,  employed  temporary  hemostatic  means,  which  were 
more  efficacious.  It  appears,  in  fact,  from  the  very  vague  notions  which  we 
possess  respecting  Archigenes,  that  that  author  even  at  that  early  period 
made  use  of  the  ligature,  which  he  applied  immediately  upon  the  artery  after 
liaving  traversed  the  whole  thickness  of  the  part.  By  degrees  the  circular 
ligature  was  improved  in  the  hands  of  the  French  surgeons.  They  began  by 
removing  it  from  the  passage  of  the  artery  by  means  of  a  compress.  In  1674, 
Morel  transformed  it  into  a  true  garot  by  the  aid  of  a  small  piece  of  wood, 
v/hich  augmented  or  diminished  at  will  the  compression  of  the  vessel  during 
the  operation.  This  garot,  modified  successively  by  Nuck,  Verdue,  and 
Lavauguyon,  is  still  used ;  but  to  prevent  the  skin  from  being  pinched,  and 
to  hinder  as  much  as  possible  the  compression  of  those  parts  in  the  circum- 
ference of  the  member  which  do  not  correspond  to  the  artery,  a  compress 
several  times  doubled,  a  rolled  bandage,  or  any  other  solid  lump  or  pad  is 
now  previously  placed  over  the  vessel ;  whilst  a  plate  of  horn,  slightly  concave, 
•is  applied  to  the  opposite  side  of  the  member  below  the  part  of  the  cord  which 
is  to  be  twisted.  The  tourniquet  of  J.  L.  Petit,  invented  towards  the  com- 
mencement of  the  last  century,  and  of  which  several  modifications  have  been 
proposed  in  England  and  Germany,  has  rendered  the  employment  of  the  garot 
of  Morel  much  less  frequent.  The  instrument  of  Petit,  in  fact,  is  so  disposed, 
that  it  acts  w/ith  a  certain  degree  of  force  only  upon  the  passage  of  the  vessels 
which  are  to  be  compressed,  without  hindermg  the  circulation  in  the  colla- 
teral branches.  Besides,  when  once  applied  it  may  be  left  to  itself,  whilst  the 
garot  requires  to  be  incessantly  watched  until  the  close  of  the  operation. 
When  the  operator  can  only  command  a  small  number  of  assistants,  or  when 
those  assistants  have  not  sufficient  knowledge  to  entitle  them  to  full  confi- 
dence, in  the  country,  foi  example,  and  sometimes  in  the  army,  wlien  unfore- 
seen circumstances  render  the  amputation  of  a  member  necessary,  the  garot, 
which  can  be  fabricated  immediately,  forms  an  invaluable  resource.  The 
tourniquet  of  Petit,  if  it  could  be  procured  would  be  better;  but  in  all  other 
cases  we  should  rely  upon  the  hand  of  an  assistant.  When  the  artery  is  situ- 


150  NEW  ELEMENTS  OF 

ated  in  a  deep  hollow,  it  is  well  to  use  a  sort  of  desk-seat  furnished  with  a 
cushion.  In  this  manner  the  pain  will  be  diminished,  the  retraction  of  the 
muscles  not  in  any  way  hindered,  and  the  operator  w'-ll  act  freely  and  be 
able  to  approach  the  origin  of  the  limb  as  nearly  as  the  injury  requires.  In 
some  rare  cases,  however,  the  operator  has  recourse  to  a  surer  method.  He 
exposes  the  artery  at  a  certain  distance  above  the  place  where  the  amputation 
is  to  be  performed,  and  applies  the  ligature.  But  this  forms  a  special  indi- 
cation, and  will  be  considered  in  the  sequel. 


SECTION   III. 
METHODS    OF    OPERATION. 

A.  Amputations  in  Continuity. 

These  were  almost  the  only  amputations  practised  during  a  long  series  of 
years,  and  are  still  more  frequently  practised  tlian  any  others.  They  are  per- 
formed in  three  different  ways,  but  principally  by  the  circular  and  flap 
methods. 

Art,  1. — Circular  Method. 

In  amputating  by  the  circular  method,  the  successive  stages  of  the  operation 
are — the  division  of  the  skin,  the  division  of  the  muscles,  the  division  of  the 
bones,  the  prevention  of  hemorrhage,  and  the  dressing  of  the  wound. 

§1.  Manual. 

1st.  Division  of  the  Skin. — Celsus,  Archigenes,  Gersdof,  Theodoric,  Wise- 
man, &.C.,  in  their  day,  as  Louis,  M.  Dupuytren,  and  several  others  in  ours, 
divided  the  skin  and  the  muscles  at  the  same  stroke.  It  appears  on  the  con- 
trary, that  Maggi  dissected  the  skin  at  first  to  such  an  extent,  as  to  enable 
him  afterwards  to  cover  the  surface  of  the  stump.  But  this  method  was 
never  followed  by  the  ancients,  and  it  is  to  J.  L.  Petit  that  we  owe  its  general 
introduction.  That  author,  after  having  divided  circularly  the  cutaneous 
envelope  of  the  limb,  caused  it  to  be  drawn  up  by  an  assistant,  or  drew  it  up 
himself  to  the  extent  of  about  two  fingers'  breadth.  Cheselden  pursued  nearly 
the  same  method  and  at  the  same  time;  but  Alanson  seems  to  have  been  the 
first  wlio  recommended  that  the  skin  should  be  dissected  and  turned  back  so 
as  to  form  a  sort  of  ruffle,  a  practice  which  was  afterwards  adopted  by  Lassus, 
M.Richerand,  and  many  other  French  surgeons.  Messrs.  Guthrie,  Grjefe, 
&c.  think  that  the  aponeurosis  and  some  of  the  fleshy  fibres  might  without  in- 
convenience be  divided  on  the  same  stroke ;  and  that  this  would  ensure  the 
complete  division  of  the  skin,  and  enable  that  membrane  to  be  more  easily 
retracted.  Hey  and  Langenbeck  are  of  an  opposite  opinion.  What  advan- 
tage, in  fact,  can  result  from  this  careful  tracing  of  the  periphery  of  the  muscles 
and  the  aponeurosis  ? — whether  the  knife  penetrate  a  little  more  or  less  deeply. 
Provided  the  integuments  are  divided  tnroughout  their  whole  thickness,  the 
remainder  of  the  operation  will  not  be  rendered  more  difiicult  nor  less  so. 
The  surgeons  who,  like  Hey  and  M.  Brunninghausen,  desire  that  tlie  skin 
should  entirely  cover  the  stump,  have  laid  it  down  as  a  principle  that  the  cir- 
cumference ot  the  limb  should  first  be  measured,  so  as  to  preserve,  for 
example,  two  inches  of  the  integuments  for  a  v/ound  which  is  to  be  four  inches 


OPERATIVE   SURGERY.  151 

broad.  Lassus  is  said  to  have  followed  this  direction  with  success.  In  my 
opinion,  these  minute  precautions  are  altogether  useless.  The  best  method, 
when  it  is  not  intended  to  reach  the  bone  at  the  first  stroke,  is  to  divide  with 
the  knife  the  diiFerent  cellular  fibrous  bands  which  connect  the  exterior  en- 
velope to  the  subjacent  parts,  Avhilst  an  assistant  draws  it  back  with  more  or 
less  force,  as  may  be  required.  The  pain  is  less,  the  skin  preserves  a  greater 
thickness,  and  nothing  can  be  more  easy  than  to  raise  it  in  this  way  to  the 
extent  of  two  or  three  inches. 

In  order  to  make  this  division,  the  hand  of  the  operator  passes  beneath  the 
parts  describing  a  segment  of  a  circle,  and  applies  the  knife  upon  the  ante- 
rior surface  of  the  limb.  It  is  useless  here  to  follow  the  advice  of  Mynors, 
to  incline  the  edge  upward  so  as  to  divide  the  integuments  bevel-wise.  The 
incision  should  be  made  perpendicularly,  the  knife  cutting  from  heel  to 
point,  and  circumscribing  the  member  in  as  regular  a  manner  as  possible.  ^ 
The  hand  is  at  first  turned  in  pronation,  and  is  gradually  brought  into  supi- 
nation as  it  passes  first  on  the  inside  and  afterwards  beneath  the  member. 
If  the  operator  desires  to  make  this  incision  at  once,  the  hand  turns  gradually 
upon  the  handle  of  the  instrument  in  such  a  way  as  to  be,  at  the  end  of  the 
stroke,  in  a  forced  state  of  pronation.  By  this  method  he  will  avoid  that 
disagreeable  and  fatiguing  turn  of  the  wrist  which  is  experienced  by  the  greater 
part  of  those  surgeons  who  do  not  perform  the  incision  at  two  separate  move- 
ments. To  a  skillful  practitioner  it  certainly  would  not  be  difficult  to  proceed 
as  I  have  directed;  but  I  do  not  see  what  great  inconvenience  there  can  be, 
after  having  divided  the  skin  on  the  inside,  on  the  outside,  and  beneath,  in 
withdrawing  the  knife  as  it  is  done  by  many  surgeons,  and  with  much  ad- 
dress by  M.  Blicke,  of  London,  and  carrying  it  above  for  the  purpose  of 
uniting,  by  a  second  incision,  the  two  extremities  of  the  first.  This,  how- 
ever, evidently  is  matter  of  choice,  and  not  of  necessity. 

2d.  Division  of  the  Flesh. — The  section  of  the  muscles  seems  to  have  par- 
ticularly fixed  the  attention  of  surgeons  for  about  a  century  past.  From  the 
time  of  Celsus  the  knife  was  carried  a  little  above  the  dead  parts,  and  the  in- 
teguments, together  with  the  entire  thickness  of  the  flesh,  were  divided  at  the 
first  stroke.  Celsus  detached  the  deeper  muscles  and  raised  them  in  such  a 
way  as  to  be  able  to  saw  the  bone  a  little  further  up,  and  bring  theiii  down 
again  to  cover  the  stump.  This  precept  of  Celsus  has  been  long  neglected, 
and  \Viseman,  J.  L.  Petit,  and  Cheselden,  in  making  the  section  of  the  soft 
parts  at  two  movements,  seem  also  to  have  forgotten  it.  It  was  Louis  who  de- 
monstrated that  the  conical  figure  of  the  stump,  which  was  almost  always  left 
by  the  ancient  methods,  was  owing  to  the  retraction  of  the  muscles  more  than 
to  that  of  the  skin,  and  consequently  recommended  that  the  muscular  layers 
should  be  divided  at  two  movements.  At  the  first  stroke  Louis  divided  the 
integuments  and  the  superficial  muscles,  which  he  caused  to  be  drawn  back 
as  strongly  as  possible,  favoring  their  retraction  by  all  the  means  in  his  power ; 
the  deeper  strata  were  divided  by  a  second  stroke,  after  which  he  sawed  the 
bone  in  the  ordinary  manner.  Le  Dran  says,  "  I  cut  at  a  single  stroke  the 
integuments  and  half  the  thickness  of  the  muscles;  then  I  cause  the  skin  and 
flesh  to  be  drawn  back  as  much  as  possible,  and  then  make  a  circular  inci- 
sion to  the  edge  of  the  skin  thus  withdrawn ;  by  this  second  stroke  I  do  not 
cut  the  skin,  but  only  the  muscles  down  to  the  periosteum.  This  process  is 
very  similar  to  that  of  Pigray  or  Celsus,  and  differs  very  little  from  that  of 
Louis.  The  latter  author,  however,  deserves  the  credit  of  having  improved 
it,  and  caused  its  importance  to  be  generally  admitted.  Valentine,  in  his 
critical  researches  in  surgery,  imagined  that  it  was  necessary  in  dividing  the 


152  NEW    ELEMENTS   OF 

muscles  to  place  them  successively  in  a  state  of  extension  at  the  moment  of 
incision;  so  that  at  the  thigh,  for  example,  the  limb  ought  to  be  turned  first 
backwards,  then  outwards,  then  forwards,  and  finally  inwards,  while  the  ope- 
rator made  the  circuit  of  the  member  with  the  instrument.  This  odd  idea 
never  had,  and  never  ought  to  have  a  partizan.  Desault  combined  the 
methods  of  Petit  and  Louis,  that  is  to  say,  he  recommends  with  the  first  of 
these  authors  to  divide  and  withdraw  the  skin  in  the  first  place;  and  with 
the  second,  to  divide  afterwards  the  superficial  muscular  stratum  as  far  up 
as  the  skin  was  raised,  and  to  commence  the  section  of  the  muscles  at  the 
place  to  which  the  first  layer  retracted. 

Alanson  published,  in  1784,  a  new  method  of  performing  amputations.  After 
having  dissected  and  turned  back  the  skin,  that  surgeon  divided  all  the 
muscles  at  one  stroke,  taking  care  to  direct  obliquely  upwards  the  edge  of 
his  knife,  and  eventually  to  carry  the  point  of  his  knife  still  more  obliquely 
completely  round  the  bone ;  his  end  being  to  obtain  a  hollow  cone,  the  base 
of  which  would  be  at  the  circumference  of  the  wound.  Langenbeck  com- 
bated tliis  mode  of  practice,  and  Wardenburg  attempts  to  prove  that  it  is 
impossible  to  have  a  conical  wound  by  following  to  the  letter  the  directions 
of  Alanson;  ''inasmuch  as  the  knife,"  says  he,  "held  obliquely,  must  ne- 
cessarily describe  a  spiral  and  not  a  circular  line."  Loefler  and  Loder,  who 
undertook  the  defence  of  Alanson  a  short  time  afterwards,  endeavored  to 
prove,  on  the  contrary,  that  it  is  not  difficult  to  prevent  this  tendency  to  a 
spiral  course.  It  appears  that  upon  this  point  Messrs.  Langenbeck,  Graefe, 
&c.,  have  misunderstood  the  process  of  the  English  surgeon.  M.Dupuytren, 
in  fact,  who  has  adopted  it  for  a  considerable  time,  and  subjected  it  to  some  im- 
portant modifications,  uses  it  daily  at  the  Hotel  Dieu  with  the  greatest  success. 
As  the  knife  is  penetrating,  when  it  is  directed  obliquely  it  will  be  found  suf- 
ficient to  hold  its  handle  in  a  proper  position,  to  prevent  it  from  straying 
from  the  circular  direction.  Alanson  has  also  remarked  that  it  is  principally 
with  the  point  of  the  knife  that  the  operator  is  enabled  to  cut  out  a  cone  from 
the  thickness  of  the  muscles.  In  the  process  of  M.  Dupuytren,  an  assistant 
forcibly  retracts  the  soft  parts,  whilst  the  operator,  holding  the  knife  as  directed 
i)y  Alanson,  divides  at  a  single  stroke  the  skin  and  the  entire  thickness  of 
the  flesh;  he  then  carries  tTie  instrument  without  changing  his  hold  about 
the  base  of  the  fleshy  cone,  which  rests  upon  the  bone,  in  consequence  of  the 
retraction  of  the  superficial  muscles  ;  this  is  done  with  extreme  rapidity, 
and  there  results  from  it  the  appearance  of  a  hollow  cone  very  favorable  to 
the  reunion  of  the  wound.  Finally,  Bell  having  divided  the  skin  after  the 
manner  of  J.  L.  Petit,  and  the  muscles  by  the  method  of  Wiseman,  carries 
between  them  and  the  bone  the  amputating  knife,  in  order  to  divide  their 
adhesions  to  the  extent  of  about  two  inches,  and  raise  them  afterwards  with 
greater  facility. 

All  the  methods  have  undergone  further  modifications,  which  it  is  unne- 
cessary here  to  mention.  The  brevity  of  the  text  of  Celsus  enables  us  to  dis- 
cover in  that  author  the  origin  of  the  methods  of  Petit,  Louis,  Bell,  and  even 
that  of  M.  Dupuytren.  If  it  is  doubtful  whether  at  that  time  any  surgeon  had 
followed  a  method  similar  to  those  which  are  practised  at  the  present  day,  it 
is  not  so  with  the  method  thus  described  by  Pigray.  "  After  having  retracted 
the  skin  with  both  hands,  the  whole  thickness  of  the  flesh  is  to  be  divided 
around  the  limb,  above  the  disease  :  then,  with  a  cleft-bandage,  the  divided 
flesh  is  drawn  back,  in  order  to  sav/  the  bone  as  high  up  and  as  near  to  the 
flesh  as  possible.  The  hemorrhage  being  arrested  by  caustics,  astringents, 
or  a  ligature,  the  skin  is  brought  down  and  united  in  front  of  the  wound,  by 


OPERATIVE    SURGERY.  153 

two  stitches  crossing  each  other.  The  most  remarkable  circumstance  con- 
nected with  these  apparently  different  processes  is,  that,  when  closely  ex- 
amined they  are  for  the  most  part  seen  to  lead  to  the  same  results.  Whether 
the  operator  incise  at  a  first  stroke  the  superficial  muscles,  and  at  a  second 
the  deeper  layer,  after  the  manner  of  Louis  ;  whether  he  follow,  on  the  con- 
trary, the  instructions  of  M.  Dupuytren  ;  whether  he  divide  the  soft  parts  at 
three  strokes,  as  recommended  by  Desault,  or  whether  he  follow  Alanson  or 
Bell ;  if  he  but  take  the  trouble  to  favor  the  retraction  of  the  flesh,  the  bone 
will  be  exposed  at  two,  three,  or  four  inches  above  the  point  where  tiie  incision 
was  commenced.  In  dividing  the  muscles  therefore  at  the  time  of  amputation, 
it  is  much  less  important  to  conform  to  any  particular  rule  than  is  generally 
supposed.  The  method  of  Bell  found,  in  1829,  a  new  defender  in  M.  Hello, 
a  naval  surgeon,  who  recommends  that  it  should  always  be  used  in  preference 
to  tlie  formation  of  a  hollow  cone.  From  the  trials  that  I  have  made  of  M. 
Bell's  method,  it  certainly  does  appear  to  me  that  the  muscles  thus  detaciied 
reapply  themselves  with  greater  facility,  and  are  more  easily  put  in  contact, 
and  maintained  face  to  face  from  the  bottom  towards  the  edges  of  the  wound 
than  by  any  otiier  method.  It  is  only  unfortunate  that  the  operation  is  ren- 
dered by  it  a  little  longer  and  more  diflicult. 

The  most  rational,  sure,  and  generally  applicable  method  is  the  following : — 
The  skin  is  divided  at  a  single  stroke,  without  a  too  rigorous  regard  to  the 
subjacent  parts,  and  is  drawn  up  by  an  assistant  while  the  surgeon  divides, 
to  the  extent  of  two  or  three  fingers'  breadth,  the  filaments  which  attach  it  to 
the  aponeurosis  or  the  muscles.  Applied  at  the  edge  of  the  retracted  skin, 
the  knife  divides  circularly  all  the  muscles  down  to  the  bone,  or  at  least  near 
enough  to  the  bone  to  ensure  the  complete  division  of  the  superficial  stratum. 
The  assistant  then  forcibly  retracts  the  parts,  and  by  a  second  stroke  the  ope- 
rator incises  all  the  fleshy  fibres  of  the  profound  stratum  at  the  place  where  it 
begins  to  hide  itself  under  the  retracted  extremities  of  the  previously  divided 
muscles.  Whether  the  knife  is  held  obliquely  or  perpendicularly  is  of  no 
consequence  to  the  definitive  result;  and  whether  the  operator  penetrates  at 
first  to  the  bone,  or  simply  to  the  deep  seated  muscular  stratum,  is  also  almost 
the  same.  In  both  cases  it  is  equally  necessary  to  carry  a  second  incision 
two  or  three  inches  above  the  first,  through  the  most  adherent  muscular  fibres. 

3d.  Section  of  the  Bones. — The  muscles  having  been  divided,  are  drawn 
up  by  the  aid  of  a  retractor.  For  this  purpose,  woollen  or  linen  bags,  or 
plates  of  leather  and  even  of  metal  were  formerly  used.  F.  de  Hilden,  Gooch, 
Bell,  and  Percy,  praised  these  instruments  ;  but  surgeons  of  the  present  day 
are  content  with  a  simple  cleft  compress,  the  undivided  part  of  which  is  laid 
upon  the  posterior  part  of  the  flesh  rather  than  upon  the  anterior,  as  recom- 
mended by  M.  Graefe ;  its  two  free  extremities  are  crossed  and  turned  in 
front ;  and  the  assistant,  who  embraces  the  whole  with  his  hands,  thus  draws 
back  the  soft  parts  in  order  to  protect  them  from  the  action  of  the  saw.  Be- 
fore proceeding  farther,  most  surgeons  recommend  that  t\\^  periosteum  should 
be  carefully  divided  and  scraped  away.  Wiseman  performed  this  denuda- 
tion with  the  back  of  his  amputating  knife.  Since  his  time,  however,  the 
bistoury  or  the  edge  of  the  ordinary  knife  has  been  preferred.  Some  practi- 
tioners, with  M.  Gr£Efe,  scrape  downwards  ;  others,  with  M.  Brunninghausen, 
push  the  membrane  upwards,  in  order  afterwards  to  bring  it  down  upon  the 
track  of  the  saw.  These  are  all  useless  precautions,  as  has  been  proved  by 
Messrs.  Alanson,  Guthrie,  and  Cooper,  and  before  them,  by  J.  L.  Petit  and 
Le  Dran.  They  are  recommended  for  the  purpose  of  lessening  pain,  and  pre- 
venting tetanus  and  the  exfoliation  and  inflammation  of  the  bone,  together 
20 


154  NEW    ELEMENTS   OF 

with  the  suppuration  of  the  surrounding  parts ;  as  if  the  periosteum  could  exert 
the  slightest  influence  upon  the  production  of  such  phenomena!  When  it  has 
been  carefully  divided,  one  of  two  things  must  happen  :  1st.  The  saw  is  car- 
ried a  little  higher  than  the  denuded  part  without  its  being  perceived  by  the 
operator,  and  then  the  scraping  is  of  no  eft'ect.  2d.  The  saw  is  indeed  applied 
upon  the  intended  place,  and  in  that  case  it  is  difficult  to  avoid  leaving  a 
small  part  deprived  of  its  envelope,  which  circumstance  will  almost  necessa- 
rily produce  necrosis.  On  the  whole,  then,  if  the  surgeon  attains  the  proposed 
end  the  precaution  is  hurtful,  and  if  he  fails  it  is  at  best  useless.  We  should 
then  confine  ourselves  to  detaching  the  fleshy  fibres  exactly,  with  the  knife 
or  bistoury.  That  done,  the  operator  embraces  the  member  with  the  left  hand, 
placing  the  thumb  immediately  above  or  below  the  point  which  is  to  sustain 
the  action  of  the  instrument.  The  saw,  held  in  the  right  hand,  is  applied  per- 
pendicularly and  moved  rapidly  to  and  fro  with  short  strokes  until  a  way  is 
made  ;  afterwards  it  is  drawn  from  heel  to  point,  and  pressed  very  lightly. 
Wliilst  there  is  yet  considerable  portion  of  bone  to  be  traversed  by  the  saw 
the  operator  may  proceed  quickly,  but  when  he  approaches  the  end  of  the 
division  he  must  observe  the  greatest  caution.  At  this  period  the  assistants 
also  should  redouble  their  care  to  maintain  the  opposite  parts  of  the  member 
in  their  natural  direction.  If  the  assistant  who  holds  the  diseased  part  lower 
it,  the  bone  will  inevitably  break  before  it  has  been  entirely  divided  ;  if  he 
raise  it,  on  the  contrary,  the  action  of  the  saw  will  be  impeded  and  the  ope- 
ration thus  rendered  more  difficult.  It  is  necessary  also,  that  the  operator 
should  be  habituated  to  the  use  of  the  instrument,  and  that  in  sawing  he  should 
be  careful  not  to  incline  it  either  to  one  side  or  the  other.  With  attention  to 
these  instructions  the  bone  will  generally  be  cleanly  divided.  But  if  any 
points  or  asperities  remain  at  its  extremity,  they  should  be  immediately  re- 
moved either  with  incisive  pincers,  which  are  generally  used,  with  a  small 
saw,  which  appears  to  me  to  be  the  best  instrument  or,  when  they  are  suffi- 
ciently long,  with  the  same  saw  which  has  been  used  for  the  amputation.  The 
edges  of  the  section  are  usually  so  sharp  that  some  surgeons,  such  as  Messrs. 
Graafe  and  Hutchinson,  have  recommended  that  they  should  be  rounded  with 
a  tile  or  with  the  edge  of  a  short  and  firm  scalpel.  This  practice,  however, 
is  not  imitated  by  other  surgeons ;  both  theory  and  observation  unite  in  demon- 
strating its  inutility. 

4.  Ilamostasis. — Immediately  after  the  section  of  the  bone,  the  operator 
removes  the  cleft  compress  and  proceeds  to  close  the  vessels. 

A.  Topicals. — We  do  not  now,  as  in  the  time  of  Paul  of  Egina,  cauterize 
the  wound  with  a  hot  iron,  boiling  oil,  or  melted  lead;  nor  stufl' it  with 
oakum  or  plasters  smeared  or  saturated  with  the  white  of  eggs,  bole  arme- 
nic,  or  oilier  astringents,  used  by  Guy  of  Chauliac,  and  almost  all  the  surgeons 
of  the  middle  ages  ;  nor  have  we  recourse  to  arsenic,  vitriol,  or  alum,  still 
more  lately  recommended  by  Lavauguyon  and  Le  Dran  ;  nor,  finally,  employ 
the  sponge,  or  agaric  of  the  oak,  as  was  proposed  by  Brossard  and  Morand 
towards  the  middle  of  the  last  century.  M.Binelli,  however,  says,  that  with 
a  water  of  Ins  invention  it  is  easy  to  arrest  every  kind  of  hemorrhage;  and 
several  experiments  seem,  in  fact,  to  support  liis  assertion.  M.  Bonafoux 
composes  with  charcoal,  gum,  and  colophony,  a  powder  which  he  recommends 
as  possessing  the  same  properties.  Finally,  Messrs.  Talricli  and  Grand  have 
discovered  a  liquid,  the  efficacy  of  which  has  been  put  out  of  doubt  by  nume- 
rous experiments  upon  dogs,  sheep,  horses,  &c. ;  but  application  of  these 
novel  means  having  never  yet  been  made  upon  the  human  subject,  I  abstain 
from  any  further  discussion  of  them. 


OPEBATIVE    SURGERY.  155 

B.  The  ligature  is  justly  preferred.  Pare  is  the  author  of  this  important 
modification.  If  Galen,  Avicenna,  Tagault,  and  some  others,  had  already 
mentioned  it,  it  must  be  confessed  that  it  was  without  advantage  to  the  prac- 
tice of  surgery.  F.  de  Hilden,  Wiseman,  Dionis,  and  De  la  Motte,  who 
speedily  adopted  it,  were  not  long  in  causing  its  general  dissemination,  and 
now  for  a  long  time  it  is  only  by  way  of  exception  that  it  is  ever  neglected, 
or  that  other  means  are  substituted  in  its  place.  The  operator  commences 
with  the  principal  artery,  inasmuch  as  it  is  more  easily  found  than  any  other, 
is  more  necessary  to  be  obliterated,  and  because  the  other  arteries  will  also 
afterwards  be  discovered  with  less  difficulty  on  account  of  the  greater  quan- 
tity of  blood  which  will  be  conveyed  to  them.  The  principal  artery  then  is 
talcen  up  with  pincers,  embracing  its  whole  thickness,  but  carefully  avoiding 
the  nerve  and  vein.  Some  practitioners,  Desault,  Hey,  &:c.,  have  however 
recommended,  at  least  for  the  great  trunks,  that  the  operator  should  reach 
and  tie  at  the  same  time  the  deep  artery  and  vein,  by  directing  one  of  the 
branches  of  the  pincers  into  the  mouth  of  each.  They  intended  by  this  means 
to  guard  against  hemorrhages  which  miglit  arise  from  the  great  veins.  The 
moderns  reject  this  practice  ;  first,  as  useless,  and  afterwards  as  dangerous  ; 
useless,  because  the  concentric  circulation  of  the  veins  does  not  permit  the 
blood  to  escape  by  their  mouths  into  the  body  of  the  stump,  and  because  even 
if  that  accident  happen  it  is  not  necessary  to  have  recourse  to  the  ligature; 
dangerous,  because,  say  they,  in  strangling  a  great  vein  the  operator  runs  the 
risk  of  producing  inflammation  in  its  coats.  As  to  the  ligature  of  the  nervous 
cords,  that  is  a  practice  which  all  agree  in  discountenancing.  Instead  of  pin- 
cers, Bromfield,  and  the  greater  part  of  English  surgeons  make  use  of  the  tena- 
culum; but  this  instrument,  although  it  renders  the  application  of  the  thread 
more  sure  and  easy,  is  not  so  convenient  as  the  pincers  for  seizing  the  vein 
and  drawing  it  out  without  laceration ;  this  is  no  doubt  the  reason  why  the 
tenaculum  is  rarely  used  in  France.  But  whichever  may  be  used,  when  once 
the  artery  has  been  seized  the  operator  endeavors  to  bring  it  out  from  the 
surface  of  the  wound;  an  assistant  then  passes  a  thread  beneath  it,  bringing 
the  ends  together  above  so  as  to  form  a  loop,  which  he  passes  beyond  the' 
end  of  the  pincers  :  these  are  then  turned  horizontally.  It  is  tightened  by 
seizing  its  extremities  with  the  last  fingers  of  both  hands,  and  drawing  them 
upwards,  while  with  the  fore-fingers  and  thumbs  the  knot  is  pressed  as  deeply 
as  possible  into  the  w^ound.  Some  persons,  according  to  the  advice  oF 
M.  Richerand,  prefer  pulling  upon  the  thread  in  such  a  way  as  to  draw  the 
extremities  backwards,  beyond  the  place  where  the  artery  is  found.  If  the 
vessel  is  found  at  the  bottom  of  an  excavation,  the  same  end  will  be  attained 
by  holding  the  ligature  away  from  the  knot  on  each  side  with  the  fore-fingers, 
which  there  represent  a  sort  of  pulley.  All  these  rules,  however,  are  unne- 
cessary to  a  surgeon  of  any  intelligence ;  every  such  practitioner  will  adopt 
tliat  method  which  appears  to  him  the- most  convenient  and  the  most  safe. 
The  principal  artery  being  closed,  the  others  are  carefully  sought  for  and 
successively  obliterated  in  the  same  manner,  except  that  it  is  unnecessary  to 
isolate  them  so  exactly  from  the  small  veins  and  other  tissues  which  surround 
them. 

Single  threads  are  employed  for  vessels  of  the  second  or  third  order,  and 
double  or  triple  ones  for  the  great  trunks.  In  England,  where  fine  ligatures 
have  been  generally  adopted  in  the  treatment  of  aneurisms,  double  and  triple 
threads  are  no  longer  used  after  amputations.  The  principal  artery  is  some- 
times so  hard,  and  encrusted  with  phosphate  of  lime,  as  to  crack  like  glass 
under  the  application  of  the  ligature ;  in  these  cases  a  small  cone  of  linen. 


156  .  NEW   ELEMENTS   OF 

cork,  elastic  gum,  or  any  other  similar  substance,  should  be  introduced  within 
it;  or  a  small  cylinder,  like  to  that  which  is  called  Scarpa's  roll,  should  be 
placed  between  the  artery  and  the  ligature,  which  ought  to  be  larger  than 
those  used  for  healthy  trunks.  Finally,  it  has  been  thought  by  some  that 
simply  flattening  the  vessel  would  be  a  sufficient  precaution  against  hemor- 
rhage. 

Sometimes  the  blood  escapes  from  the  interior  of  the  bone,  either  by  transu- 
dation or  from  the  trunk  of  its  proper  artery.  A  small  graduated  compress 
applied  upon  the  place  from  which  the  blood  issues,  whilst  the  operator  seeks 
the  other  vessels,  will  usually,  says  Mr.  Ramsden,  be  found  sufficient  to 
arrest  this  hemorrhage ;  otherwise  it  would  be  necessary  to  have  recourse  to 
cauterization,  or  to  place  a  morsel  of  wax,  or  plugs  of  lint  or  agaric  in  the 
medullary  canal.  A  great  number  of  arterial  branches  may  be  seen  during  this 
operation  which  cannot  be  found  immediately  afterwards,  and  which  sometimes 
a  little  later  cause  a  very  abundant  flow  of  blood.  This  phenomenon  is  ex- 
plained in  a  way  which  appears  to  me  any  thing  but  satisfjictory.  I  do  not 
see  why  the  momentary  absence  of  hemorrhage  should  be  attributed  to  spasm 
of  the  divided  arteries,  to  their  retraction,  or  to  the  instantaneous  action  which 
the  air  exercises  upon  them.  If  they  seem  to  reopen  at  the  expiration  of  a 
few  hours,  that  circumstance  is  evidently  produced  by  the  concentric  deter- 
mination of  the  organic  actions  consequent  upon  the  operation,  which  after- 
wards gives  place  to  an  eccentric  movement — a  reaction  more  or  less  lively, 
whicii  carries  the  fluids  back  from  the  interior  towards  the  exterior.  The 
practice  followed,  first  by  Parrish,  in  America,  by  Klein,  in  Germany,  by 
several  surgeons  in  England,  and  even  by  Messrs.  Dupuytren  and  Lisfranc, 
in  France,  of  leaving  the  wound  open  for  several  hours  in  order  to  give  time  to 
the  lesser  arterial  branches  to  return  to  their  natural  state,  does  not  appear  to 
be  in  accordance  with  reason,  and  I  believe  I  may  permit  myself  to  condemn 
it  as  a  general  method. 

Since  immediate  reunion  after  amputation  has  been  proposed  and  followed 
by  a  great  number  of  practitioners,  there  has  been  an  endeavor  to  leave  as  few 
foreign  bodies  in  the  wound  as  possible.  They  begin  by  cutting  one  of  the 
ends  of  each  ligature  very  near  to  the  artery.  M.  Weitch,  who  believed  him- 
self the  inventor  of  this  modification,  insisted  strongly,  in  1806,  upon  the 
advantages  which  resulted  from  it.  He  employed  then,  as  has  since  been 
recommended,  very  fine  silk  threads,  in  order  to  be  able  to  cut  both  ex- 
tremities and  leave  the  knot  about  the  artery.  Drs.  Haire,  Wilson,  Belcombe, 
Maxwell,  Hennen,  &c.  had  followed  this  practice  long  before  it  was  men- 
tioned by  Mr.  Lawrence.  Messrs.  Collier,  S.  Cooper,  and  Delpech,  have  also 
tried  it  with  success ;  nevertheless,  Messrs.  Cross,  Dauning,  Guthrie,  &c. 
have  remarked  that  these  ligatures  frequently  produced  secondary  abscesses. 
It  appears,  moreover,  from  the  researches  of  Messrs.  Hennen  and  Carwar- 
dine,  that  this  practice  of  cutting  the  ends  of  the  ligature  very  close  to  the 
knot,  was  followed  in  diSerent  countries  of  Europe  from  the  year  1780.  As 
it  appeared  that  thread  or  silk  could  not  be  absorbed,  but  acted  always 
as  foreign  bodies,  ligatures  formed  of  other  substances  were  introduced. 
Ruysch  had  already  proposed  broad  strips  of  leather,  the  use  of  which  Beclard 
has  revived  in  France.  In  America,  Dr.  Physick  tried  ligatures  of  deer-skin. 
These  latter  are  much  praised  by  Dr.  Jameson,  who  has  long  employed  them. 
Others  have  had  recourse  to  catgut,  &c.,  and  to  the  intestines  of  silk  worms; 
but  experience  has  not  yet  pronounced  upon  the  real  and  definitive  merit  of 
these  diiferent  substances.  Ligatures  of  thread,  single  or  double,  according 
to  the  volume  of  the  artery,  are  generally  used  in  Paris.    When  they  have 


OPERATIVE   SURGERY.  \57 

been  applied,  and  before  proceeding  to  the  dressing,  one  of  the  ends  is  cut 
very  near  to  the  vessel,  in  order  to  diminish  tlie  mass  which  they  form  in  the 
midst  of  the  tissues ;  the  other  extremity  remains  on  the  outside  of  the  wound, 
and  serves  to  withdraw  the  knot  when  it  has  become  detached  from  the  artery. 

C.  Compression. — M.  Koch,  surgeon  of  the  hospital  of  Munich,  affirms  that 
for  more  than  twenty  years  he  has  not  in  any  case  had  recourse  to  the  liga- 
ture after  amputation.  He  confines  himself  to  compressing  the  principal 
artery  of  the  member  by  means  of  graduated  compresses,  and  a  rolled  band- 
age extending  from  the  trunk  almost  to  the  wound,  which  he  unites  imme- 
diately. Numerous  facts,  he  says,  support  this  practice,  and  prove  that  it  is 
not  necessary  to  tie  the  arteries  in  order  to  prevent  the  passage  of  the  blood 
to  the  surface  of  the  stump.  A  question  of  a  serious  nature  seems  to  me  to  be 
at  the  bottom  of  these  assertions.  The  annals  of  science  contain  facts  with- 
out number,  which  prove  that  the  most  voluminous  arteries  may  be  divided 
without  giving  rise  to  any  effusion  of  blood.  Every  one  knows  that  lacerated 
wounds,  amputations  after  gangrene,  and  wounds  by  lire-arms,  have  often 
astonished  practitioners  in  this  particular.  S.Wood  had  the  shoulder  torn 
off  by  the  wheel  of  a  mill,  and  was  cured  without  an  artery  being  tied. 
l)e  la  Motte,  Carmichael,  Dorsey,  and  Mussey,  each  report  a  similar  case. 
A  child  nine  years  of  age,  mentioned  by  Benomont,  had  its  leg  torn  off,  and 
was  cured  in  the  same  manner.  In  another  case,  the  thigh,  violently  sepa- 
rated from  the  haunch,  was  unattended  by  any  flow  of  blood.  The  ampu- 
tation of  the  thigh  related  by  Tcheps,  Scharschmidt,  Theden,  Thomson, 
Messrs.  Taxil,  S.  Cooper,  Beauchene,  Segond,  Labesse,  presented  the  same 
phenomenon.  Messrs,  Arbe,  Lizars,  Mudie,  Smith,  and  Flandin,  mention 
several  amputations  of  the  leg,  arm,  fore-arm,  &:c.,  which  were  attended  with 
similar  results ;  and  I  have  myself  witnessed  several  cases  of  the  same 
description.* 

The  researches  which  I  have  made  upon  this  point  of  practice,  have  led  me 
into  several  experiments  the  principal  results  of  which  are  here  detailed : — 

D.  5rjiisi7io-.-^Bruising  is  rarely  sufficient,  except  for  small  arteries  ;  if  those 
who  practise  it  after  having  cut  or  torn  the  cord  of  newly-born  infants  ;  if  the 
animals  who  effect  it  by  chewing  the  umbilical  cord  of  their  young,  succeed 
thus  in  preventing  hemorrhage,  it  is  because  the  circulation  generally  ceases 
of  itself  in  the  umbilical  vessels  after  birth.  Nevertheless,  after  havino-  em- 
ployed it  successfully  upon  the  epigastric  artery  and  those  of  the  leg  and 
fore-arm,  I  can  conceive  that  Le  Dran  may  have  contented  himself  with  this 
practice  after  dividing  the  seminal  cord  of  man. 

E.  Plugging. — A  cone  of  alum  or  sulphate  of  iron,  about  three  times  in 
length,  placed  in  the  crural  artery  and  even  in  the  carotid  of  a  cat  or  doo-, 
fixes  itself  promptly,  and  is  generally  sufficient  to  arrest  the  effusion  of  bloocf ; 
but  the  species  of  eschar  which  results  from  it  preventing  immediate  reunion, 
it  is  possible  that  the  blood  may  re-appear  at  the  coming  away  of  this  foreign 
body ;  it  should  be  added  too,  that  its  introduction  is  not  always  easy  except 
in  the  great  arteries.  Wax  produces  the  same  effects,  but  being  more  slip- 
pery and  exerting  no  chemical  action  upon  the  vessel,  it  requires  to  be  thrust 
m  more  deeply  :  nevertheless,  if  when  it  is  introduced  the  operator  pushes 
it  downwards  with  pincers  or  with  the  fingers  through  the  walls  of  the  vascu- 
lar tube,  the  extremity  of  which  he  at  tlie  same  time  holds  firmly  closed, 
there  will  be  formed  a  sort  of  knot,  which  the  blood  will  have  some  difficulty 
in  removing.     The  stylet  which  Chastanet  seems  to  have  used  long  since  for 

♦Journal  Hebdomadaire,  1S30-1831. 


158  NEW   ELEMENTS    OF 

the  same  purpose,  though  less  sure,  yet  quite  frequently  effects  the  obliteration 
of  the  artery.  The  point  of  a  bougie  is  far  better,  at  least  whenever  it  is  made 
to  penetrate  not  less  than  an  inch.  Catgut,  deer  skin,  or  chamois  leather, 
being  scarcely  foreign  bodies,  offer  still  greater  advantages,  in  consequence  of 
their  presenting  no  obstruction  to  the  immediate  closure  of  the  wound.  These 
different  substances  form  a  species  of  cork,  the  manner  of  using  which  is  too 
simple  to  require  a  particular  explanation.  M.  Miquel,  of  Amboise,  made 
simdar  observations  at  the  close  of  the  year  1828.  I  have  incontestably 
proved,  says  he,  by  thirteen  experiments,  that  by  introducing  into  the  arteries 
of  a  dog  a  foreign" body,  particularly  an  instrumental  cord,  a  morbid  state  is 
speedily  and  invariablj"  produced,  which  renders  them  incapable  of  receiving 
the  blood,  although  they  may  not  be  mechanically  obliterated. 

F.  Folding  back. — AVhen  it  is  not  too  difficult  to  isolate  the  artery  in  order 
to  fold  it  upon  itself,  as  was  practised  by  Theden  upon  the  intercostal,  and 
by  Le  Dran  upon  the  whole  of  the  cord,  after  castration,  this  method  will 
almost  invariably  stop  the  flow  of  blood.  To  do  this  it  is  sufficient  to  bend 
back  the  extremity  of  the  vessel,  to  double  it,  and  to  push  it  a  little  way  into 
the  flesh,  or  to  close  the  wound  immediately  over  it,  in  order  to  maintain  the 
artery  in  the  position  that  has  been  given  to  it.  A  branch  of  the  external 
mammary  and  two  branches  of  the  subscapulars,  thus  treated  in  the  month 
of  August,  1828,  at  the  hospital  of  the  school  of  medicine,  in  the  case  of  a  fe- 
male upon  whom  I  had  operated  for  an  enormous  tumor  at  the  left  arm-pit,  were 
unattended  with  the  slighest  flow  of  blood.  The  same  is  true  of  an  a^ed 
woman  whom  I  relieved  from  a  cancer  in  the  breast,  towards  the  termination 
of  the  year  1829,  at  the  Hospital  St.  Antoine  ;  and  of  a  third  patient  in  the 
month  of  January,  1830,  in  whose  case  I  was  obliged  to  remove  the  first  meta- 
carpal bone.  As  it  is  possible,  however,  that  without  this  doubling  tlie  flow 
of  blood  might  have  ceased,  prudence  recommends  delay  in  coming  to  a 
conclusion,  notwithstanding  the  authority  of  Mr.  Guthrie,  who,  after  having 
said  that  the  slightest  pressure  exercised  with  the  extremity  of  the  fore-finger 
suflices  to  arrest  hemorrhage,  adds :  *'  If  the  orifice  of  the  artery,  whether  by 
the  effect  of  a  natural  curvature  of  the  vessel  or  by  accident,  retracts  or 
turns  to  one  side  in  such  a  way  as  to  put  itself  in  contact  with  a  somewhat 
solid  muscular  surface,  that  simple  contact  will  prevent  any  escape  of  blood. 

G.  The  perpendicular  compression,  which  J.  L.  Petit  endeavored  to  intro- 
duce during  the  last  century,  has  not  been  adopted.  By  directing  plugs  of 
linen,  agaric,  sponge,  or  lint,  upon  the  arteries  at  the  bottom  of  the  wound, 
with  the  assistance  of  a  machine,  we  should  but  aggravate  the  usual  results 
of  the  operation,  without  being  sure  of  preventing  hemorrhage.  Even  in  his 
famous  case  of  the  Marquis  of  Roquelin,  Petit  would  have  done  better  in 
exposing  the  principal  arterial  trunk  of  the  limb  above  the  solution  of  conti- 
nuity, than  in  proceeding  as  he  did  upon  that  occasion. 

Sometimes  tne  arteries  are  so  deeply  hidden  in  the  flesh  after  amputation, 
that  it  is  impossible  to  seize  or  take  them  up  with  either  tenaculum  or  pincers. 
On  these  occasions,  if  they  are  at  all  events  to  be  tied,  a  thread  must  be  passed 
round  them  by  means  of  a  suture  needle,  at  the  risk  of  embracing  more  or 
less  of  the  circumjacent  tissues. 

7.  Torsion. — A  question  completely  novel,  as  it  springs  from  the  experi- 
ments before  referred  to,  is  that  of  torsion,  as  a  substitute  for  ligature  after 
amputation.  I  was  conducted  to  this  discovery,  in  1826,  while  putting  to  the 
proof  upon  dogs  the  various  known  means  of  preventing  hemorrhage.  I  had 
never  tried  it  upon  man,  and  had  not  sufficiently  varied  my  experiments  upon 
animals  to  permit  myself  to  speak  upon  the  subject,  except  to  the  students 


OPERATIVE    SURGERY.  159 

who  attended  mj  lectures  upon  surgery,  at  the  close  of  the  year  182r.  But 
on  the  13th  November,  1828,  after  having  amputated  the  arm  of  the  girl  Rohan, 
in  the  presence  of  Messrs.  Al.  Dubois  and  Mai  teste,  I  twisted  the  radial  and 
ulnar  arteries,  doubled  back  the  anterior  interosseal,  and  immediately  closed 
the  wound.  No  hemorrhage  resulted,  and  a  cure  was  effected  in  twenty- 
tiiree  days.  On  the  4th  December  following,  I  followed  the  same  mode  of 
procedure  and  with  similar  success,  after  the  amputation  of  the  first  meta- 
tarsal bone.  The  patient  was  a  strong  and  vio;orous  male  adult.  It  was  not 
however  until  the  21st  September,  1829,  that  I  practised  amputation  of  the 
thigh  without  ligatures.  I  had  to  twist  only  the  crural  artery,  and  two  small 
muscular  branches.  No  hemorrhage,  followed.  The  youn^  girl,  nineteen  years 
of  age,  who  did  well  until  the  fourth  day,  died  on  the  twelfth.  An  examination 
of  the  body  discovered  several  purulent  and  tuberculous  collections  in  the 
lungs.  The  articulation  of  the  hip  was  in  the  height  of  suppuration.  Some 
days  later,  the  26th  of  the  same  month,  I  did  nearly  the  same,  after  ampu- 
tating the  arm  of  a  young  man  twenty-three  years  of  age.  The  humeral  artery, 
the  great  anastomotic,  and  two  branches  of  the  external  collateral,  were  twisted 
without  difficulty,  but  several  other  branches  offered  greater  resistance. 
Seeing,  at  the  expiration  of  a  quarter  of  an  hour,  that  in  spite  of  the  tourniquet 
the  blood  continued  to  flow',  I  removed  the  dressings.  Nothing  flowed  from 
the  twisted  arteries.  The  hemorrhage  proceeded  from  those  which  had  been 
bruised,  and  from  three  others  which  I  had  not  at  first  perceived.  I  tied  them 
all,  and  the  blood  did  not  re-appear.  The  patient  died  on  the  sixth  day,  and 
the  examination  of  the  corpse  discovered  no  other  lesion  than  a  deep  disease 
of  the  scapulo-humeral  articulation.  The  vessels  both  arterial  and  venous, 
presented  no  trace  of  inflammation,  and  the  arterial  extremities,  firmly  closed, 
were  in  both  these  cases  lost,  as  it  were,  in  the  midst  of  the  other  tissues. 

I  became  from  this  time  convinced  that  torsion  would  succeed  as  well  upon 
the  arteries  of  man  as  upon  those  of  dogs,  and  that  in  cases  of  necessity  it 
would  be  possible  to  use  it  instead  of  the  ligature.  It  remains  to  be  seen 
whether  it  is  better  and  ought  to  be  preferred  to  the  latter.  The  experiments  of 
M.Thierry,  who  was  unacquainted  with  mine  first  made  upon  horses,  and  com- 
mencing at  the  beginning  of  July,  1829  ;  those  that  M.  Amussat  made  known 
to  the  academy  on  the  15th  of  the  same  month,  three  years  after  my  first  attempts, 
and  which  he  has  so  frequently  repeated  since ;  those  of  Messrs.  Lieber, 
Klu^e,Schrader,  Tyro,  Reigner,  and  Dard,upon  animals;  of  Blandin,  Iloux, 
Ansiaux,  Fricke,  Dieft'enbach,  Rust,  Fourcade  and  Bedor,  Lallemand  and  Del- 
pech,  Guerin^Jobert,  and  Key,  upon 'the  human  subject,  without  definitively 
decidingthis  question,  are  sufficiently  numerous  to  render  its  solution  probable. 

Modes  of  Operation. — Like  every  thing  else  which  depends  \ipon  the  hands 
of  men,  the  manner  of  twisting  the  arteries  will  vary  according  to  the  ideas  or 
caprices  of  each  practitioner. 

1.  M.  Thierry,  who  recommends  that  it  should  be  done  parallel  with  the 
axis  of  the  vessel,  contents  himself  with  seizing  the  divided  tube  by  its  ex- 
tremity with  Percy's  pincers,  or  rather  with  pincers  the  chaps  of  which  should 
be  larger  or  smaller  according  to  the  calibre  of  the  artery,  and  turns  it  upon 
itself  from  four  to  eight  or  ten  times,  without  fixing  the  base. 

2.  In  Germany  several  other  modifications  have  been  already  proposed. 
M.  Kluge,  for  example,  boasts  much  of  an  instrument  of  his  invention,  which 
by  unloosing  a  spring,  causes  the  pincers  to  turn  upon  themselves. 

3.  For  my  own  part  I  use  any  kind  of  grooved  pincers,  or  even  the  ordi- 
nary ligature  pincers.  After  having  seized  with  this  instrument  the  vessel  at 
its  extremity,  I  isolate  it  from  the  surrounding  tissues,  and  then  seize  it  towards 


iF  »' 


160 


NEW    ELEMENTS    OF 


its. root  at  the  bottom  of  the  wound  with  another  pair  of  pincers,  so  as  to  fix 
it,  or  perhaps  with  the  thumb  and  fore-finger,  whilst  with  the  lirst  pincers  I 
turn  it  upon  its  axis  from  three  to  eight  times,  and  not  three  times  onlj  for 
the  great  arteries,  as  I  have  been  erroneously  made  to  say. 

4.  M.  Amussat  recommends  that  the  artery  should  be  seized  with  pincers 
having  round  branches,  and  drawn  out  some  lines  from  the  bleeding  surface ; 
that  after  itibas-been  carefully  isolated  from  the  veins,  the  nervous  filaments, 
and  all  the  tissues  which  surround  it,  the  blood  which  it  contains  should  be 
crowded  back,  and  that  it  should  be  fixed  towards  its  root  with  a  second  pair 
of  pincers,  whilst  th.e  first  pair  break  by  gentle  movements  the  internal  and 
middle  tunics  ;  that  the  extremity  of  the  artery  should  then  be  twisted 
somewhat  rapidly  from  six  to  ten  times  at  the  same  time  that  the  stationary 
pincers  fix  it,  without  pressing  it  too  much  towards  the  flesh,  and  that  as  soon 
as  the  rupture  of  the  inner  membranes  has  been  accomplished,  they  should  be 
crowded  back  in  the  direction  of  the  heart,  by  acting  through  the  cellular 
tunic  as  I  have  described  under  the  article  aneurism.  Instead  of  pusliing 
back  and  leaving  the  isolated  part  of  the  artery  at  the  bottom  of  the  wound, 
the  operator  may  continue  to  twist  it  until  he  detaches  it  completely,  and  leave 
only  a  sort  of  gimlet  point  in  the  middle  of  the  wound.  "Nevertheless,  it 
must  be  acknowledged,"  says  M.  Vilardebo,  from  whom  I  borrow  these  details, 
"that  these  manoeuvres  are  more  easily  executed  when  tlie  torsion  is  limited 
by  the  fingers  than  when  the  operator  makes  use  of  two  instruments.  The 
second  pincers  are  only  useful  in  fraying  the  artery  and  crowding  back  the 
broken  coats.  After, this,  the  thumb  and  the  index  finder  of  the  left  hand 
seize  the  extremity  of  the  vessel  at  the  point  beyond  which  the  inner  coats 
have  been  pushed,  and  makes  first  several  turns  with  the  pincers,  to  which 
the  operator  afterwards  approaches  the  fingers  and  continues  the  twisting  a 
moment  longer  ;  he  seizes  the  artery  still  nearer  and  nearer  to  the  instrument, 
always  continuing  the  torsion,  and  so  on  till  the  fingers  meet  the  instrument. 
The  operation  is  terminated  by  rolling  the  spiral  thus  formed  into  the  shape 
of  a  cork-screw,  and  by  pushing  it  into  the  depth  of  the  parts." 

Remarks. — Two  things  require  to  be  separately  considered  in  this  process, 
1st,  the  isolation,  and  2dly,  the  torsion  of  the  vessel.  The  first,  which  applies 
equally  to  the  ligature  and  to  torsion,  is  incomparably  the  most  difficult  and  the 
most  complicated.  Although  the  great  arteries,  surrounded  by  healthy  tissues, 
flexible  and  elastic  themselves  and  free  from  disease — all  those  which  are 
seated  in  the  muscular  or  cellular  interstices,  may  be  easily  enough  taken  up, 
divested  of  the  surrounding  lamellae,  lengthened  and  drawn  oiit  several  lines — 
it  is  far  from  being  so  with  those  which  creep  along  in  the  thickness  of  some 
of  the  tendons  or  of  voluminous  nerves,  and  which  adhere  by  their  circumfe- 
rence or  their  external  surface  to  the  fatty  strata  that  envelope  them  ;  which 
are  fragile,  scarcely  perceptible,  crushed  by  the  least  pressure,  and  which  one 
is  afraid  to  let  go  when  they  have  once  been  seized.  If  it  were  absolutely 
necessary,  the  operator  might  doubtless  reach  them  in  the  majority  of  cases 
with  time,  address,  and  precaution.  But  what  benefit  would  result  from  this? 
It  is  an  error  which  has  been  a  hundred  times  demonstrated,  to  believe  that 
it  is  dangerous  to  comprise  a  few  lamella  of  the  cellular  tissue,  or  fleshy  fibres 
in  the  ligature  at  the  same  time  with  the  artery.  Nervous  filaments,  and  even 
small  veins  intercepted  in  this  manner,  do  not  in  reality  give  rise  to  any  other 
inconvenience  than  that  of  causing  for  the  time  a  slight  increase  of  pain.  One 
must  be  a  stranger  to  the  habitual  practice  of  the  great  hospitals,  to  charge  to 
imperfect  isolation  of  the  arteries  the  accidents  which  so  frequently  follow 
amputation.    So  that  it  is  only  in  applying  torsion,  that  these  preliminaries  are 


^ 


OPERATIVE    SURGERY.  161 

indispensable;  from  which  it  follows,  let  us  say  at  once,  that  as  regards 
execution  the  ligature  will  always  hare  the  advantage.  Happily,  we  may 
safely  neglect  a  part  of  the  instructions,  given  by  M.  Amussat.  In  following 
them  to  the  letter,  M.  Jobert  saw  the  hemorrhage  reappear  by  the  twisted 
arteries.  Mr.  Fricke,  who  follows  almost  the  same  method  as  myself,: 
Messrs.  DieiFenbach,  Rust,  &c.,  who  have  only  partially  adopted  these 
instructions,  have  rarely  observed  the  same  inconvenience.  It  is  not 
because  I  have  continued  to  employ  my  own  mode  of  procedure  that  the 
torsion  has  sometimes  miscarried  in  my  hands.  Wherever  the  vessel 
was  easily  taken  up,  caused  to  project,  fixed  behind  with  other  pincers  or 
with  the  pulp  of  the  two  fingers,  the  obliteration  was  perfect,  although  I 
might  not  have  thought  it  necessary  to  isolate  it  farther.  For  the  rest,  this 
difficulty  is  the  only  one,  so  far  that  I  know  to  be  connected  with  torsion. 
When  the  favorable  conditions  which  I  have  mentioned  above  manifest 
themselves,  and  the  practitioner  gives  the  necessary  attention  to  the  operation^ 
the  arteries  will  be  as  firmly  closed  as  if  they  had  been  tied.  The  inflam- 
mation and  suppuration,  whether  external  or  internal,  €«f  the  vascular  and 
nervous  fasciculus,  do  not  appear  to  be  more  likely  to  occur  after  torsion  than 
under  the  influence  of  the  ligature,  except  perhaps  when  the  torsion  is  prac- 
tised with  a  simple  pair  of  pincers,  and  without  taking  the  precaution  to  limit  its 
extent  towards  the  heart,  as  in  the  process  of  M.  Thierry,  for  example.  At 
least  there  is  nothing  in  the  facts  publishetl  at  Berlin,  at  Hamburgh,  and  at 
Paris,  together  with  those  which  have  come  under  my  own  observation,  to  show 
that  the  fears  of  the  professor  of  MontpeUier  have  any  foundation.  The  re- 
proach which  has  been  thrown  upon  torsion  of  leaving  a  piece  of  the  artery 
to  act  as  a  foreign  body  in  the  wound,  appears  to  me  without  foundation.  Id 
the  two  subjects  operated  upon  by  me  at  the  Hospital  St.  Antoine,  this  vascu- 
lar stump,  still  distinguishable,  was  firmly  united  with  the  surrounding  tissues 
so  as  to  give  no  further  trouble,  and  I  have  never  heard  that  other  prac- 
titioners nave  shown  this  circumstance  to  have  an  injurious  tendency.  Thus, 
the  only  undeniable  defedts  of  torsion  are  that  it  does  not  always  offer  so 
much  securit^p^  as  the  ligature  ;  that  it  is  not  applicable  in  all  cases ;  that  it 
requires  considerable  skill  and  practice  to  execute  it  properly ;  and  that  it 
renders  the  operation  longer  and  more  fatiguing.  On  the  hand,  by  leaving  no 
foreign  body  in  the  wound,  it  offers  the  great  advantage  of  favoring  imme- 
diate union,  of  off*ering  no  irritation  to  the  bleeding  surface,  and  of  helping 
us  to  bring  about  a  cure  without  suppuration.  In  this  respect,  however,  the 
attempt  of  the  operator  will  scarcely  be  satisfactory.  The  patients  of  M. 
Amussat,  with  the  exception  of  a  child  who  recovered  at  the  end  of  twelve 
or  fifteen  days,  were  not  cured  sooner  than  they  would  have  been  by  the 
use  of  the  ligature.  Union  strictly  by  the  first  intention  has  not  been  ob- 
tained by  Messrs.  Fricke,  at  the  Hamburgh  Hospital ;  Ansiaux,  at  the  Liege 
Hospital ;  Dieftenbach  and  Rust,  at  the  Berlin  Hospital ;  Guerrin,  at  Paris; 
Bedor  and  Fourcade,  at  the  Troyes  Hospital ;  Lallemand  and  Delpech,  at  the 
Montpellier  Clinique,  nor  by  Key,  at  Guy's  Hospital,  in  any  cases  of  ampu- 
tation whatever.  This  being  the  case,  torsion  has  no  real  claim  to  preference 
except  in  some  operations  which  are  practised  upon  the  soft  parts  alone.  In 
fact,  ligatures  well  applied,  can  always  be  removed  at  the  sixth  or  twelfth 
day  :  and  a  host  of  facts  prove,  that  after  their  removal,  eight  or  fifteen  day8> 
and  sometimes  less,  suflBce  to  complete  the  cure.  And  we  cannot  see  how  an 
extensive  wound,  comprising  bone,  muscle,  aponeurosis,  so  many  different 
tissues  through  the  whole  thickness  of  a  limb,  can  be  fully  cicatrized,  firmly- 
united  in  less  than  twelve  or  twenty  days.  On  the  whole,  I  believe  that  after 
21 


162  NEW   ELEMENTS  OF 

amputations  it  is  useless  to  be  at  much  pains  in  twisting  those  arteries  which 
present  any  difficulties  in  the  way  of  torsion ;  but  that  it  would  be  better  to 
tie  them  at  once,  leaving  to  torsion  in  such  cases  the  rank  of  an  exceptionary 
method.* 

§  2.  Dressing. 

There  are  two  general  methods  of  treating  the  wound  resulting  from  ampu- 
tation ;  sometimes  the  lips  are  united  as  exactly  as  possible,  and  the  most 
perfect  contact  is  aimed  at.  Sometimes,  on  the  contrary,  they  are  kept  apart 
by  placing  between  them  foreign  bodies  and  several  pieces  of  dressing.  In 
the  first  case  the  operator  seeks  to  obtain  what  is  called  immediate  union,  or 
hy  first  intention;  in  the  second,  suppuration  is  favored,  and  the  cure  or  cica- 
trization is  only  ohta.me6.  mediately  or  by  second  intention. 

A.  Mediate  Reunion. — Until  the  end  of  the  last  century  surgical  writers 
speaT:  only  of  mediate  reunion  after  circular  amputation,  but  the  operation  was 
far  from  being  always  performed  upon  these  principles. 

The  ancients  were  m  the  habit  of  filling  the  wound  witli  compresses  or 
sponj^es  dipped  in  vinegar;  treating  it  in  all  respects  like  all  other  solutions 
of  continuity  in  which  they  wished  to  bring  about  suppuration.  Those  who, 
like  Archigenes,  Heliodorus,  Paul  of  Egina,  &c.,  had  recourse  to  cautery  to 
suspend  the  hemorrhage,  made  use  at  first  of  garlic  and, salt  to  cause  the 
separation  of  the  eschar,  and  afterwards  of  cataplasms  of  honey,  meal,  eggs 
or  simply  of  emollient  substances.  The  Arabs  have  particularly  vaunted  the 
use  of  astringents,  styptics,  and  bole  armenic;  they  also  frequently  employed 
the  balm  of  sulphur.  F.de  Hilden  thought  to  simplify  the  dressing  by  .en- 
veloping the  stump  in  a  woollen  bag  stuffed  with  different  substances.  Wise- 
man preferred  Fabricius'  bag — the  bladder  of  an  ox.  He  employed  also  the 
dry  suture  to  bring  the  lips  of  the  wound  a  little  nearer  together.  Sharp 
wished  to  discard  the  hot  iron ;  but  in  order  to  hinder  the  soft  parts  from 
retracting,  he  had  recourse,  like  Pigray,  to  two  ligatures  crossing  each 
other  in  (ront  of  the  stump.  This  was  the  progress  to  the  mode  which  was 
generally  followed  towards  the  close  of  the  last  century.  At  the  present  day 
it  is  -practised  in  the  following  manner  :-^Some  practitioners  bring  together 
the  ligatures  into  a  cord  at  the  most  depending  part  of  the  wound  ;  and  after 
having  enclosed  them  in  a  simple  compress,  cause  them  to  be  held  there  by 
an  assistant.  Others  cut  both  extremities  close  to  the  knot.  Some  bring  them 
out  separately,  and  fix  them  by  as  many  small  morsels  of  diachylon  upon  the 
corresponding  points  of  the  skin.  Afterwards,  a  fine  linen  cloth  covered  with 
cerate,  and  pierced  full  of  holes,  is  placed  over  the  whole  extent  of  the  bleed- 
ing surface ;  the  edges  of  which  are  brought  more  or  less  forward,  so  as 
to  form  a  large  hollow.  This  hollow  is  filled  with  picked  lint,  some  regular 
bats  are  placed  above,  two  rather  long  compresses  dispersed  cross-wise  should 
embrace  the  whole  extent  of  the  stump,  whilst  a  third  envelops  the  circum- 
ference :  a  bandage  of  convenient  breadth  and  length  then  keeps  the  whole 
in  plaCe.  Instead  of  applying  a  piece  of  fine  linen  immediately  upon  the 
wound,  as  was  done  by  Messrs.  Boyer  and  Roux,  and  many  others,  some 

•  Although  I  employed  myself  on  the  subject  of  torsion,  and  experimented  upon  and 
proposed  it  a  longtime  since  (1826),  yet,  when  M.  Amussat  also  macje  it  the  object  of  his 
researches  in  1829, 1  at  first  kept  silence,  hoping  that  that  gentleman  would  arrive  at 
results  completely  conclusive  ;  now,  however,  as  the  opinions  which  I  had  then,  and  which 
I  hftve  just  now  advanced,  seem  to  flow  naturally  from  all  the  works  published  upon  the 
sulyept,  1  deem  myself  authorized  to  promulgate  it  here  without  reserve  ;  entreating  the 
reader  not  to  confound  that  exposition  with  the  extravagant  hopes  which  this  hemostatic 
resource  has  excited  in  the  minds  of  sqme  persons. 


OPERAXrVE   SURGERY.  16^ 

surgeon*  still  pursue  the  method  of  the  past  age,  and  till  the  solution  of  conti- 
nuity with  sponge,  agaric,  or  lint,  but  surround  the  circumference  with  a  fillet 
or  band  of  linen  cut  into  points  upon  its  external  edge,  and  smeared  with 
cerate.  The  compress,  pierced  with  holes,  appears  to  me  preferable.  The 
latter  is  easily  turned  over  the  edges  of  the  wound,  and  there  is  no  fear  of 
the  lint  or  other  parts  of  the  dressing,  contracting  adhesions  with  the  living 
parts  which  have  been  divided.  Finally,  the  second  dressing  may  be  per- 
formed without  painy  and  with  the  greatest  facility  whenever  the  operator 
judges  it  advisable.  The  cross  of  >lalta,  formerly  in  general  use,  has  given 
place  to  the  oblong  compresses,  which  are  more  easily  applied  and  more 
easily  adapted  to  the  forms  of  the  different  stumps.  The  operator  must  be 
careful  not  to  push  them  too  forcibly  towards  the  root  of  the  member,  for  he 
would  not  fiiil  to  crowd  back  the  muscles  and  the  skin,  the  retraction  of  w^hich 
it  is  necessary  rather  to  check  than  to  favor.  It  is  for  the  purpose  of  avoiding- 
this  retraction,  and  diminishing  as  much  as  possible  the  projection  of  the 
bone  which  results  from  it,  that  Wiseman,  and  more  particularly  Louis, 
recommends  the  application  of  the  confining  bandage  from  above  downwards, 
and  not  from  below  upward.  In  this  particular  I  cannot  too  strongly  recom 
!nend  the  method  followed  by  M.Richerand.  The  bandage  is  passed  at  first 
once  or  twice  round  the  trunk,  it  is  then  directed  upon  the  root  of  the  member 
and  brought  by  successive  turns,  moderately  tight,  to  the  level  of  the  end  of 
the  bone.  The  remainder  of  the  dressing  is  conducted  in  the  manner  just 
described.  A  new  bandage,  or  the  remainder  of  the  first,  serves  to  fix  the 
compresses  by  a  second  set  of  turns,  and  to  maintain  the  whole  in  place.  By 
this  means  the  muscles  are  prevented  from  easily  retracting;  the  skin  is 
pushed  forwards,  and  this  method  will  moreover  in  a  great  measure  prevent 
the  swelling  of  the  stump,,  the  erysipelatous  or  phlegmonous  infiammations  of 
which  it  often  becomes  the  seat,  and  even  phlebitis,  which  it  is  so  necessary 
to  combat  from  the  moment  that  it  seems  disposed  to  make  its  appearance. 

B.  Inwiediate  Union. — Tho' method  of  bringing  together  the  edges  of  the^ 
wound,  of  immediately  closing  it,  does  not  appear  to  me  to  have  originateci 
earlier  than^  the  time  of  Alanson,  or  at  the  farthest  than  that  of  Gersdorf.  It 
was  folloAved  by  Hay,  and  shortly  afterwards  by  almost  all  the  surgeons  ot 
Great  Britain ;  but  it  was  viewed  amongst  us  with  a  certain  degree  of  re- 
pugnance, except  by  Percy,  who  had  occasion  to  use  it  frequently  and  to 
prove  its  utility  in  the  midst  of  camps.  Pelletan,  M.  Larrey,  &c.  at  first 
strongly  opposed  it;  but  Messrs.  Dubois,  Richerand,  Roux,Boyer,Dupuytren, 
Delpech,  and  almost  all  the  distinguished  practitioners  of  Paris  and  the  other 
cities  of  France,  concluded  by  adopting  it  in  most  cases.  It  appears,  however, 
that  at  the  Hotel  Dieu  M.  Dupuytren  has  found  occasion  to  be  less  satisfied 
with  it  than  at  first ;  that  at  ta  Charite  M.  Roux  believed  it  his  duty  to 
limit  its  application,  and  M.  Lisfranc  seldom  makes  use  of  it  at  La  Pitie.. 

To  unite  by  first  intention,  it  is  still  more  necessary  than  by  the  other 
method  that  no  foreign  bodies  should  be  left  in  the  wound  which  it  is  possible 
to  extract.  The  operator  begins  therefore  by  carefully  removing  the  clots 
and  the  threads  which  are  not  indispensable,  cleansing  the  sui-rounding  parts 
with  a  sponge,  and  by  dryin*  the  whole  with  a  soft  linen  clotb.  This  done, 
he  brings  together  as  exactly  as  possible  the  divided  parts,  taking  care  to 
leave  no  greater  space  between  them  at  the  bottom  than  at  the  edges  of  the 
wounds  While  an  assistant  holds  the  parts  in  this  state,  the  operator  applies 
the  adhesive  straps.  By  commencing  with  those  of  the  middle,  it  will  in 
general  be  found  more  easy  afterwards  to  apply  the  others.  Three  or  four 
are  generally  sufficient.    It  is  a  rule  to  leave  a  free  space  between  them. 


164  NEW   ELEMENTS   OF 

instead  of  covering  the  whole  of  the  stump.  The  longer  thej  are,  all  other 
things  being  equal,  the  better  they  will  hold,  the  less  they  fatigue  the  skin, 
and  the  more  perfectly  they  will  attain  the  end  proposed.  To  sustain  their 
action  it  is  often  useful  to  confine  at  the  same  tin.e  upon  the  sides  of  the 
wound,  parallel  to  its  greatest  diameter,  graduated  compresses  more  or  less 
thick,  or  rolls  of  lint,  either  between  the  straps  and  the  skin,  or  between 
the  bandage  and  the  straps.  This  is  the  only  way  in  most  cases  to  prevent 
the  accumulation  of  fluids  at  the  bottom  of  the  wound,  and  to  obtain  a  fair 
and  regular  union. 

If  the  threads  have  not  been  cut  near  the  arteries,  the  operator  brings  them 
out  separately,  and  fixes  them  between  the  emplastic  straps  by  means  of  small 
ligature  compresses. 

Instead  of  the  pinked  bandage,  or  the  pierced  compress  placed  over  the 
whole  anterior  surface  of  the  stump,  some  use  a  broad  and  thin  bat  of  charpie 
equably  smeared  with  cerate.  On  this  point  everyone  should  be  free  to  do 
as  he  sees  fit.  The  important  point  is  to  prevent  the  adhesion  of  the  pieces 
of  the  dressing  to  the  parts  about  the  wound.  Dry  charpie  in  soft  bats  is 
then  so  disposed  as  to  cover  the  sides  and  front  of  tlie  stump.  For  this,  two 
or  three  bats  are  enough  ;  more  would  be  rather  hurtful  than  serviceable,  from 
the  heat  which  would  be  cherished  by  them.  The  oblong  compresses  neces- 
sarily vary  in  number  or  size  according  to  the  size  of  the  stump.  The  middle 
of  each  should  fall  just  upon  the  wound,  and  the  ends  reach  without  stretching 
to  the  root  of  the  limb.  That  which  is  commonly  laid  across  or  around  to  fix 
the  others  a  little  above  their  point  of  crossing,  is  very  seldom  of  any  real  use, 
A  simple  flexible  bandage,  rather  narrow  than  too  broad ,  finishes  the  dressing. 
After  naving  carried  this  by  circular  turns  from  the  end  of  the  stump  towards 
the  root  of  the  limb,  the  operator  brings  it  back  in  the  same  way  to  the  wound, 
in  front  of  which  M.Roux,  among  others,  has  a  habit  of  crossinjK  it  several  times, 
both  for  the  purpose  of  imitating  that  kind  of  cap  which  was  formerly  so  much 
employed,  and  to  obtain  an  application  of  the  bandage  more  regular  and 
more  neat,  but  augmentin;^  the  perpendicular  compression  at  the  expense  of  the 
circular.  As  this  piece  ot  prettiness  may  compromise  the  safety  of  the  patient, 
it  should  be  omitted  at  least  whenever  there  is  reason  to  apprehend  a  stag- 
nation of  fluids  in  the  depths  of  the  wound. 

Instead  of  plasters,  which  make  what  is  called  in  the  schools,  the  dry 
suture,  some  operators  employ  the  bloody  suture,  that  is  to  say,  they  sew  up 
the  wound.  This  method,  to  which  Pigray,  Wiseman,  F.  de  Hilden,  Sharp, 
&c.  had  recourse  in  order  to  retain  the  skin,  has  been  particularly  eulogized 
of  late  years,  by  Hey,  M.Benedict  of  Breslau,  and  by  M.Delpech,  who  affirms 
that  he  has  derived  from  it  the  greatest  advantages;  so  that  at  Montpellier  it 
is  scarcely  ever  dispensed  with  after  amputations.  The  interrupted  suture  is 
preferred  in  such  cases,  although  the  furrier's  is  equally  convenient.  For 
greater  security,  and  to  ease  the  threads,  the  operator  may,  as  recommended 
by  M.Delpech,  place  some  small  emplastic  straps  between  them.  If  the  em- 
ployment of  this  kind  of  suture  were  not  attended  with  great  pain;  if  the 
reunion  of  the  integuments  formed  the  most  important  part  of  the  operation  ; 
if  the  plasters  did  not  eft'ect  the  same  purpose  v/hen  properly  applied  ;  M. 
D.'s  method  would  doubtless  long  since  have  been  adopted;  the  contrary 
however  being  generally  admitted  to  be  the  case,  every  thing  seems  to  promise 
that  in  future  adhesive  straps  will  continue  to  supply  its  place.  ^  Seeing 
that  after  the  cure  by  first  intention,  the  cicatrix,  although  linear  'at  first 
rarely  fails  to  become  puckered  and  to  be  surrounded  with  radiated  wrinkles, 
just  as  after  secondary  union,  M.Roux  has  sometimes  determined  upon  pro- 


OPERATIVE    SURGERY.  165 

duciTig  this  wrinkling  from  the  first  by  crossing  the  plasters  in  different 
flirections,  instead  of  placing  them  parallel  with  each  other.  But  his  first 
iittempts  having  been  unsuccessful,  so  skillful  a  surgeon  has  of  course  promptly 
given  up  tliis  practice. 

W!ien  the  operator  begins,  like  Louis,  Alanson,  and  M.  Richerand,  by  fixing 
a  long  bandage  round  the  trunk,  and  brings  it  down  by  successive  turns  to 
'the  base  of  tlie  wound,  it  is  upon  this  bandage  that  the  straps  must  have  their 
hold  ;  and  differently  from  the  other  pieces  of  linen,  this  should  be  changed 
as  seldom  as  possible.  Kern,  Klien,  Walther,  and  the  greater  part  of  the 
German  surgeons  considering  the  wound  which  results  from  an  amputation 
the  same  as  any  other  recent  and  simple  solution  of  continuity,  use  neither 
lijit  nor  charpie,  but  just  cover  the  stump  with  compresses  kept  continually 
wet  with  cold  water.  This  practice  has  found  many  imitators  in  England  and 
America,  even  among  the  surgeons  in  the  hospitals,  and  I  understand  from 
M.  Castello,  physician  to  the  king,  and  professor  in  the  university  of  Madrid, 
that  it  has  been  for  a  long  time  followed  throughout  all  Spain.  In  France  it 
has  as  yet  found  but  a  small  number  of  partizans.  This  is  to  be  regretted, 
as,  if  1  am  not  mistaken,  the  results  obtained  by  foreigners  have  been  most 
satisfactory.  Disencumbered  of  a  heap  of  useless  dressings,  the  stump  is 
kept  tnuch  more  cool ;  by  preventing  or  moderating  the  inflammation  to  which 
it  is  subject,  we  place  the  contiguous  surfaces  in  the  best  possible  condition 
for  immediate  union,  and  the  general  reaction  is  reduced  to  a  small  matter. 
The  experiments  which  I  have  made,  show  nevertheless,  that  cold  water, 
although  frequently  useful,  is  not  always  without  its  inconveniences. 

Appreciation  of  Immediate  Union. — The  ancient  method  of  treating  ampu- 
tatory  wounds  is  likely  to  produce  a  conical  stump,  necrosis  of  the  bone, 
exhaustion  of  the  patient  by  the  continuance  of  suppuration,  and  the  most 
lively  pain  after  every  dressing.  Three,  four,  five,  six,  and  even  seven  or 
eight  months,  are  sometimes  required  for  cicatrization,  and  when  accom- 
plished, it  occurs  in  so  thin  and  imperfect  a  form  that  it  is  torn  by  the  least 
effort,  and  is  always  accompanied  by  a  considerable  deformity  of  ihe  end  of 
the  stump.  By  the  new  method,  say  Alanson,  Messrs.  Guthrie,  Klein,  &c., 
the  patient  sutlers  incomparably  less;  the  fever  is  always  slight;  no  debili- 
tating suppuration  ensues;  the  stump  remains  firm,  round,  and  well  sup- 
ported ;  and  at  the  end  of  eight,  ten,  fifteen,  twenty,  or  thirty  days,  the  cicatrix 
becomes  solid,  and  the  patient  is  in  a  fit  state  to  use  an  artificial  limb.  Out  of 
ninety-two  soldiers  who  were  treated  in  this  manner  by  Percy  upon  the  field 
of  battle,  eighty-six  were  cured  in  twenty-six  days  ;  and  out  of  seventy, 
Lucas  lost  only  five.  But  while  in  France  the  chief  of  the  military  surgeons 
advocated  with  so  much  ardor  the  practice  of  immediate  reunion,  the  indi-  ^^ 
vidual  at  the  head  of  the  civil  practitioners  applied  himself  to  its  proscription,  ^jm^ 
Out  of  six  patients,  Pelletan  saved  only  one;  in  all  these  cases  there  were^gp 
effusions  of  blood  and  pus  between  the  lips  of  the  wound,  and  over  the  passage 
of  the  vessels;  and  the  only  patient  he  cured,  owed  his  recovery  to  an  irrup- 
tion of  pw.s  which  burst  the  adhesion  of  the  straps.  "  There  is  danger,  then," 
says  he,  '*  in  closing  a  wound  from  which  blood  must  be  poured  out,  which 
has  an  inclination  to  suppurate,  whether  on  account  of  the  ligatures  which 
irritate  it,  or  because  the  bone,  more  or  less  affected  by  the  action  of  the  saw, 
has  necessarily  a  disposition  to  exfoliate."  "The  cure  by  first  intention  is 
more  prompt,"  says  M.  Gouraud,  who  adopts  the  objections^^of  Pelletan,  "  but 
it  is  more  sure  by  immediate  union:  by  prolonging  itself,  the  suppuration 
prepares  the  patient  for  the  changes  which  take  place  throughout  the  body 
after  the  loss  of  a  considerable  member;  and  whenever  amputation  is  per- 


166  NEW    ELEMENTS   Ot 

formed  for  a  disease  of  long  standing,  secondary  union  is  tlj«  orily  method 
that  can  be  properly  adopted."  It  may  be  replied,  that  if  the  accidents 
mentioned  by  Pelletan  frequently  take  place,  such  circumstances  are  rather 
the  result  of  a  want  of  necessary  precaution,  than  the  inevitable  conse- 

3uences  of  the  operation.  That  there  may  be  some  danger  in  stopping  sud- 
enly  a  profuse  suppuration  of  old  standing,  in  closing  in  eight  days  a  wound 
which  results  from  the  removal  of  a  member  which  has  for  a  long  time  per- 
formed the  office  of  a  secretory  organ,  is  very  true ;  but  ought  theseexceptions, 
these  feeble,  and  frequently  questionable  motives,  to  have  weight  against  all 
the  perils  of  mediate  reunion  ? 

In  avoiding  one  extreme  it  is  always  necessary  to  guard  against  falling  into 
the  other.  It  the  bleeding  surfaces  can  be  easily  brouglit  into  apposition;  if 
h«althy  parts  only  remain  in  the  stump,  immediate  reunion  has  immense 
advantages,  and  ought  certainly  to  be  attempted.  In  contrary  cases,  the 
operator  is  permitted  to  conduct  himself  otherwise,  to  confine  himself  to 
bringing  somewhat  nearer  together  the  lips  of  the  wound  after  having  placed 
betv»  cen  them  balls  or  tents  of  lint,  eitiier  bare,  or  with  tiie  interposition  of 
a  linen  cloth  pierced  with  holes.  It  would  be  'imprudent,  even  dangerous, 
to  persist  in  maintaining  the  contact,  if  in  the  'course  of  three  or  four  days 
the  blood  or  other  fluids  have  escaped  in  sufficient  quantity  to  hinder  the 
fair  co-aptation  of  the  parts  from  the  bottom  of  the  wound  towards  the  edges. 
It  is  then  proper  to  allow  an  issue,  large  and  W'ee^  to  the  fluids  which  have 
accumulated  behind  the  straps  or  the  sutures,  between  the  integuments  or 
the  divided  muscles;  to  cleanse  gently  the  M'hole  extent  of  the  sinous  or 
fistulous  passage,  and  afterwards  to  dress  it  with  great  care  and  tenderness, 
and  to  think  only  of  union  by  the  second  intention.  By  proceeding  thus  the 
operator  will  obtain  very  frequently,  if  not  always,  a  complete  cicatrization 
in  the  space  of  fifteen,  twenty,  or  thirty  days,  even  after  the  amputation  of 
the  thigh,  as  I  witnessed  at  UHopital  de  Perfectionnemeiit,  during  the  period 
of  my  service  there  with  Messrs.  Bougon  and  Roux. 

C  '^Combination  of  the  two  Methods. — In  order  to  reconcile  the  two  pre- 
ceding methods,  it  would  be  easy  to  contrive  a  third,  by  applying  to  circular 
amputation  what  is  recommended  by  O'Halloran  for  the  nap-operation.  After 
iuiving  dressed  the  wound  of  the  stump  for  eight  or  ten  days  without  closing 
it,  until  it  has  beconic  mundified  and  regularly  cove-red  witli  cellular  granu- 
lations of  a  vermilion  color,  there  is  nothing  to  prevent  bringing  together  tiie 
sides  of  the  wound,  and  attempting  to  procure  secondarily  something  like 
immediate  union.  I  have  practised  this  metlwd  a  number  of  times  with 
success,  particularly  at  the  Hopital  Sl.Antoine^  in  the  case  of  a  patient  whose 
thigh  had  been  amputated  by  M.  Beauchere  ;  and  again  after  amputations  of 
tlie  fingers,  the  metacarpal  and  metatarsal  bones,  and  of  the  legs  and  arms. 
It  has  also  been  used  with  equal  success  by  M.  Roux,  and  has  been  extrava- 
gantly praised  by  Paroisse.  All  the  ligatures  having  come  away,  the  wound 
being  cleansed,  and  the  suppuration  of  a  healthy  character,  it  is  generally  easy 
to  put  the  edges  of  the  wound  in  contact,  either  at  once  or  by  degrees,  and 
thus  obtain  co-aptation  soon  and  without  inconvenience.  I  am  of  opinion 
then,  that  with  very  few  exceptions  it  is  best  to  aim  at  immediate  reunion ; 
but  if  unpleasant  symptoms  occur  which  are  justly  ascribable  to  this  mode  of 
practice,  the  operator  ought  without  hesitation  to  re-open  the  wound.  1  will 
add,  that  the  results  of  this  method  are  much  more  under  the  influence  of  art 
than  those  of  secondary  reunion,  and  that  consequently  they  will  be  good 
or  bad  according  to  the  ability  or  inability  of  the  practitioner;  according  as 
he  shall  attach  more  or  less  importance  to  certain  practical  precautions  which 


OPERATIVE    SUROERI^I'iiJd-  167 


cannot  be  leamed  from  books,  and  of  which  only  those  who  have  used  them 

can  appreciate  the  importance. 

§  3. — Consecutive  Treatment, 

Tlie  patient  having  been  returned  to  his  bed,  should  be  laid  in  the  most 
easy  position,  a  hoop  should  be  placed  to  support  the  weight  of  the  covering 
and  to  prevent  it  from  bearing  upon  the  stump,  which  reposes  gently  on  a 
cusliion  or  a  folded  cloth. 

1st.  The  Position  of  the  Stump. — This  part  is  generally  kept  a  little  ele- 
vated, so  that  the  muscles  may  be  relaxed,  which  according  to  the  opinions 
of  some  persons  diminishes  the  determination  of  the  i!aids  towards  the  wound. 
Some  advantage  is  indeed  derived  from  this  posture  in  that  respect,  while 
there  is  no  suppuration.  But  when  tills  occurs,  the  posture  in  question 
favors  the  inflammation  of  the  intermuscular  cellular  substance,  the  donud- 
ation  of  the  bone,  phlebitis,  and  the  formation  of  abscesses ;  the  wisest  plan 
then,  is  to  follow  the  advice  of  Hippocrates  and  of  Alanson,  and  to  place  the 
stump  in  a  horizontal  position,  or  even  inclining  downward,  as  soon  at  least 
as  suppuration  is  about  to  take  place,  and  indeed  in  every  instance  where  the 
form  of  the  member  will  admit  of  this  arrangement. 

2(1.  Immediate  Medication. — One  or  two  spoonsful  of  wine  may  be  useful 
in  diminishing  the  torpor  or  faintness  wliich  commonly  follows  the  operation. 
During  the  remainder  of  the  day  a  gently  antispasmodic  anodyne  is  adminis- 
tered by  spoonsful,  with  the  ^infusion  of  linden,  violet,  wild  poppy,  or  ^  )me- 
tJnng  of  that  kind,  sweetened  with  any  kind  of  syrup,  as  a  ptisan.  Except 
in  cases  where  the  patient  is  enfeebled  by  long  suftering,  the  strictest  diet  is 
to  be  strictly  enforced. 

3(1.  The  Regimen  is,  in  other  respects,  the  same  as  that  enforced  in  acute 
diseases,  or  after  all  the  greater  operations.  When  the  patient  is  robusl  or  of 
a  sanguine  constitution,  and  the  operation  has  been  performed  for  a  recent 
injury,  if  there  has  been  no  great  effusion  of  blood,  some,  fearing  a  siulden 
plethora,  have  said  much  of  the  importance  of  diminishing  the  quantity  of  the 
fluids  to  prevent  internal  inflammations  and  the  dangers  of  a  general  reaction. 
Many  practitioners  in  Germany,  England,  and  America,  pursue,  however,  an 
opposite  course.  M.  Koch,  of  Munich,  administers  to  his  patients  from  the 
very  first  day,  coffee,  wine,  and  even  food.  M.Benedict  contends,  that  bleeding 
instead  of  preventing  accidents  is  the  means  of  favoring  their  occurrence. 
It  is,  says  he,  the  strongest  subjects,  men  whose  bodies  are  full  of  blood,  that 
most  easily  resist  the  operation  of  morbific  causes,  upon  whom  inflammations 
are  healed  with  the  greatest  facility.  Consequently,  the  more  you  bleed  them 
the  more  you  weaken  them  ?  the  more  exposed  are  they  to  disease  ;  the  inflam- 
mations which  they  contract  become  the  more  dangerous  and  the  more  diffi- 
cult to  tpeat.  This  severe  diet,  these  abundant  evacuations  of  blood  prescribed 
by  some  operators,  before  and  immediately  after  amputation,  do  not  secure 
any  real  advantage  except  where  intervening  diseases,  inflammatory  symptoms 
manifest  themselves  upon  the  patient. 

4th.  The  First  Dressing  should  not  take  place  in  ordinary  cases  until 
about  the  expiration  of  three  or  f(mr  days,  and  sometimes  even  five  or  six, 
according  to  the  opinions  of  C.  Magati',  Monro,  and  others,  and  the  pre- 
sent practice  in  Spain.  Patients  in"  general  have  a  great  dread  of  it,  and 
indeed  it  was  formerly  something  for  them  to  fear.  No  precaution  was 
taken  to  prevent  tlie  adherence  of  the  lint  or  of  the  compresses  to  the  bottom 
or  the  edges  of  the  wound ;  and  as  it  took  place  one  or  two  days  after  the 


fc 


iC8 


Xir;V    KLEIflKNTS    OF 


(>{)erati()n,  and  cor.soijMeru! v  !><  f.Me  mi p|;U ration  was  established,  it  is  no 
Nvonder  tliat  l)ie  recolit'ctioji  of  it  has  been  preserved,  and  that  it  is  even  more 
dreaded  than  amputation  \Ue\i\  Oi»  (l.is  point  it  must  be  said  that  patients 
have  been  agreeably  disa[)pointed.  Pieces  of  linen  or  bandages  being  covered 
with  cerate  always  render  the  separation  of  the  other  dressing  more  easy;  at 
the  expiration  of  three  or  four  days  the  humidity  and  the  natural  sweating 
of  the  wound  have  on  their  part  loosened  the  adhesions  which  might  before  have 
required  force  to  effect  a  separation,  so  that  the  first  dressing  does  not  inflict 
more  pain  than  those  that  follow.  An  assistant  lays  hold  of  the  stump,  which 
he  clasps  and  gently  holds  in  his  two  hands,  always  being  careful  not  to  give  it 
the  slightest  jerk.  The  bandage,  the  compresses,  being  soaked  with  blood  or 
other  fluids,  commonly  harden  together,  in  drying,  so  that  it  is  very  often 
more  difficult  to  remove  them.  If  then  after  having  soaked  them  with  lukewarm 
v/ater,  the  operator  does  not  succeed  in  their  removal,  it  will  be  found  neces- 
sary for  that  purpose  to  apply  the  scissors. 

These  first  pieces  being  detached,  the  tint  is  freely  moistened,  and  the  outer 
layers  oidy  are  removed  while  it  yet  adheres  too  "firmly.  As  soon  as  it  is 
exposed,  the  wound  should  be  cleansed  by  gently  dropping  upon  it  lukewarm 
water,  and  afterwards  dried  with  apiece  of  old  fine  linen  or  pledgets  of  lint, 
after  which  the  dressings  are  reapplied  as  in  the  first  instance,  and  are  so 
removed  and  renewed  from  day  to  day. 

If  immediate  union  is  aimed  at,  and  no  especial  accident  occurs,  this  first 
dressing  is  still  further  delayed.  But  in  every  instance,  as  it  is  in  fact 
but  seldom  that  complete  agglutination  takes  place  in  every  point,  it  is  equally 
requisite  to  cleanse  the  stump  on  the  third,  fourth,  or  fifth  day.  If  there  is 
no  suppuration  to  be  discovered  ;  if  there  is  no  threatening  of  the  formation 
of  sinus  or  fistulous  passages  ;  the  lips  of  the  incision  should  not  be  touched. 
The  most  that  can  be  allowed,  is  to  remove  one  of  the  straps,  and  to  imme- 
diately replace  it.  In  the  contrary  case,  and  when  the  plasters  have  become 
loose,  they  should  be  renewed  one  after  the  other,  and  by  gentle  pressure  the 
purulent  or  other  fluids  should  be  assisted  to  escape.  In  order  to  detach 
tliese  bandages,  the  operator  draws  them  successively  from  their  extremities 
\n  the  direction  of  the  summit  of  the  stump,  from  whence  they  should  be 
separated  last,  as  there  would  be  danger,  in  pulling  them  at  one  hold  from 
one  Qm\  to  the  other,  of  destroying  the  adhesions  which  is  yet  too  weak  to 
resist  the  slightest  pull. 

5th.  The  Ligatures  seldom  come  away  until  the  eighth  or  tenth  day  after 
having  divided  by  ulceration  the  artery  which  they  surrounded;  it  would 
consequently  be  useless  to  endeavor  to  withdraw  them  sooner;  but  when  they 
remain  longer,  it  may  be  of  some  advantage  to  draw  upon  them  gently  at  every 
flressing.  They  are  probably  retained  by  some  lamellar  of  fibrous  substance 
included  with  the  artery  in  the  knot.  The  more  immediately  they  encircle 
the  artery,  the  sooner  they  v/ill  come  away.  There  is  every  reason  to  suppose 
thi«t  their  presence  in  the  wound  is  useless  after  the  second  or  third  day,  and 
that  they  might  safely  be  removed  after  that  period,  if  it  could  be  done  with 
ease.  I  have  seen  them  yield  on  the  third  and  on  the  fourth  day,  without  any 
111  consc(juences,  after  amputation  of  the  arm  and  of  the  leg.  M.Beaufils  of 
Nancy,  who  holds  that  after  the  sixth  day  it  is  best  to  hasten  their  separation, 
has  contrived  to  subject  them  to  a  permanent  tension  to  fulfill  this  indication, 
which  MM.  Kluge  and  Lau,  have  since  endeavored  to  establish  as  an  axiom. 


OPERATIVE   SURGERY.  169 


§  4.  Accidents. 

The  accidents  to  which  the  amputation  of  the  limbs  may  give  rise,  are 
serious  and  numerous ;  some  may  occur  at  the  moment  of  the  operation,  others 
at  a  longer  or  shorter  period  after. 

1st.  During  the  Operation — Hemorrhage* — To  patients  in  a  weak  state  of 
health,  the  loss  of  blood  durinj^  the  operation  may  cause  immediate  and  real 
danger ;  it  sometimes  takes  place  before  the  operator  has  time  to  tie  up  the 
vessels,  either  because  the  tourniquet  has  been  relaxed  or  displaced,  or  because 
the  assistant  does  not  well  apply  compression,  or  because  the  operator  experi- 
ences unusual  difficulty  in  taking  up  the  arteries.  To  prevent  these  inconve- 
niences, it  has  been  proposed  to  apply  the  ligature  to  the  principal  artery  of 
the  limb  before  commencing  the  incision  of  the  soft  parts.  M.  Blandin, 
reports  an  example  of  this  practice,  which  is  still  followed  at  the  hospital 
"  Beaujon,"  by  M.  Marjolin.  Mr.  Guthrie  and  some  others  have  thought  to 
do  better,  in  tying  the  arteries  from  time  to  time  as  they  were  cut.  The  art  has 
no  other  resource  in  this  kind  of  accident  than  compression,  mediate  or 
immediate,  lateral  or  perpendicular,  when  the  ligature  cannot  be  applied. 
But  there  is  still  another  species  of  hemorrhage  which  does  not  require  tlie 
same  kind  of  remedy;  I  mean  that  which  comes  from  the  veins,  a  kind  of 
hemorrhage  which  is  very  abundant  with  some  persons,  and  is  even  some- 
times very  troublesome.  It  is  caused  by  the  provisional  compression  pre- 
venting the  blood  from  returning  in  the  direction  of  the  trunk,  or  else  to  some 
defect  in  the  respiration.  In  order  to  stop  the  effusion,  some  persons  advise 
to  tie  the  principal  vein;  Monro,  Bloomfield,  Hey,  and  Guthrie,  are  of  this 
opinion.  Amongst  ourselves  the  practice  is  generally  different.  We  remove 
at  once  every  thing  which  may  impede  the  course  of  the  blood  towards  the 
heart.  We  induce  the  patient  to  make  long  inspirations,  and  the  hemorrhage 
is  almost  instantly  arrested. 

The  syncopes  which  result  from  hemorrhage,  pain,  or  the  state  of  excite- 
ment into  which  the  operation  sometimes  throws  the  patient,  require  little 
more  than  moral  means.  A  spoonful  of  wine,  when  the  symptoms  are  fore- 
seen, cold  water,  vinegar,  or  cologne  water  sprinkled  on  the  face,  or  applied 
to  the  nose,  and  all  the  other  remedies  generally  used  in  such  cases,  do  not 
require  more  particular  mention  here.  It  is  not  unfrequently  the  case,  that 
immediately  after  the  separation  of  the  limb  the  stump  is  seized  with  a  tremor 
■which  it  is  very  difficult  to  allay,  or  with  a  species  of  convulsive  or  spas- 
modic movement  which  requires  the  greatest  attention.  At  such  a  moment 
we  should  attract  as  forcibly  as  possible  the  attention  of  the  patient,  and 
rouse  his  courage ;  we  intreat  him  to  hold  for  himself  the  root  of  his  limb, 
unless  it  should  be  thought  better  that  an  assistant  should  clasp  it  firmly  with 
both  hands  until  the  dressing  is  completed :  this  state  generally  remains  but 
a  few  minutes;  if  it  seems,  however,  disposed  to  continue  longer,  the  stump 
when  placed  upon  the  bed  should  be  fixed  by  a  cloth  or  napkin  folded  in  the 
manner  of  a  cravat.  This  is  a  juncture  at  which  opiates  are  particularly  indi- 
cated. 

2d.  After  the  Operation,  the  accident  to  which  the  patient  is  most  liable 
is  that  of  hemorrhage,  which  happens  either  because  some  important  arteries 
have  been  left  untied,  or  because  one  or  more  of  the  ligatures  have  become 
relaxed,  but  more  frequently  than  is  often  believed  from  a  species  of  imi- 
tative exhalation  proceeding  from  the  surfaces  of  the  wound.  After  the  third 
or  fourth  day,  hemorrhage  rarely  occurs  but  in  this  way,  unless  the  ligaturc-i 
22 


170  NEW  ELEMENTS   OF 

should  liave  cut  some  of  the  arteries  by  ulceration  :  after  the  eighth  or  tenth 
day  it  is  difficult  to  account  for  it,  Bromfield,  Guthrie,  and  other  practitioners, 
have  seen  it  appear  after  a  delay  of  three  weeks,  a  month,  or  even  a  longer 
period.  There  is  reported  an  observation  of  a  patient  operated  upon  by 
M.  Roux,  in  whose  case  hemorrhage  did  not  appear  until  after  the  expiration 
of  two  months.  The  inflammation  of  which  the  vascular  tunics  become  the 
seat,  in  the  thickness  of  the  stump,  the  suppuration  which  surrounds  them  at 
the  bottom  of  fistulous  passages,  can  alone  account  for  this  species  of  perfora- 
tion. Hey  and  Hennen  contend  that  consecutive  hemorrhage  is  frequently 
caused  by  the  skin  retracting  and  compressing  circularly  the  subjacent  tis- 
sues, particularly  the  venous  canals,  and  that  it  is  by  th^  vessels  of  this 
latter  class  that  the  blood  is  permitted  to  escape.  This  opinion  seems  to  me 
any  thing  but  well  founded.  When  the  blood  escapes  through  the  medium 
of  the  veins  (according  to  Ponteau),  it  is  to  be  attributed  to  the  unequal  or 
too  forcible  compression  exerted  by  the  bandage  upon  the  stump,  rather  than 
to  the  contraction  of  the  skin.  It  is  then  sufficient  to  remove  the  dressings 
and  to  re-'i^pply  them  more  methodically,  in  order  to  immediately  remedy  the 
accident.  Another  species  of  hemorrhage  which  appears  to  have  been  first 
eradicated  by  M.  Gouraud,  is  that  which  comes  from  the  bones  in  case  of 
necrosis  5  the  blood  is  perceived  at  each  dressing  to  arise  between  the  living 
and  the  dead  tissue  ;  compression  or  obstruction  will  not  arrest  its  progress, 
nothing  in  fact  but  the  removal  of  the  affected  organ.  Congestion,  or  a  sliglit 
inflammation  of  the  stump,  are  causes  of  hemorrhage  which  may  be  checked 
in  diff*erent  ways.  Ist.  By  frequently  soaking  all  the  dressings  anew  with  cold 
water.  2d.  By  applying  the  tourniquet  or  the  garot  to  the  principal  artery 
of  the  part.  After  having  found  tliese  means  insufficient,  it  is  then  proper  to 
remove  the  dressings,  in  oi^er  to  seek  for  and  to  tie  the  vessel  which  gives 
rise  to  the  effusion.  As  it  is  but  seldom  that  after  the  first  twenty-four  hours 
this  last  method  of  treatment  succeeds,  in  consequence  of  the  changes  which 
have  taken  place  over  the  v/hole  extent  of  the  bleeding  surface,  there  is  then 
nothing  to  be  done  except  to  applj  agaric  or  sponge  upon  the  point  from 
whence  the  blood  exudes,  as  advised  by  White  and  Brossard,  or  to  stuff  the 
wound  in  anyway  whatever  until  the  hemorrhage  is  arrested;  to  use  the  ma- 
chine invented  by  Petitj  to  compress  the  open  vessels  immediately  by  means 
of  pellets  of  lint  or  of  linen  sprinkled  over  with  colophonyjby  the  fingers  of 
the  assistants,  which  are  successively  relieved  for  the  space  of  some  days,  or 
what  is  much  better  when  it  can  be  done,  to  discover  the  principal  artery  and 
to  tie  it  above  the  wound,  as  Messrs.  Roux,  Dupuytren,  Delpech,  Somme,  Ghi- 
della,  and  Arnel  have  done  with  success.  Yet  in  a  case  cited  by  Blandin,  and 
some  others  mentioned  by  Mr.  Guthrie,  this  ligature,  after  the  manner  of  Anel, 
has  failed  in  stopping  the  effusion  of  the  blood,  and  the  patient  has  finally  suc- 
cumbed. If  the  open  vessel  should  be  surrounded  by  soft  parts,  the  ope- 
rator may  cut  round  its  circumference  with  a  single  sweep  of  the  point  of  a 
bistoury  at  the  bottom  of  the  wound,  and  close  it  immediately  by  placing 
a  thread  in  the  circle  of  the  incision,  as  M.  Sanson  has  once  done  with 
success. 

It  would  be  wrong  to  count  as  a  hemorrhage  that  sweating  which  rarely 
fails  to  soak  through,  or  to  affect  in  some  degree  the  dressings,  the  linen,  and 
even  sometimes  the  whole  thickness  of  the  cushions,  after  the  first  or  second 
day.  Evep  when  it  is  pure  blood  and  not  a  sanguineo-serous  effusion,  there 
is  no  occasion  for  alarm  unless  the  patient  have  experienced  from  it  some 
degree  of  weakness.  As  a  general  rule,  while  the  pulse  keeps  its  force,  and 
the  paleness  of  the  countenance  is  not  increased,  cold  ablutions  and  the  tour- 


OPERATfVE   SURGERY.  1ft 

niquet  will  suffice,  if  it  should  be  thought  proper  to  make  any  application 
whatever. 

Conical  figure  of  the  Stump. — This,  which  was  formerly  the  almost  inevi- 
table result  of  amputation,  has,  since  the  works  of  J.  L.  Petit  and  of  Louis, 
become  extremely  rare.  By  immediate  union,  it  is  almost  always  prevented. 
It  is  now  only  after  cure  by  suppuration  that  it  sometimes  occurs.  As  it  is 
owing  entirely  to  the  retraction  of  the  muscles,  it  depends  upon  the  operator 
to  avoid  it,  unless  the  healing  of  the  wound  have  been  retarded  by  some 
unforeseen  obstacle.  The  processes  of  Petit,  Brunninghausen  and  others,  which 
consist  in  bringing  only  the  skin  over  the  surface  of  the  stump,  are  considered 
as  less  efficacious  than  those  of  Louis,  of  Alanson,  Desault,  and  of  Dupuy- 
tren,  or  all  those  in  fine,  which  consist  in  cutting  upon  the  bone  the  adherent 
muscles  farther  up  than  those  which  are  loose;  but  this  is  a  question  to  be 
hereafter  considered. 

Upon  this  subject  it  must  not  be  forgotten  that  the  muscles  retract  much 
more  upon  some  subjects  than  upon  others,  in  proportion  as  they  may  be 
formed  of  longer  fibres;  may  have  been  divided  farther  from  their  point  of 
origin  ;  may  have  been  more  irritated,  be  slower  in  reuniting,  or  in  incorporating 
themselves  with  the  cicatrix;  and  we  should  not  confound  their  primitive 
with  their  secondary  retraction. 

The  contraction  whi<:h  immediately  follows  their  division  is  not  the  only 
one  which  is  observed.  The  muscles  are  frequently  seen,  and  particularly 
upon  persons  of  much  strength  or  fullness  of  make  at  the  time  of  operating, 
but  who  have  become  enfeebled  soon  after — they  are  frequently  seen,  as  I 
have  said,  to  retire  deeply  into  the  sheaths,  to  abandon  the  bones  which  they 
have  previously  entirely  covered,  and  to  ^ive  a  conical  form  to  the  stump 
which  had  presented  a  deep  hollow  at  the  time  of  the  first  dressing.  So  that 
the  first  division  should  be  made  so  much  farther  from  the  last  as  the  limb  is 
larger,  and  the  amputation  too  should  be  performed  further  from  its  root  in 
the  same  proportion. 

After  the  operation,  the  retraction  should  be  opposed  by  applying  to  the 
stump  the  moderately  compressive  bandage  of  the  ancients,  as  improved  by 
Alanson,  Louis,  Richerand,  and  others ;  taking  care  that  instead  of  having  a 
tendency  to  force  the  flesh  backwards,  every  part  of  the  dressings  shall,  on  the 
contrary,  operate  so  as  to  bring  it  forwards.  The  wound  should  be  dressed 
as  gently  as  possible,  avoiding  every  thing  which  might  irritate,  favor  suppu- 
ration, or  delay  the  union ;  and  the  part  should  be  placed  in  a  state  between 
flexion  and  extension,  so  that  all  the  muscles  may  be  somewhat  relaxed. 

From  whatever  cause  it  may  arise,  the  projection  of  the  bone  is  always  an 
unfortunate  circumstance;  when  it  is  but  slight,  and  not  accompanied  by 
denudation,  according  to  the  practice  of  M.  Gouraud  it  should  not  bo  touched. 
Nature  will  perfect  her  own  work,  and  will  finally  displace  the  cicatrix,  so 
as  to  bring  the  skin  over  the  end  of  the  stump. 

Exfoliation,  which  was  long  considered  an  inevitable  consequence  of  ampu- 
tation, is  now  counted  an  unfortunate  accident.  As  it  is  extremely  slow  in 
its  progress,  requiring  thirty,  forty,  or  perhaps  sixty  days  to  complete  its 
work,  it  should  seldom  be  left  to  the  unassisted  eftbrts  of  nature.  The  hot 
iron  or  potential  cautery,  the  nitrate  of  mercury,  for  instance,  which  were 
until  of  late  frequently  employed,  and  that  even  by  Sabatier,  have  scarcely 
any  eft'ect  in  hastening  the  process. 

It  is  much  better  to  remain  contented  with  slight  eff()rts  with  the  forceps, 
repeated  at  every  dressing,  upon  the  osseous  eschar,  as  soon  as  it  becomes 
movable.     It  is  well  to  remark,  moreover,  that  the  eschar  will  frequently 


172  NEW  ELEMENTS  OF 

disappear  without  any  apparent  exfoliation.  An  adult,  whose  leg  had  been 
amputated  by  M.  Beauchene,  was  affected  by  necrosis  of  the  angle  of  the  tibia, 
of  which  we  satisfied  ourselves  by  means  of  the  probe.  The  wound  closed 
over  it,  but  a  small  abscess  betrayed  itself  about  a  month  afterwards ;  I  opened 
it  and  a  fluid  and  reddish  pus  issued  forth,  but  the  necrosis  no  longer  existed, 
and  the  fistula  soon  finally  healed.  In  another  case  where  the  whole  stump 
had  suppurated,  I  saw  for  a  long  time  the  extremities  of  the  tibia  and  fibula 
of  a  lime-like  whiteness,  slightly  tinged  with  yellow,  jagged,  sonorous,  and, 
in  short,  completely  dead.  By  degrees  they  were  lost  in  the  thickness  of 
the  flesh,  the  cicatrization  was  affected,  and  in  the  space  of  four  months  the 
cure  was  complete. 

Removal  of  the  dead  bone,  which  was  the  subject  of  so  much  debate  in  the 
ancient  academy,  is  given  by  Sabatier  as  a  simple  and  easy  operation  with- 
out pain  ;  by  others,  as  a  second  amputation,  often  more  dangerous  than  the 
first.  Wlien  this  operation  is  resorted  to,  it  must  be  performed  high  enough 
to  avoid  the  necessity  of  its  repetition;  high  enough  to  secure  the  patient 
against  a  recurrence  of  the  projection.  It  is  easy  to  see,  that  if  the  integu- 
ments and  the  superficial  muscles  are  to  be  much  removed  from  the  end  of 
the  bone,  the  operation  must  be  extremely  painful,  whilst,  if  nothing  is  to  be 
done  but  to  saw  off  the  superfluous  part  at  a  few  lines  above  the  necrosis,  the 
operation  will  be  one  of  trifling  importance. 

Inflammation  sometimes,  and  particularly  after  immediate  union,  seizes 
upon  the  periosteum,  which  suppurates  and  peels  off.  The  bone  thus  denuded, 
seldom  fails  to  mortify  through  either  the  whole  or  a  part  of  its  thickness. 
At  other  times,  the  necrosis  begins  in  the  tissue  of  the  organ  itself,  and  the 
danger  of  the  accident  is  then  increased.  The  first  duty,  in  such  a  case,  is 
to  open  with  the  bistoury  a  free  passage  for  the  escape  of  the  pus,  or  other 
morbid  fluids,  and  endeavor  to  restrain  the  extension  of  the  disease  by  ajiply- 
ing  an  expulsive  compression  from  the  root  of  the  stump  down  to  the  wouncl. 
Then  we  must  wait  the  exfoliation,  or  else  when  the  disease  has  ceased  to 
extend,  the  dead  bone  is  cut  off,  or  amputation  is  again  performed  at  a  higher 
point,  as  in  the  remedy  for  conicity. 

3d.  The  Hospital  Putrefaction,  which  often  follows  amputation,  is  one  of  the 
most  unfortunate  complications  which  can  possibly  occur.  When  it  attacks 
the  stump  and  invades  to  a  considerable  extent  the  muscles  of  the  integu- 
ments, when  the  bone  is  denuded,  and  when  topical  applications  and  among 
them  caustics  have  been  essayed  in  vain,  then  amputation  above  the  next 
articulation,  or  if  that  is  not  practicable,  simply  above  the  limits  of  the  affected 
part,  is  our  last  resource.  M.  Gouraud  has  obtained  many  unexpected  cures 
in  the  army,  and  in  the  Hospital  of  Tours,  where  I  have  myself  witnessed 
them.  Messrs.  Percy,  Willaume,  and  Desruelles,  have  also  followed  the 
practice,  and  I  do  not  hesitate  to  recommend  it  in  the  cases  which  I  have 
defined. 

4th.  The  Inflammatory  Swelling  of  the  Stump  sometimes  presents  itself  under 
the  form  of  a  simple  erysipelas,  and  sometimes  with  the  characters  of  erysipe- 
latous phlegmon.  In  the  first  case  if  the  skin  alone  is  affected,  the  emplastic 
straps  are  often  the  cause,  either  on  account  of  their  being  too  ti^ht,  or  be- 
cause they  contain  too  great  a  proportion  of  irritating  matters.  It  is  enough, 
then  to  remove  them,  and  to  envelope  the  inflamed  surface  for  some  days  with 
emollient  cataplasms.  In  the  second  case  the  accident  becomes  more  serious, 
and  requires  more  particular  attention.  The  inflammation  is  quickly  carried  to 
a  great  extent;  the  skin  and  the  muscles  are  soon  dissected  by  pus;  the  subcu- 
taneous tissue,  the  deepest  cellular  interstices  sometimes  mortify  and  come 


OPERATIVE    SURGERY.  173 

ftwaj  in  sloughs,  an  ataxic  or  adynamic  fever  arises,  and  puts  the  patient  in 
'he  greatest  danger.  Secondary  reunion  is  seldom  attended  with  similar  acci- 
lents.  This  is,  therefore,  one  of  the  best  founded  objections  which  can  be 
idduced  against  primitive  coaptation. 

From  their  first  onset,  these  symptoms  should  be  combated  with  energy. 
They  are  sometimes  calmed  by  laying  the  entire  surface  of  the  wound  bare 
30  as  to  dress  it  flat,  or  by  covering  the  stump  with  leeches,  and  afterwards 
with  cataplasms ;  but  when  such  means  fail  of  success,  or  it  is  too  late  to 
make  the  application,  the  most  efficacious  remedy  which  is  known  to  me  is 
that  of  deep  and  multiplied  incisions.  In  1828,  at  the  close  of  summer,  I 
had  occasion  to  try  the  flap  method  in  amputating  the  leg;  the  whole  thick- 
ness of  the  stump  soon  became  the  seat  of  inflammation  ;  erysipelas  and 
purulent  collections  already  occupied  the  inferior  third  of  the  thigh;  stupor 
and  other  adynamic  symptoms  advanced  with  frightful  rapidity.  I  thought 
the  patient  lost,  beyond  all  hope.  M.  Beauchene,  who  thought  differently, 
made  eight  or  ten  incisions  in  the  diff'erent  inflamed  parts  of  the  skin.  The 
symptoms  from  that  time  began  to  retrograde,  and  the  patient  recovered, 
much  to  my  astonishment  I  must  confess.  Against  that  erysipelas  of  a  grey- 
ish tint  which  so  often  terminates  in  gangrene  after  amputation,  M.Larrey 
employs  the  actual  cautery.  The  hot  iron  being  applied  with  some  force  in 
such  a  form  as  to  imitate  the  branches  of  the  fern  or  the  nerves  of  a  laurel 
leaf,  for  example,  or  any  other  figure,  upon  the  inflamed  points,  produces 
sometimes  most  wonderful  effects,  the  extraordinary  results  of  which  I  have 
myself  witnessed  at  the  *'  Hopital  de  la  garde.^^ 

If  the  disease  has  become  local  after  having  given  rise  to  numerous  general 
symptoms,  there  sometimes  results  a  denudation  of  the  bone  or  fistulous 
passages,  a  pointed  stump,  which  can  only  be  remedied  by  a  second  amputation. 
"Experience  has  taught  me,"  says  Gouraud,  "  that  the  patient  endures  the 
amputation  of  the  stump  better  than  that  of  the  limb,  and  that  the  first  has  a 
greater  chance  of  success  than  the  second  ;  out  of  ten  individuals  upon  whom 
1  operated  in  this  way  in  1814  and  1815,  nine  were  cured."  Instead  of 
aff'ecting  the  whole  stump,  the  inflammation  confines  itself  in  some  cases  to 
the  cellular  tissue  about  the  vessels,  and  particularly  about  the  subcutaneous 
veins ;  it  then  soon  forms  for  itself  in  the  course  of  these  vessels  small  purulent 
spots  or  abscesses  which  should  be  opened  at  an  early  period,  if  antiphlogistics  , 
or  compression  have  proved  unable  to  prevent  them. 

5th.  Phlebitis. — The  veins  often  become  inflamed,  either  separately  or 
with  the  surrounding  parts.  Here,  as  in  every  other  case,  phlebitis  is 
extremely  dangerous.  Hunter,  Abernethy,  Travers,  and  others,  proved  it 
long  since.  The  symptoms  of  adynamia,  putridity,  and  of  ataxia,  to  which 
it  very  soon  gives  rise,  are  almost  always  followed  by  death,  so  that  it  is  one 
of  the  most  formidable  accidents  which  can  possibly  occur  after  amputation. 
The  dangers  with  which  it  is  accompanied,  attributed  until  quite  lately  to 
the  propagation  of  the  inflammation  from  the  stump  towards  the  heart,  in 
fact  depend  entirely  upon  another  cause.  The  mixture  of  pus  with  the 
blood,  and  its  transportation  through  all  the  organs,  present  a  much  more 
satisfactory  explanation,  as  I  believe  I  was  the  first  formally  to  express  in 
1824,  1825,  1826,  and  particularly  in  1827;  and  as  has  been  since  proved  by 
Messrs.  Marechal,Reynaud  of  Marseilles,  Dance,  Legallois,  Arnott,  Blandin, 
and  others  ;  an  explanation  of  which  several  of  the  ancients  had  some  vague 
notion.  Purulent  resorption  is  another  accident  of  which  the  dangerous 
results  are  exactly  similiar.*     The  recent  researches  begun  by  M.  Monod, 

^'  ♦  See  introduction. 


174  NEW  ELEMENTS  OF 

and  continued  by  M.  Rejnaud  and  others,  go  to  prove  that  the  inflammation 
of  the  medullary  tissue  of  the  bones,  of  their  proper  veins,  and  of  their  spongy 
substance,  participate  also  in  the  production  of  the  symptoms  generally  attri- 
buted to  phlebitis  or  the  resorption  of  pus  ;  but  this  question  demands  further 
investigation,  and  if  decided  in  the  affirmative,  would  make  entirely  for  ampu- 
tations in  the  articulation,  by  exposing  more  fully  the  dangers  of  amputation 
in  the  body  of  the  limbs. 

6th.  Cystitis. — **  It  is  often  necessary,"  says  M.  Gouraud,  "to  use  the 
sound  upon  the  subjects  of  amputation,"  and  many  observers  have  made  the 
same  remark.  Whatever  may  be  the  primitive  cause,  cystitis  is  no  very  rare 
occurrence  after  amputation,  particularly  of  tlie  abdominal  extremities.  It 
should  be  apprehended  at  the  least  symptom  of  any  affection  about  the  uri- 
nary passages.  I  need  not  say  that  vesications  should  be  proscribed  when 
this  affection  is  threatened  ;  but  M.  Blandin  is  certainly  mistaken  in  con- 
necting it  with  the  use  of  this  therapeutic  agent,  for  it  is  observed  when  no 
preparation  of  cantharides  has  been  used,  as  I  have  myself  seen  in  the 
case  of  a  female,  upon  whom  amputation  of  the  thigh  had  been  performed  by 
M.  Roux,  in  1826.  For  more  ample  details  upon  the  accidents  which  have 
been  here  passed  in  review,  upon  tetanus,  and  every  other  disease  which  may 
complicate  the  results  of  amputation,  I  can  only  refer  to  the  treatises  on 
pathology,  properly  so  called. 

Changes  which  take  place  in  the  Organic  State  of  the  Subjects  of  Amputation, 
After  the  removal  of  a  limb,  changes  sometimes  of  a  very  remarkable  nature 
occur  in  the  person  of  the  subject  known  to  all  surgeons,  and  of  late  well 
described  by  Messrs.  Gouraud,  Cloquet,  and  others.  Some  affect  the  stump, 
others  the  constitution  in  general. 

1st.  In  the  Stump. — The  muscles,  the  cellular  tissue,  the  aponeurosis,  the 
tendons,  the  bones  themselves,  undergo  at  the  place  of  section  a  transform- 
ation of  such  a  character,  that  all  the  parts  are  confounded  in  attaching  them- 
selves to  the  cicatrix,  and  constitute  there  nothing  but  lamallae  or  fibrous 
cords,  more  or  less  dense,  and  more  or  less  distinct.  Afterwards  the  stump, 
which  had  at  first  become  meagre,  becomes  the  seat  of  a  more  vigorous  nutri- 
tive action,  increases  in  size,  and  at  a  longer  or  shorter  period  puts  itself  in 
this  respect  upon  a  level  witli  the  root  of  the  other  limb. 

2d.  In  the  rest  of  the  Economy. — The  subjects  of  amputation  attain  a  remark- 
able embonpoint,  acquire  an  increase  of  energy  in  the  organs  of  digestion, 
of  circulation,  and  of  reproduction;  the  fluids  of  life  being  obliged  to  move 
in  a  more  contracted  circle,  increase  the  activity  of  all  the  functions.  They 
tend  to  induce  the  characteristics  of  the  sanguine  temperament.  The 
sanative  efforts  of  nature  to  remedy  the  plethora  of  the  economy,  manifest 
themselves  according  to  age  or  sex,  by  epistaxis,  hemorrhoides,  more  abun- 
dant menstruation,  frequent  stools,  transpiration,  and  more  copious  secretions. 
Garengeot  advises,  that  in  order  to  prevent  plethora  and  a  revulsion  of  blood, 
bleeding  should  be  practised  from  time  to  time  upon  those  who  have  been 
subjects  of  amputation ;  that  at  least  one-fourth  part  of  their  customary  nou- 
rishment should  be  taken  off  during  the  first  year,  and  the  subject  should 
abstain  from  all  violent  exercises.  A  soldier  of  the  army  of  the  eastern 
Pyrenees  had  both  thighs  amputated,  and  recovered.  The  activity  of  all  the 
viscera,  and  especially  of  the  stomach,  increased  in  a  singular  decree;  in  a 
short  time  this  man  became  extremely  fleshy,  the  consequences  ot  which  it 
was  difficult  to  calculate.  The  dejections  became  more  frequent  without 
any  perturbation  of  the  bowels,  but  the  immobility  to  which  this  double  muti- 
lation subjected  him,  produced  a  diseased  plethora.    A  species  of  carriage 


OFERATIVE   SURGERY.  175 

was  procured  for  him,  but  this  passive  movement  did  more  harm  than  good, 
for  it  favored  the  digestion  more  than  transpiration  or  the  other  excretions. 
This  unfortunate  man  finally  sunk  under  the  burden  of  sanguineous  plethora. 
**I  have  made  these  observations  by  hundreds,"  says  Mr.  Gouraud,  "and 
they  certainly  appeared  to  me  to  be  worthy  of  the  attention  of  the  faculty." 
I  have  myself  seen  two  very  marked  instances  of  a  similar  character. 

Art,  2. — The  Flap  Operation, 

History, — Amputation  by  flaps  seems  to  be  ascribed  by  Sprengel  and  Gag- 
nier,  to  Celsus,  Maggi,  and  others  of  the  older  surgeons,  such  as  Pare  and 
Hilden,  and  was  not,,  as  is  generally  believed,  proposed  for  the  first  time  by 
Lowdham  in  his  letter  addressed  to  Young,  and  published  in  1679.  We  shall 
see  presently  that  Leonides  and  Heliodorus  have  clearly  described  it.  It  con- 
sists in  cutting  out  of  the  soft  parts  one  or  more  flaps,  which  permit  the  wound 
to  be  immediately  and  completely  closed.  After  Lowdham,  this  method  was 
extravagantly  praised,  and  differently  modified  by  Verduin,  of  Amsterdam,  in 
1669 ;  by  Sabourin,  of  Geneva,  in  1702;  by  Morand,  De  la  Faye,  Garengeot, 
before  the  middle  of  the  last  century.  It  was  opposed  by  Koenerding,  a 
countryman  of  Verduin,  by  Heister,  and  many  others,  but  was  soon  defended 
by  P.  Massuet,  Le  Dran,  Ravaton,  Vermale,  Quesnay,  and  others.  Since 
then  O'Halloran,  Messrs.  Dupuytren,  Roux,  Guthrie,  Klein,  Kern,  Langen- 
beck,  Larrey,  Lisfranc,  and  a  multitude  of  other  surgeons,  have  had  recourse 
to  it ;  so  that  its  history  presents  really  two  distinct  epochs,  the  one  compre- 
hending all  that  was  said  of  it  during  the  last  century,  and  the  other  belonging 
particularly  to  the  present  time. 

Appreciation. — Lowdham  holds  that  this  method  is  more  prompt,  less  dan- 
gerous, that  it  occasions  less  risk  of  tetanus  or  hemorrhage  than  circular  ampu- 
tation, that  it  renders  the  ligature  of  the  vessels  useless,  prevents  exfoliation, 
obtains  a  speedy  cure,  and  makes  very  easy  the  application  of  an  artificial  limb. 
Of  these  advantages  there  are  several  which  have  not  been  confirmed  by  expe- 
rience. In  the  first  place  it  cannot  be  perceived  how  it  can  be  less  painful 
than  the  circular  method,  or  can  more  surely  prevent  tetanus.  The  exfo- 
liation of  the  bone  is  a  very  rare  thing;  instead  of  being  frequent,  as  it  was 
then  thought,  and  as  the  preventive  means  are  not  to  be  applied  to  the  stump 
itself,  it  is,  in  this  respect,  a  matter  of  indifference  whether  the  amputation 
has  been  performed  by  one  method  or  the  other.  Finally,  it  is  easy  to  see 
that  it  does  not  dispense  with  the  ligature  of  the  vessels,  and  that  the  incision 
scarcely  ever  cicatrizes  without  suppurating  for  a  longer  or  shorter  period. 
Immediate  reunion  is  an  incontestable  advantage;  and  if  the  improvements 
in  the  circular  method  did  not  permit  the  attainment  of  the  same  end  in 
the  majority  of  cases,  there  is  no  doubt  that  amputation  by  flaps  would,  at 
this  day  be  generally  preferred.  It  must  also  be  confessed,  that  it  makes  it 
easy  to  avoid  the  protrusion  of  the  bone,  the  pointed  shape  of  the  stump,  and 
that  it  preserves  enough  of  the  soft  parts  to  close  without  dragging  the  widest 
and  deepest  wounds. 

Manual. — The  flap  operation  is  performed  in  two  general  ways,  from 
without  inwards  or  from  within  outwards.  In  the  one,  the  incision  is  carried 
from  the  skin  towards  the  bones,  whilst  in  the  other  the  operator  commences 
by  plunging  the  knife  through  the  member  so  as  to  cut  the  flap  from  its  root 
towards  its  free  border.  If  the  first  method  is  more  regular  and  more  sure,  the 
second  is  much  more  rapid  and  more  brilliant.  In  operating  in  the  first  of  these 
juodes,  it  is  well  to  begin  by  dividing  the  integuments  at  the  first  stroke,  and 


176  »EW    EL^MfeNTS   OJF 

causing  these  to  be  drawn  back  by  an  assistant,  to  effect  at  a  second  stroke 
the  division  of  the  muscles  a  little  higher  up.  By  this  mode  it  is  easy  to 
give  to  the  flaps  the  desired  form  and  dimensions ;  but  the  operation  is  di- 
vided into  stages,  and  thus  made  less  rapid. 

In  piercing  at  first  the  thickness  of  the  limb,  the  point  of  the  instrument 
is  liable  to  contact  with  the  bone,  and  often  attacks  organs  which  it  might 
be  best  to  preserve,  divides  irregularly  some  tissues  which  it  is  important  to 
cut  smoothly,  and  does  not  always  cut  the  flaps  ias  thick  as  is  necessary  for 
the  attainment  of  the  end  proposed.  This  mode  of  operating  has  in  our  days 
found  numerous  partisans  and  able  defenders,  but  it  is  hardly  ever  adopted 
any  more  than  the  preceding,  except  in  amputations  at  the  joints*  On  the 
whole,  it  appears  to  me  that  too  much  value  has  been  accorded  to  the  flap 
method.  The  wound  which  results  necessarily  presents  a  more  extended 
surface  than  if  it  had  been  circular.  The  muscles  which  the  operator  is  so 
careful  to  preserve,  expose  him  to  several  inconveniences.  If  inflammation 
seizes  them,  they  suppurate  very  profusely,  imbibe  the  fluids  like  a  sponge,  and 
favor,  in  a  very  high  degree,  purulent  resorption  and  phlebitis.  And  again, 
they  seldom  attach  themselves  over  the  extremity  of  the  stump  in  the  centre 
of  the  cicatrix.  After  all,  it  is  always  the  skin  that  corresponds  with  the 
osseous  protrusions  which  the  semilunar  form  of  the  flaps,  by  the  retraction 
of  the  angles  of  the  wound,  favors  more  than  any  other  method.  For  the  rest, 
it  offers  a  certain  number  of  distinct  varieties.  Lowdham,  Verduin,  Sabourin, 
Guthrie,  and  Grsefe,  content  themselves  with  a  single  flap,  which  they  apply 
against  the  bleeding  surface.  Vermale  advises  to  make  a  flap  on  each  side, 
and  to  form  them  by  thrusting  the  point  of  the  knife  upon  the  part  of  the  bone 
where  the  saw  is  to  be  applied.  In  order  to  avoid  deception  with  regard  to 
their  length,  he  advises  before  commencing  to  mark  with  a  red  thread  the 
points  of  departure  and  of  termination.  Ravaton  and  Bell  divide  the  skin 
and  the  whole  thickness  of  the  muscles  circularly,  at  the  first  stroke  of  the 
knife ;  another  incision,  which  falls  upon  the  bone  parallel  to  its  axis  behind 
and  before,  serves  then  to  separate  two  flaps,  which  are  immediately  dis- 
sected and  drawn  up.  The  procedure  of  Vermale  is  now  almost  the  only 
one  which  is  followed,  even  for  the  formation  of  a  single  flap.  The  practice 
of  Ravaton  should  by  no  means  be  imitated.  The  circular  division  first  made 
is  completely  wasted.  The  flaps  thus  squarely  cut  are  too  thick  towards  the 
end,  and  retard  considerably  the  direct  reunion. 

Two  flaps  should  always  be  preferred  whenever  it  is  possible  to  give  them 
a  size  and  thickness  nearly  equal ;  but  if  this  cannot  be  effected,  it  is  much 
better  to  have  but  one.  In  this  latter  case  it  is  required  that  the  flaps,  in 
order  to  close  the  wound,  should  be  of  considerable  length,  that  it  should  be 
bent  nearly  at  a  right  angle,  that  it  should  be  subjected  to  a  pressure,  and  to 
tractions  which  should  be  very  likely  to  compromise  the  success  of  the  ope- 
ration. 

We  shall  see,  in  describing  amputations  in  particular,  the  cases  in  which 
this  method  of  operating  is  inapplicable. 

Art.  Z.-^The  Oval  Method. 

This  method  is  less  ancient  than  the  two  preceding*  It  was  described  at 
the  commencement  of  the  present  century  by  M.  Chasley,  Messrs.  Langen- 
beck,  Beclard,  Guthrie,  and  Richerand,  as  applicable  to  certain  particular 
amputations,  but  it  was  not  really  generalized  until  the  year  1827,  by  M. 
Scoutetten.     According  to  his  opinion,  its  principal  advantage  is  that  of 


OPERATIVE   SURGERY.  Iff 

always  permitting  the  incision  to  be  made  from  without  mWards,  from  the 
superficial  towards  the  deeper  parts,  as  in  the  circular  method,  and  of  pre- 
serving enough  of  the  flesh  to  bring  the  lips  of  the  wound  together  as  easily 
as  in  the  flap  method  ;  so  that,  says  he,  it  places  itself  between  these  two, 
and  is,  so  to  speak,  a  link  between  them.  It  is  certain,  that  by  the  oval 
method  a  neat  and  regular  division  is  obtained,  and  that  most  frequently 
enough  of  the  tissues  may  be  preserved  to  justify  an  attempt  at  direct  reunion, 
and  that  there  are  but  few  points  of  the  members  to  which  it  is  not  appli- 
cable. 

Its  distinct  character  is  to  present  an  incision  of  an  ovoid  form,  already 
recommended  by  Lassus,  in  1793  ;  by  M.  Chasley,  in  1803  and  1804  ;  by  M. 
Langenbeck,  in  1809 ;  and  from  which  Mr.  Scoutetten  derived  the  title  which 
I  have  preserved  for  it.  It  is  performed  in  two  ways,  scarcely  distinguish- 
able the  one  from  the  other.  In  the  first  and  the  oldest  mode,  the  operator 
begins  by  describing  a  triangular  flap  in  the  form  of  a  V  inverted,  a  little 
below  the  passage  where  it  is  necessary  to  apply  the  saw,  or  to  disarticulate 
the  bone.  After  having  turned  down  the  apex  of  this  triangle,  and  raised  the 
two  lips  of  the  incision,  he  passes,  by  penetrating  the  joint  either  from  above 
to  below  or  from  one  side  to  the  other,  behind  the  bone,  grazing  its  lower 
surface,  and  finishes  by  reuniting  the  two  previous  incisions  at  the  base  of  V, 
where  the  vessels  had  been  preserved.  M.  Scoutetten  prefers  giving  his 
incision  from  the  first  a  form  completely  oval,  being  careful,  in  passing  under 
the  vascular  and  nervous  lash  or  upon  the  part  which  is  to  form  the  greater 
extremity  of  the  oval,  to  divide  only  the  integuments.  This  is  no  otherwise 
important  than  as  giving  a  little  more  regularity  to  the  incision. 

Some  persons  have  advised  a  combination  of  these  methods  in  certain  cases, 
for  the  purpose  of  profiting  by  the  advantage  of  the  one,  and  of  avoiding  the 
inconveniences  of  the  others.  It  is  thus  that  O'Halloran  adopts  the  fol- 
lowing modification,  which  in  his  opinion  should  command  every  suffrage  in 
favor  of  the  method  of  Lowdham.  Instead  of  applying  compression  to  sup- 
press hemorrhage,  he  advises,  as  also  does  Garengeot,  to  tie  the  arteries  care- 
fully, and,  to  be  more  certain  that  no  serious  accidents  may  happen  on  the  part 
of  the  stump,  he  advises  to  dress  the  wound  flat,  and  let  it  suppurate  for  eight 
or  twelve  days,  then  to  raise  it  as  soon  as  it  is  covered  with  cellular  granu- 
lations, and  adapt  it  carefully  to  the  rest  of  the  wound.  White  and  M.  Pa- 
roisse  declare  that  they  have  tested  this  modification  in  practice  a  great 
number  of  times  with  the  most  favorable  results,  and  I  have  come  to  the  con- 
clusion, from  the  experiments  which  I  made  of  it  under  the  head  of  secondary 
direct  unions,  that  it  has  been  but  badly  appreciated  amongst  us,  and  that 
in  a  multitude  of  cases  it  holds  out  the  most  undeniable  advantages.  What 
O'Halloran  has  added  to  the  procedure  of  Lowdham,  Beclard  has  advised  for 
that  of  Vermale — when  the  flaps  are  formed  of  tendinous  parts,  of  fibrous 
sheaths,  and  of  synovial  sacs.  After  having  cut  the  skin  circularly,  instead 
of  incising  the  other  soft  parts  in  the  same  manner,  M.  J.  Cloquet  has  thought 
that  in  certain  cases  it  would  be  better  to  pass  the  knife  between  them  and 
the  bones,  and  to  cut  outwards  as  in  the  flap  method.  M.  Dupuytren  has 
applied  the  same  modification  to  the  flap  operation. 

B. — Amputations  in  Contiguity, 

History, — The  perusal  of  the  works  of  Hippocrates  teaches  that  amputation 
at  the  joint  was  often  practised  by  the  ancients.     Galen  and  Heliodorus  speak 
of  it  in  the  most  explicit  terms.    Even  the  Arabs  were  not  ignorant  of  it 
23 


178  NEW  ELEMENTS   OF 

Sprengel  is  evidently  mistaken,  when  he  asserts  that  it  had  not  been  men- 
tioned from  the  time  of  the  Grecian  writers  up  to  that  of  Munnicks.  Guy  de 
Chauliac  formally  avers,  that  "if  corruption  reaches  to  near  the  joint,  the 
member  should  be  cut  off  in  the  joint  itself  with  a  razor  or  other  instrument, 
without  using  the  saw."  Pare  has  not  passed  it  by  in  silence.  F.  de  Hilden 
treats  of  it  as  a  common  method,  and  Pigray  expresses  himself  thus  on  the  same 
subject :  *•  Some  persons  make  a  difficulty  of  cutting  into  the  joint  or  near  it, 
on  account  of  the  nervous  parts,  but  the  danger  is  not  so  great.  I  have  seen 
many  cases  of  it  which  turned  out  well."  The  efforts  of  Le  Dran,  of  Morand, 
of  Heister,  of  Brasdor,  and  of  Hoin,  have  only  brought  it  again  into  vogue,  by 
doing  away  the  prejudices  with  which  it  had  been  surrounded  by  the  physio- 
logy of  the  middle  ages.  It  is  practised,  like  amputation  in  the  continuity, 
by  the  three  principal  methods,  but  most  commonly  by  the  flap  method  and 
by  the  oval.  We  shall  see,  however,  that  the  circular  method  is  quite  appli- 
cable to  it,  and  that  it  is  even  preferable  in  a  good  number  of  cases. 

Appreciation.'— The  advantages  of  disarticulation  are,  that  it  is  more  prompt 
and  more  easy  of  execution  than  the  preceding,  that  it  does  n6t  require  the 
division  of  the  bones,  facilitates  an  immediate  reunion,  and  admits  of  the 
preservation  of  a  greater  length  to  the  limb.  It  is  attended,  however,  with 
the  inconvenience  of  laying  bare  large  osseous,  or  cartilaginous  surfaces,  at 
least  in  most  cases  ;  requirmg  the  use  of  instruments  on  me  thickest  points 
of  the  skeleton,  and  those  which  are  least  abundantly  furnished  with  soft 
parts  ;  compelling  us  frequently  to  make  use  of  tendinous  or  synovial  tissues 
to  close  the  wound  ;  of  presenting  a  solution  of  continuity  perhaps,  a  little 
less  regular;  but  it  is  not  true,  as  it  was  long  thought,  that,  all  other  things 
being  equal,  it  exposes  more  than  amputation  in  continuity,  to  nervous  affec- 
tions, to  tetanus,  to  abscesses,  to  purulent  fistulse,  and  to  the  symptoms  of 
general  reaction,  although  these  phenomena  may  sometimes  have  occurred 
after  it.  It  is  executed  with  an  inconsiderable  number  of  instruments,  and 
does  not  require  such  complicated  dressings  as  the  other  method.  A  knife, 
or  the  simple  bistoury  is  almost  always  sufficient  for  every  step  of  the  ope- 
ration; the  conicity  of  the  stump,  the  projection  of  the  bones,  tne  retraction 
of  the  muscles,  are  the  less  to  be  feared,  as  the  soft  parts  are  scarcely  dis- 
placed, the  adhesion  of  the  flaps  is  easily  obtained,  and  inflammation  does  not 
develop  itself  to  a  greater  degree  than  is  necessary  to  determine  a  direct 
union. 

As  the  division  passes  through  only  the  skin,  the  cellular  or  fibrous  tissues, 
and  some  of  the  muscular  attachments,  inflammation,  abscess,  or  general  re- 
action are  generally  less  to  be  feared;  although  large  in  appearance,  the 
wound  is  in  reality  but  small  in  extent,  because  the  cartilaginous  crusts 
which  form  the  bottom  being  insensible  and  inert,  perform  no  part  in  the  pro- 
cess of  inflammation  or  of  suppuration. 

The  fears  entertained  by  the  surgeons  of  the  last  century,  of  wounding  the 
diathrodial  cartilages,  of  exposing  them  to  the  air,  or  of  touching  them  with 
the  instrument,  are  at  the  present  day  exploded.  Instead  of  so  many  pre- 
cautions heretofore  recommended  in  order  to  avoid  the  articular  surface  which 
rests  at  the  bottom  of  the  wound,  many  of  the  moderns  have  even  gone  so 
far  as  to  recommend  wounding  it  on  purpose.  M.  Gensoul,for  example,  is 
of  opinion  with  Richter,  that  by  cutting  it  off  with  the  point  of  the  knife 
you  multiply  the  chances  of  cicatrization  in  the  first  intention.  This  prac- 
tice, which  IS  also  adopted  by  some  of  the  Parisian  surgeons,  and  which  is 
accompanied  with  no  inconvenience,  yet  appears  to  rest  upon  a  reason  the 
importance  of  which  is  by  no  means  proved.    In  fact,  it  is  inaccurate  tG  say. 


OPERATIVE   SURGERY.  17^ 

with  Beclard  and  many  others,  that  after  amputation  in  continuity,  the 
smooth  front  of  the  cartilage  does  not  unite  itself  with  the  flap,  that  it  remains 
free  even  after  a  final  cure,  unless  inflammation  have  been  by  some  means  or 
the  other,  excited  in  it.  Whether  the  instrument  has  touched  it  or  not,  it 
contracts  nevertheless,  and  that  very  quickly,  firm  adhesions  with  the  tissues 
which  cover  it.  If  the  agglutination  is  not  immediate,  the  cartilage  is  some- 
times pushed  forward  by  cellular  granulations  which  arise  from  the  bone 
behind  it,  and  detaches  itself  in  small  parcels,  sometimes  in  large  flakes, 
sometimes  in  the  formof  a  shell,  and  exposes  a  vermilion  wound,  which  cica- 
trizes easily.  In  a  contrary  case  it  does  not  at  first  sensibly  change  its 
aspect ;  it  only  loses  its  polish,  and  becomes  rugous  5  but  a  molecular  action 
is  sure  to  develop  itself,  to  sap  it  insensibly,  and  to  cause  its  entire  disap- 
pearance. It  is  a  true  epidermis  of  the  bone,  a  simple  **anhiste"  stratum, 
and  cannot  retain  its  distinctive  characters  longer  than  the  articular  move- 
ments are  kept  up.  As  soon  as  any  of  the  living  tissues  rest  upon  it,  the 
vitality  of  the  bones  expel  or  destroy  it  in  creating  the  cellulo-fibrous  stratum 
which  forms  the  basis  of  every  perfect  cicatrix.  In  which  ever  way  the  ope- 
ration is  performed,  the  tendons,  aponeurosis,  nerves,  and  vessels,  at  last  fix 
themselves  firmly  upon  the  extremity  of  the  stump,  so  that  the  patient  can 
move  it  with  as  much  ease  as  before  the  operation. 

When  the  articulation  is  surrounded  by  a  large  capsule,  it  is  well  to  remove  it 
as  completely  as  possible  with  the  bone,  without,  however,  in  any  case  disturbing 
that  portion  which  remains.  Instead  of  the  tendons  being  left  to  hang  out- 
side of  the  incision  they  should  on  the  contrary  be  cut  as  deeply  as  possible, 
in  order  that  their  presence  may  not  impede  the  direct  reunion.  The  incision 
of  the  fibrous  or  synovial  sheaths,  advised  by  Garengeot  and  Bertrandi,  with 
a  view  to  prevent  inflammation  or  to  oppose  the  formation  of  purulent  fistulae, 
is  entirely  useless,  and  should  not  be  practised  without  particular  indication. 

The  fistulae  which  sometimes  follow  in  the  train  of  amputations  at  the  joints, 
are  formed  either  because  some  point  of  the  cartilaginous  surface  which  has 
not  exfoliated  nor  united  with  the  flap  of  soft  parts,  continues  to  exhale 
synovia;  or  perhaps  because  one  or  several  of  the  tendinous  sheaths  or  bursae 
yvhich  have  not  closed,  furnish  fluids  of  a  similar  kind.  Compression,  irritat- 
ing injections,  caustics,  &c.  easily  heal  them,  and  they  are  seldom  followed 
by  any  unpleasant  symptom.  For  the  rest,  amputations  in  continuity  are  not 
always  free  from  accidents  of  the  same  kind.  On  the  whole  then,  the  extir- 
pation of  limbs  is  not  more  dangerous  than  amputation  properly  so  called. 


CHAPTER   II. 

AMPUTATIONS   IN   PARTICULAR. 
SECTION   I. 


Thoracic  Extremity, — The  superior  extremities,  which  are  so  much  exposed 
by  constant  use  and  their  relations  to  external  agents,  to  contract  all  kinds 
of  lesion,  frequently  require  amputation.  It  should  here  be  held  as  a  general 


180  NEW   ELEMENTS   OF 

principle,  that  as  little  should  be  removed  as  possible.  The  smallest  portion 
which  can  be  preserved  rarely  fails  to  be  useful.  Thus  we  amputate  sepa- 
rately, the  fingers,  the  different  bones  of  the  metacarpus,  the  hand  itself,  the 
wrist,  the  fore-arm  in  its  continuity  and  at  its  articulation,  the  arm  at  the 
different  points  of  its  length  and  at  its  union  with  the  shoulder,  and  the 
shoulder  itself. 

Art.  1. — Finger9» 

The  amputation  of  the  fingers,  an  operation  scarcely  recognized  by  the 
ancients,  is  now  performed  frequently  and  in  many  different  ways,  whether 
the  operation  is  confined  to  the  removal  of  one  of  their  phalanges,  or  whether 
they  are  removed  entirely,  whether  amputation  is  performed  in  the  continuity 
of  the  bones  which  compose  them,  or  whether* you  prefer  to  disarticulate  them. 

Aiuitomical  Remarks. — The  fingers  have  for  the  basis  of  their  structure 
three  osseous  pieces,  which  are  articulated  by  ginglymas  for  the  two  anterior 
phalanges,  and  by  enarthrosis  for  the  metacarpal  phalanx.  They  further 
consist  of  tendons,  fibrous  sheaths,  synovial  sacs,  arteries,  voluminous  nerves, 
and  a  cutaneous  stratum  remarkable  in  the  appearance  of  its  anterior  portion. 
On  their  palmar  face  are  found  the  two  flexor  tendons  and  the  fibro-synovial 
canal  in  which  they  glide.  The  one  is  attached  to  the  articular  tuber  of  the  last 
phalanx,  and  by  a  fibrous  cord  to  the  metacarpal  phalanx.  The  two  strands  of 
the  second  attach  themselves  to  the  sides  of  the  middle  phalanx.  As  all  these 
tendons  meet  in  the  hollow  of  the  hand  in  order  to  reach  the  wrist  or  the 
fore-arm,  there  can  be  nothing  more  dangerous  than  the  inflammation  of  their 
sheaths  after  the  amputation  of  the  fingers.  The  cellular  tissue,  gathered  to 
the  front  in  the  form  of  a  cushion,  directs  to  this  quarter  in  the  search  of  soft 
parts  to  cover  the  stump  after  the  operation.  Their  dorsal  face  being  more 
round  renders  it  impossible  to  cut  upon  it  a  flap  of  proper  size  or  thickness. 
The  two  arteries  which  run  along  their  sides  lie  too  near  to  the  bone  to  let 
compression  be  substituted  for  the  ligature.  The  two  phalangeal  articulations 
present  this  circumstance  worthy  ot  remark,  that  being  held  by  two  very 
strong  lateral  ligaments,  and  in  the  rear  by  firm  tendons,  they  cannot  be  passed 
through  without  certain  precautions.  The  pulley  in  which  they  terminate, 
and  the  small  cavities,  separated  by  a  ridge  which  may  be  found  upon  the 
posterior  extremity  of  these  two  phalanges,  is  also  important  to  be  noticed,  if 
we  desire  to  give  a  sure  direction  to  the  action  of  the  bistoury. 

The  skin  presents  data  so  much  the  more  important  as  its  pathologic  state 
does  not  ordinarily  deprive  us  of  them.  Amongst  the  number  of  folds  and 
wrinkles  with  which  it  is  furnished  on  the  dorsal  side  of  the  articulation,  there 
are  three  which  should  be  particularly  noted.  The  one  which  is  perfectly 
transversal  corresponds  always  with  the  inter-articular  line;  the  second,  con- 
vex towards  the  hand,  lies  over  the  point  of  union  of  the  head  of  the  posterior 
phalanx  with  its  body;  the  third,  convex  towards  the  end  of  the  finger,  guides 
to  the  corresponding  point  of  the  anterior  phalanx.  The  palmar  side  of  the 
distral  phalangeal  articulation  is  immediately  beneath,  or  at  the  most  at  one 
line  in  front  of  the  only  crease  which  the  skin  presents  in  this  place.  It  is 
the  same  with  the  middle  articulation,  in  relation  to  the  deepest  line  of  the 
teguments  by  which  it  is  surrounded. 

The  metacarpo- phalangeal  articulation,  which  is  surrounded  in  the  same 
manner  as  the  preceding  by  two  lateral  ligaments,  and  the  flexor  and  extensor 
tendons,  has  besides,  before  or  on  its  sides  the  terminations  of  the  lumbri- 
cales  and  interosseous  mucles,  and  the  trunk  of  the  collateral  arteries,  which 


OPERATIVE   SURGERY.  181 

divides  a  little  farther  on.  As  this  phalanx  turns  upon  the  head  of  the  meta- 
carpal bone,  the  latter  is,  during  flexion,  almost  entirely  concealed  beneath 
the  former,  which  forms  of  itself  the  projection  which  is  then  remarked  upon  the 
fist.  These  articulations  are  not  all  on  the  same  line;  the  transverse  mark  in 
the  palm  of  the  hand,  which  corresponds  to  the  articulation  of  the  fore  and  little 
fingers,  is  found  several  lines  behind  that  of  the  middle  fingers.  The  best 
means  of  discovering  these  joints,  is  to  seek  for  them  at  about  ten  or  twelve 
lines  from  each  interdigital  commissure.  From  this  disposition  it  arises,  that  the 
small  cushion  of  their  anterior  face  may  easily  serve  to  form  a  flap  capable  of 
completely  covering  the  metacarpal  bones  after  the  removal  of  all  the  fingers. 

§  1.  Partial  Amputation. 

Formerly  the  fingers  were  always  amputated  in  the  continuity  of  their  pha- 
langes, and  by  proceedings  more  worthy  of  a  butcher  than  of  a  surgeon.  Even 
from  the  time  of  F.  de  Hilden,  the  operation  was  performed  with  cutting 
nippers,  a  gouge,  scissors,  or  some  other  instrument  of  a  similar  description, 
accompanied  by  a  blow  with  a  mallet  or  small  leaden  hammer :  more  recently, 
it  was  thought  that  a  great  step  had  been  taken  towards  perfection,  by  the 
substitution  of  a  small  saw  in  the  place  of  the  former  instruments,  which  had, 
according  to  Hilden,  besides  their  coarseness,  the  inconvenience  of  breaking 
the  bones,  and  of  giving  rise  generally  to  the  most  serious  consequences. 
Verdue,  Petit,  Garengeot,  Sharp,  and  all  the  moderns,  have  opposed  this 
manner  of  operating,  so  that  for  along  time  the  amputation  of  the  fingers  in 
the  continuity  has  been  discarded.  It  is  said  that  the  operation  is  much 
more  difficult,  and  that  the  portion  of  phalanx  which  it  preserves  cannot  be 
of  any  use.  On  this  point  it  appears  to  me  that  they  have  gone  too  far  ;  and 
that  in  accordance  with  the  ideas  of  Le  Dran,  Guthrie,  and  S.  Cooper,  it 
would  be  much  better  when  it  can  be  done  to  saw  the  phalanx  than  to  ex- 
tirpate it  entirely,  for  there  is  no  part  of  any  of  the  fingers  which  has  not  its 
use  and  its  importance. 

1st.  Manual. — A.  In  the  Continuity. — Supposing  that  the  disease  is  confined 
to  either  of  the  two  farther  articulations,  it  is  evident  that  it  cannot  be  en- 
tirely removed  except  by  cutting  the  posterior  phalange  to  a  certain  distance 
from  the  affected  joint,  and  that  the  remainder  of  the  bone  will  not  be  without 
its  value  to  the  patient.  This  slight  operation  may  be  performed  by  the  cir- 
cular or  flap  method. 

Circular  Method. — In  the  first  case  the  operator  incises  the  integuments 
as  near  as  possible  to  the  diseased  part.  He  then  forces  them  back  in  order 
to  divide  the  tendons,  and  to  make  section  of  the  bone  with  a  little  saw,  at 
about  three  or  four  lines  higher  than  the  point  of  beginning. 

Flap  Method. — In  the  second  case  the  operator  may  content  himself  with  a 
single  flap,  which  should  be  cut  in  front,  or  he  may,  as  was  already  done  by 
Heliodorus,  make  two,  each  somewhat  shorter  than  if  it  were  alone,  when 
the  state  of  the  soft  parts  does  not  forbid.  Immediate  union  should  always 
be  attempted. 

B.  In  the  Contiguity. — Circular  Method. — The  operator  here  incises  the  skin 
at  about  three  lines  in  advance  of  the  joint.  The  assistant  draws  it  back  to 
permit  him  to  divide  higher  up  the  extensor  tendon,  and  to  enter  between  the 
phalanges  from  the  dorsal  side,  after  having  divided  the  lateral  ligaments. 
In  coming  out  through  the  joint  to  the  palmar  side,  the  bistoury,  by  a  conti- 
nuous movement,  divides  the  flexor  tendons.   This  method  is  very  ancient,  was 


1^8  NEW    ELEMENTS   OF 

pointed  out  by  Garengeot,  recommended  by  Sharp,  Bertrandi,  Leblanc, 
Lassus,  and  others,  and  generally  adopted  in  England ;  is  as  good  as  any 
other,  and  easily  admits  of  immediate  union. 

Flap  Method. — a.  Process  of  Oarengeot. — Flaps  of  the  same  lengthy  one 
Dorsal,  the  other  Palmar. — Garengeot  recommends  the  method  of  Ravaton,  or 
rather  that  of  Heliodorus,  that  is,  to  make  two  lateral  incisions, united  distrally 
by  a  circular  one,  to  dissect  and  raise  the  two  flaps  thus  formed  up  to  the 
articulation,  before  passing  through  it,  and  then  immediately  to  close  the 
wound. 

b.  Process  of  Le  Dran. — Two  Lateral  Flaps. — Instead  of  making  flaps 
before  and  behind,  Le  Dran  makes  them  lateral,  and  gives  them  a  semilunar 
form.  This  process  has  been  described  anew  by  M.  Maingault,  and  justly 
condemned  by  Blandin. 

c.  First  Process  of  M.  Lisfranc. — Single  Palmar  Flap. — An  incision  is 
made  through  the  skin  at  about  one  line  in  advance  of  the  transverse  crease, 
so  as  to  enter  the  joint  at  the  first  stroke.  The  operator  immediately  divides 
the  lateral  ligaments,  by  inclining  the  bistoury  a  little  first  to  one  side  and 
then  to  the  other ;  the  articulation  being  divided,  there  remains  nothing  more 
than  to  cut  a  palmar  fla^  long  enough  to  close  the  wound  completely.  In  this 
way  the  operation  is  finished  in  the  twinkling  of  an  eye,  and  the  cicatrix, 
carried  towards  the  dorsal  surface  of  the  finger,  is  more  advantageously  situ- 
ated than  if  on  the  front,  an  advantage  whicn  may  be  disputed,  and  is  cer- 
tainly more  than  counterbalanced  by  the  risk  of  seeing  the  phalanx  denuded 
behind.  The  disease  besides  is  far  from  always  permitting  the  operator  to 
give  the  flap  a  sufficient  length. 

d.  Second  Process  of  M.  Lisfranc. — The  diseased  finger  is  held  in  supination, 
the  bistoury  is  passed  flatwise  between  the  soft  parts  and  the  front  of  the 
phalanx,  and  forms  on  being  brought  out  a  similar  flap  to  that  in  the  preced- 
ing method.  The  operator  then  raises  up  the  instrument,  and  passes  it  through 
the  joint  from  front  to  rear,  without  leaving  any  posterior  flap. 

e.  Another  Process. — Single  Dorsal  Flap. — When  the  disease  prevents  the 
formation  of  the  flap  in  front,  the  first  process  of  M.  Lisfranc  maybe  reversed, 
making  the  first  incision  at  the  distance  of  a  line  in  advance  of  the  palmar 
crease,  and  forming  a  flap  at  the  expense  of  the  dorsal  surface  of  the  finger 
But  it  is  necessity,  and  not  preference,  that  ever  sends  us  to  this  operation, 

/.  Ordinary  Process^ — Two  Flaps. — M.  Richerand,  Gouraud,  and  others, 
advise  the  formation  of  two  semilunar  flaps,  one  dorsal  and  the  other  pal- 
mar, each  three  or  four  lines  long.  Modified  in  a  way  which  I  shall  now 
^describe,  this  process  appears  to  me  to  be  of  more  general  application  than 
any  other,  and  to  be  equally  sure  besides  being  more  prompt  in  execution. 

g.  Two  Flaps. — Palmar  Flap  longer  than  the  other. — The  operator  seizes 
the  diseased  finger,  flexes  it  slightly  and  draws  it  towards  himself,  whilst  an 
assistant  holds  the  root,  bends  the  other  fingers,  or  separates  them  from  the 
first,  and  fixes  the  whole  hand  in  pronation.  With  a  narrow  bistoury,  held 
in  the  first  position,  the  operator  then  cuts  a  small  semilunar  flap  con- 
vex towards  the  nail,  following  throughout  the  passage  ot  the  anterior  crease 
in  the  skin.  The  divided  teguments  are  withdrawn  by  the  assistant;  the  bis- 
toury which  is  carried  up  with  them  opens  the  articulation  by  cutting  across 
the  extensor  tendon,  divides  the  lateral  ligaments  on  the  right  and  left,  passes 
between  the  articular  surfaces,  avoiding  as  much  as  possible  the  projections 
which  they  present.  Then,  immediately  upon  arriving  at  the  anterior  liga- 
ment, the  edge  of  the  instrument  is  turned  forwards,  so  as  to  glide  upon  the 
palmar  surface  of  the  disarticulated  phalanx,  and  to  form  a  flap  of  from  four 


OPERATIVE   8UROE11Y.  18$ 


to  six  or  eigHt  lines  in  length.  The  anterior  flap  is  that  upon  which  most 
reliance  should  be  placed,  although  the  other  is  bj  no  means  useless.  In  order 
that  it  should  not  be  cut  too  short,  nor  left  too  long,  I  think  that  before  finish- 
ing the  division,  it  is  prudent  to  imitate  the  practice  of  M.  Delpech,  in  taking, 
so  to  speak,  an  exact  measure  by  applying  it  against  the  surface  which  it  is 
destined  to  cover. 

2d.  Dressing  and  After-treatment. — The  operation  being  finished  by  one 
method  or  another,  it  is  hardly  ever  necessary  to  tie  or  twist  the  arteries. 
The  blood  ceases  to  flow  of  its  own  accord,  or  with  the  assistance  of  a  slight 
compression.  But  if  the  arteries  should  be  tied,  each  thread  should  then  be 
ranged  in  the  corresponding  angle  of  the  wound:  the  two  flaps  being  care- 
fully brought  together,  are  held  in  contact  by  one  or  two  small  diachylon 
straps,  which  embrace  the  stump  loopwise  and  extend  to  the  wrist  upon  the 
dorsal  and  palmar  surfaces.  A  small  rag  pierced  with  holes  and  spread  with 
cerate,  some  dry  lint,  a  fine  compress,  and  a  narrow  bandage  to  confine  the 
whole,  complete  the  dressing.  A  light  diet  for  the  space  of  two  or  three 
days,  and  afterwards  aliment  somewhat  less  copious  and  succulent  than 
usual,  is  all  that  should  be  directed  in  regard  to  regimen.  Provided  the 
hand  is  carried  in  a  sling,  confinement  to  bed  is  not  necessary,  unless  in  case 
of  accidents ;  the  best  means  of  preventing  these,  and  of  even  arresting  them 
when  they  begin  to  manifest  themselves,  is  to  establish  an  exact  and  regular 
compression  from  the  fore-arm  to  the  wound  embracing  the  hand,  properly 
padded  on  both  surfaces. 

f  2.  Amputation  of  the  Whole  Fingtr, 

Some  surgeons,  and  Lassus  among  the  rest,  have  laid  down  the  precept^ 
that  when  the  middle  phalanx  is  diseased  the  first  should  be  removed  at 
the  same  time;  because,  say  they,  this  being  preserved  alone  remains 
immovable,  and  becomes  a  source  rather  of  embarrassment,  than  of  utility. 
To  remedy  this  inconvenience,  which  he  explains  by  saying,  that  after  the 
removal  o^  the  second  phalanx  the  flexor  tendons  lose  their  points  of  attach- 
ment, and  the  power  of  acting  upon  the  first  phalanx,  M.  Lisfranc  makes, 
in  the  first  place,  one  or  two  longitudinal  incisions  in  front  of  the  metacarpal 
phalanx,  through  the  whole  thickness  of  the  soft  parts,  so  as  to  determine  the 
inflammation  of  the  tendons  and  their  adherence  to  the  surrounding  tissues; 
this,  however,  makes  two  operations  of  one ;  and  as  I  have  already  remarked 
elsewhere,  and  M.  Scoutetten  since,  the  object  proposed  by  M.  Lisfranc  is 
effected  without  operation  by  the  fibrous  cord  which  attaches  one  of  the  flexor 
tendons  to  the  first  phalanx  of  the  fingers.  But  even  if  this  anatomical  dis- 
position did  not  exist,  the  immobility  described  by  Lassus  need  not  be  appre- 
hended. After  the  cure,  the  extensor  and  the  flexor  tendons  are  always 
found  fixed  about  the  cicatrix,  if  not  upon  the  bone  itself,  at  least  in  such  a 
manner  that  nothing  hinders  them  from  extending  or  bending  the  stump. 
And,  in  fact,  observation  proves  that  these  fears  are  merely  theoretical.  It 
is  not  therefore  right  to  amputate  the  whole  finger,  unless  the  disease  has 
extended  so  far  as  absolutely  to  demand  it,  and  will  not  permit  us  to  ampu- 
tate in  the  continuity,  and  saw  the  phalanx  at  a  healthy  point.  Observing 
that  after  the  operation  the  two  collateral  fingers  find  themselves  kept  apart 
in  an  unsightly  manner  by  the  head  of  the  intermediate  metacarpal  bone, 
M.  Dupuytren,  with  Messrs.  Sanson  and  Begin,  prefers  the  amputation  of 
the  latter  bone  in  its  continuity,  to  the  simple  disarticulation  of  the  finger. 
But  the  patient  is  exposed  to  greater  risk  by  this  method  than  by  the  other;  and 


]^34  NEW   ELEMENTS   OF 

the  head  of  the  metacarpal  bone  after  the  disarticulation  becomes  flat,  and 
permits  the  two  adjoining  fingers  to  come  nearer  to  each  other,  so  that  it  is 
wrong  to  pass  the  metacarpo-phalangeal  articulation  without  absolute  necessity. 
This  amputation  is  only  practised  according  to  the  oval  and  flap  methods; 
the  circular,  vaguely  indicated  and  followed  by  some  practitioners,  presents 
nothing  but  inconvenience,  and  should  be  rejected. 

A.  Manual  Flap  Method. — 1st.  Process  of  Sharp. — After  having  made  a 
circular  incision  upon  the  root  of  the  finger  in  advance  of  the  commissure, 
Sharp  makes  another  on  each  side  in  order  to  form  a  dorsal  and  a  palmar  flap 
before  reaching  the  articulation.  This  method  is  essentially  bad,  and  is  never 
followed. 

2d.  Process  of  Garengeot. — The  root  of  the  diseased  finger  being  first  iso- 
lated down  to  the  articulation  by  means  of  two  lateral  and  parallel  incisions, 
is  then  uncovered  behind  by  a  transverse  or  semilunar  incision.  There  is 
then  nothing  more  to  do  than  to  divide  the  extensor  tendon  and  the  sides  of 
the  capsule,  to  pass  through  the  joint,  and  finisii  by  cutting  the  flexor  tendons 
and  the  skin  which  covers  them.  This  is  the  method  described  by  Bertrandi 
and  others.  That  which  has  been  substituted  lor  it  by  many  of  the  moderns, 
only  differs  in  that,  instead  of  being  united  by  a  transverse  incision,  the 
lateral  incisions  meet  each  other  on  the  dorsal  and  palmar  surfaces  of  the 
articulation. 

3d.  Process  of  J,  L.  Petit. — The  base  of  the  finger,  circumscribed  by  two 
semicircular  incisions,  which  pass  over  commissures  and  converge  obliquely 
so  as  to  meet  behind  and  before,  is  at  once  exposed  laterally  as  far  as  the 
articulation,  which  the  operator  opens  and  passes  through  either  from  one  side 
to  the  other,  or  from  front  to  rear. 

4th.  By  Puncture. — Instead  of  cutting  from  the  skin  towards  the  bones,  as 
just  directed,  Rossi  plunges  the  bistoury  through  from  the  dorsal  to  the  palmar 
surface,  and  cuts  successively  the  two  flaps  from  within  outwards,  that  is, 
from  their  basis  towards  their  free  extremity.  But  this  is  a  method  which 
has  no  advantage  over  the  others,  and  leaves  a  more  irregular  incision  than 
that  of  Petit,  of  which  it  is  nothing  more  than  a  repetition  reversed, 

5th.  Process  of  Le  Dran,  improved  by  the  Moderns,  and  especialli/  by  M.Lis- 
franc. — One  or  more  assistants  hold  the  hand  turned  in  pronation  and  the 
healthy  fingers,  which  they  remove  from  the  median  line,  at  the  same  time 
keeping  them  extended.  The  operator  seizes  the  diseased  member  with  the 
left  hand,  moves  it  about  a  little  in  order  to  ascertain  more  exactly  the  situ- 
ation of  the  joint,  which  the  anatomical  data  given  above  enable  him  to 
discover.  With  the  right  hand  he  passes  the  heel  of  the  bistoury,  held  in  the 
first  position,  on  the  back  of  the  articulation,  or  begins  about  four  or  five  lines 
beyond ;  carries  the  incision  of  the  skin  to  the  middle  of  the  commissure  of 
one  side,  and  by  lowering  the  wrist  prolongs  the  incision  by  a  continuous 
movement  to  the  line  which  crosses  transversely  the  palm  of  the  hand  in  front 
of  the  joint.  The  edge  of  the  bistoury  is  immediately  returned  upon  the  con- 
vexity of  the  semilunar  incision,  to  divide  the  soft  parts  down  to  the  articu- 
lation, which  is  opened  from  one  side  by  the  blade  of  the  instrument  turned 
across,  as  soon  as  it  arrives  behind  the  head  of  the  phalanx.  At  this  point  of 
the  operation  the  assistant  moderately  draws  the  skin  towards  the  wrist,  and 
to  the  right  or  left.  The  surgeon  turns  the  finger  as  if  to  luxate  it;  cuts  the 
extensor  and  flexor  tendons ;  causes  the  teguments  to  be  drawn  in  the  oppo- 
site direction,  so  as  to  keep  them  out  of  the  way  of  the  bistoury ;  and  closes 
by  forming  a  second  flap,  similar  to  the  first,  cutting  from  within  outwards, 
and  from  the  metacarpus  to  the  interdigital  commissure  of  the  opposite  pide. 


OPERATIVE    SURGERY.  185 

Remarks. — In  order  to  allow  the  flaps  greater  length,  Garengeot  and  others 
advise  to  begin  the  first  and  terminate  the  second  a  few  lines  in  advance  of 
the  commissures.  M.  Lisfranc  is  of  opinion  that  the  upper  part  should  be  cut 
square,  and  not  in  a  point,  as  is  generally  done.  It  has  appeared  to  me  that,  by 
carefully  bringing  towards  each  other  the  bases  of  the  fingers,  the  operator  may 
very  easily  bring  the  two  sides  of  the  incision  in  contact,  without  having 
recourse  to  those  precautions  which  by  the  way  are  no  otherwise  bad  than  as 
making  the  skin  liable  to  be  curled  back  upon  itself,  and  as  rendering  the 
operation  a  little  less  easy. 

After  making  the  first  incision,  to  avoid  the  risk  of  going  beyond  the  head 
of  the  metacarpal  bone  it  is  well  to  feel  with  the  index  finger  for  the  internal 
tubercle  of  the  phalanx  to  be  removed.  This  is  an  easy  thing,  since  it  is  the 
first  projection  which  is  found  in  tracing  the  face  of  the  bone  into  the  palm. 

It  is  well  to  prolong  the  first  incision  of  the  integuments  nearly  half  an  inch 
beyond  the  articulation.  This  makes  it  easier  to  cut  the  surrounding  fibrous 
parts  without  touching  the  other  lip  of  the  incision,  and  enables  us  to  cut  the 
second  flap  more  regularly. 

When  the  operator  has  taken  the  precaution  to  graze  the  sides  of  the  pha 
lanx  and  to  avoid  passing  the  head  of  tlie  metacarpal  bone,  the  trunk  of  the 
collaterals  is  generally  found  preserved ;  he  has  then  but  two  arteries  requiring 
his  attention,  and  which  he  may  tie  or  twist,  if  the  blood  does  not  of  itself 
cease  to  flow. 

This  is  the  quickest  process,  and  presents  no  other  inconvenience  than 
that  of  not  always  giving  to  the  last  flap  the  same  regularity,  nor  exactly  the 
same  form  as  the  first.    In  this  respect  the  process  of  Petit  is  to  be  preferred. 

Oval  Method. — The  hand  of  the  patient,  the  assistants,  and  tiie  operator, 
being  disposed  as  in  the  preceding  case,  the  surgeon  lays  hold  of  the  diseased 
finger  with  the  left  hand,  gently  flexes  it  drawing  it  at  the  same  time  a  little 
away  from  the  others,  begins  the  incision  on  the  dorsal  surface  farther  back 
than  the  articulation  with  the  heel  of  the  bistoury,  which  he  draws  gently 
forwards  to  the  edge  of  the  commissure  and  with  which  he  turns  the  palmar 
front  of  this  finger,  cutting  exactly  on  the  semicircular  line  by  which  it  is 
separated  from  the  hand,  properly  so  called.  Having  arrived  at  the  opposite 
border,  he  applies  the  bistoury  again  to  the  anterior  or  phalangeal  extremity 
of  the  wound,  and  then  draws  it  back  obliquely  towards  the  metacarpus,  so  as 
to  unite  the  two  extremities  of  the  incision.  Without  quitting  his  hold  upon 
the  part  to  be  removed,  the  operator  causes  the  lips  of  tlie  division  to  be  sepa- 
rated as  much  as  possible,  cuts  the  extensor  tendon,  then  the  lateral  ligaments 
and  the  posterior  half  of  the  articular  capsula,  increases  the  flexion  of  the 
finger,  drawing  it  as  if  to  disjoint  it,  passes  the  bistoury  to  its  palmar  face  by 
traversing  the  articulation,  and  finishes  by  dividing  the  flexor  tendons  and 
the  soft  parts  which  unite  the  front  of  the  phalanx  to  the  cellular  cushion  of 
the  palm. 

Instead  of  turning  the  palmar  side  of  the  finger  after  reaching  the  com- 
missure, it  is  more  convenient  to  make  the  second  incision  in  the  same  manner 
as  the  first ;  the  disarticulation  is  then  performed,  and  the  rest  of  the  operation, 
according  to  the  directions  just  given.  An  incision  in  V  is  thus  made,  and 
the  wound  does  not  present  an  oval  form  until  the  end  of  the  operation. 

According  to  the  oval  method  the  trunk  of  the  collaterals  is  seldom  divided, 
and  is  consequently  always  easy  to  tie,  if  this  is  thought  necessary.  If  too 
great  an  extent  has  not  been  allowed  to  the  point  of  skin  which  is  removed 
with  the  finger,  the  two  lips  of  the  incision  meet  without  difficulty,  and  imme- 
diate reunion  is  rendered  more  certain  and  more  sure  by  this  than  by  any 
24 


1^0  KfeW   ELEMENTS   or 

Other  method.  This,  therefore,  is  the  method  which  merits  general  adoption, 
inasmuch  as  it  does  not  require  that  the  skin  should  be  healthy  to  the  same 
extent  as  required  bj  the  others.  iThe  division  which  results,  leaving  the  pal- 
mar cushion  untouched,  presents  in  reality  a  surface  of  one  half  the  extent 
of  that  left  by  the  flap  method,  and  its  regularity  renders  coaptation  always 
easy.  But  to  execute  it  well,  it  is  necessary  to  possess  positive  anatomical 
knowledge,  to  be  very  skillful,  and  to  have  practised  it  upon  the  dead  subject. 

§  3.  imputation  of  the  Fingers  Collectively, 

Although  amputation  of  all  the  fingers  together  had  been  performed  before, 
M.  Lisfranc  was  the  first  to  give  regularity  to  this  operation,  to  show  its  ad- 
vantages, and  to  describe  its  mechanism.  The  particular  cases  which  require 
it  may  be  easily  conceived,  without  entering  into  further  details ;  cases  of  this 
kind  do  occur,  but  it  is  very  rarely. 

Manual. — The  hand  and  fore-arm  being  held,  as  for  the  amputation  of  a 
single  finger,  the  operator  lays  hold  of  those  which  he  wishes  to  remove,  by 
placing  the  thumb  across  their  dorsal,  and  the  left  hand  upon  the  palmar 
face,  flexes  them  moderately,  and  requires  the  assistant  to  stretch  the  skin 
by  drawing  it  backwards.  Then  with  a  straight  bistoury  he  makes  a  trans- 
verse incision,  slightly  convex  forwards  at  about  three  or  four  lines  below  the 
extremity  of  the  metacarpal  bones,  being  careful  to  begin  towards  the  index 
finger,  if  he  operate  upon  the  left  hand,  and  towards  the  auricular  in  ope- 
rating upon  the  right.  This  first  incision  lays  bare  the  extensor  tendons  and 
the  posterior  face  of  the  articulations.  As  soon  as  the  integuments  have  been 
suitably  drawn  back,  the  surgeon  opens  the  different  articulations,  passes 
through  them,  and  divides  their  anterior  ligaments.  There  remains  nothing 
more  for  him  to  do  than  to  pass  in  front  of  the  heads  of  all  the  disarticulated 
phalanges  a  narrow  knife,  with  which  he  cuts  forwards  a  large  semi-elliptical 
flap,  naturally  limited  by  the  groove  which  unites  the  palmar  face  of  the 
fingers  with  that  of  the  hand.  This  same  knife  might  also  serve  for  the  dorsal 
incision ;  but  as  it  has  to  pass  alternately  upon  the  projections  and  the  hollows, 
the  bistoury  is  somewhat  more  convenient.  To  avoid  the  subsequent  projec- 
tion of  the  flexor  tendons,  it  is  necessary  to  cut  them  upon  a  level  with  the 
articulation  before  finishing  the  flap.  The  arteries  opened  in  this  operation 
are  eight  in  number.  As  the  operator  bends  them  at  an  angle  in  raising  the  flap 
in  order  to  close  the  wound,  the  use  of  the  ligature  is  generally  dispensed 
with.  The  palmar  flap  most  comm.only  being  the  only  one,  and  always  of 
the  greatest  length,  does  not  require  to  be  united  to  the  dorsal  flap  by 
suture.  Adhesive  straps  suflice  to  maintain  it,  firmly  applied  against  the 
heads  of  the  metacarpal  bones ;  a  piece  of  linen  pierced  with  holes  and  covered 
with  cerate  is  next  applied,  and  is  in  its  turn  covered  with  a  thin  layer  of  lint, 
over  which  is  laid  a  fine  compress  and  several  narrow  strips,  which  embrace 
the  stump  either  directly  or  obliquely  in  the  same  direction  as  the  plastic 
straps.  After  having  suitably  cushioned  the  palm  of  the  hand,  nothing  more  is 
to  be  done  but  to  confine  all  these  pieces  with  a  bandage,  which  should  extend 
itself  bv  turns  more  or  less  close  and  moderately  tight  to  just  above  the  wrist, 
and  pass  once  or  twice  between  the  root  of  the  thumb,  the  rest  of  the  hand, 
and  the  free  extremity  of  the  stump. 


OPERATIVE   SURGERY.  187 

After  the  removal  of  a  single  finger,  the  same  bandage,  or  nearly  the  same, 
is  applicable.  But  it  should  make  some  difference  whether  flaps  have  been 
preserved  or  not.  In  the  first  case  a  narrow  strip  of  diachylon  fixes  the  pieces 
of  skin  over  the  end  of  the  bone ;  whilst  in  the  second  it  is  sufficient  to  place 
one  across,  and  to  bring  as  near  together  as  possible  the  roots  of  the  two  ad- 
jacent fingers,  by  pressing  upon  the  edges  of  the  hand  with  the  bandage.  The 
same  is  done  when  the  oval  method  has  been  followed. 

§  4.  Accidents, 

However  easy  and  trifling  it  may  appear,  the  amputation  of  the  fingers  fre- 
quently gives  rise  to  very  serious  accidents.  A  man  and  a  woman  died  after  this 
operation  in  1825  and  1826,  at  the  Hopltal  de  Perfectionnement,  and  one  of 
the  patients  upon  whom  I  operated  in  1831,  at  La  Pitie,  met  the  same  fate. 
I  could  very  easily  adduce  many  such  examples.  It  is  sufficient  to  say  that 
this  operation  should  not  be  decided  on  without  caution,  nor  for  diseases 
which  do  not  absolutely  require  it.  The  dangers  arise  from  the  inflammation 
which,  through  the  intervention  of  the  tendinous  grooves,  the  sheaths,  the  sy- 
novial membranes,  and  of  the  very  loose  lamellar  tissue  of  the  dorsal  and  pal- 
mar faces,  either  of  the  phalanges  of  the  hand,  spreads  with  a  frightful  ease  and 
rapidity  in  the  direction  of  the  wrist,  involving  at  once  the  soft  parts,  the  arti- 
culations, and  the  surface  of  the  bones,  which  soon  become  the  seat  of  a 
suppuration  which  nothing  can  arrest.  To  lay  open  the  fibrous  theca  of  each 
finger  which  has  been  amputated,  as  advised  by  Garengeot  Bertrandi,  and 
latterly  by  Barthelemy,  would  not  in  any  way  prevent  the  development  of 
these  dangerous  inflammations,  which  are  entirely  independent  of  every  thing 
like  strangulation.  When  cataplasms  or  an  abundant  application  of  leeches 
fail  to  at  once  arrest  its  progress,  nothing  but  numerous  and  deep  incisions  can 
give  real  relief.  The  remedy  is  indeed  painful,  but  the  question  is  of  life  or 
death;  and  no  man  who  has  had  an  opportunity  of  appreciating  its  sometimes 
miraculous  effects,  will  hesitate  an  instant. 

Art.  2. — Metacarpus, 

Like  the  fingers,  the  bones  of  the  metacarpus  can  be  amputated  in  conti 
nuity  or  at  the  articulations,  separately  or  together.  They  can  also  be  partly 
cut  out  or  wholly  extracted,  leaving  the  fingers  which  they  support. 

§  1.  /n  the  Continuity. 

If  the  first  and  last  metacarpal  bones  are  rarely  amputated  in  the  continuity, 
it  is  nx)t  so  with  those  which  support  the  index,  middle,  or  fourth  finger. 
These  bones  are  swollen  at  both  ends ;  concave  towards  the  palm ;  convex 
and  broader  upon  their  dorsal  face,  which  is  only  covered  by  the  flat  tendons 
of  the  extensor  muscles  of  the  fingers,  a  thin  cellular  lamina,  veins,  and  the  skin, 
and  separated  by  smaller  spaces  in  the  direction  of  the  wrist  than  elsewhere. 
They  form  all  together  a  species  of  grate,  bulging  out  behind,  the  concavity 
of  which  is  occupied  by  the  interosseous  muscles,  the  tendons  of  the  flexors, 
the  lumbricales,  the  two  arterial  arches  of  the  hand  and  the  branches  which 


188  NEW   ELEMENTS   OF 

arise  from  them,  the  radiation  of  the  median  nerve,  the  muscles  of  the  thenar 
and  hjpothenar  eminences,  the  palmar  aponeurosis,  and  the  common  inte- 
guments. Thej  enjoj  but  little  motion  at  their  proximal  articulations,  but 
can  be  brought  together  so  as  to  incline  one  before  another  at  their  digital  ex- 
tremity, whence  it  follows  that  when  one  of  them  has  been  obliquely  sawn 
in  the  middle,  it  is  easy  to  cause  in  a  great  degree  the  disappearance  of  the 
hollow  which  results,  and  that  the  deformity  which  follows  such  an  amputation 
is  less  marked  than  after  the  simple  removal  of  a  finger.  The  phalangeal 
tuber  continuing  in  the  state  of  epiphysis  until  the  age  of  from  six  to  ten  years, 
may,  according  to  M.  Lisfranc,  be  removed  with  the  bistoury,  from  the  hands 
of  children,  if  the  disease  requires  it,  in  amputating  with  one  or  all  of  the 
fingers.  At  a  more  advanced  age,  the  saw  is  indispensably  necessary.  The 
scissors,  the  gouge,  and  the  mallet,  have  been  used  for  the  removal  of  the  bones 
of  the  metacarpus,  the  same  as  in  the  amputation  of  the  fingers,  although  less 
frequently. 

1st.  Amputation  in  mass. — Louis  performed  the  operation  by  means  of  the 
saw,  so  as  to  leave  only  the  posterior  moiety,  for  a  young  girl,  who  was  very 
glad  to  keep  the  rest  of  the  hand.  Perhaps  it  would  be  better  to  cut  them 
across  in  this  w^ay  than  to  disarticulate  them,  if  the  extremity  alone  were 
affected.  The  operation  could  not  be  very  difficult.  A  semilunar  incision 
convex  towards  the  fingers  would  expose  the  dorsal  face  of  the  metacarpus; 
a  narrow  knife  pushed  through  flatwise  from  one  edge  of  the  hand  to  the  other 
between  the  bones  and  the  soft  parts,  could  form  a  palmar  flap  of  about  twelve 
or  eighteen  lines  in  length ;  a  bistoury  might  then  disencumber  each  meta- 
carpal bone  of  the  tissues  by  which  it  is  surrounded,  so  as  to  permit  it  to  be 
sawn  through  with  greater  facility  and  neatness. 

2d.  Amputation  of  a  Single  Bone. — The  parts  being  disposed  and  held  in 
the  same  manner  as  for  the  amputation  of  a  finger,  the  operator  passes 
through  the  whole  thickness  of  the  hand  from  the  back  to  the  palm,  several 
lines  beyond  the  seat  of  the  disease.  In  doing  this  he  first  causes  the  point 
of  the  bistoury,  held  in  the  third  position,  to  fall  perpendicularly  upon  the 
bone  ;  then  carries  it  a  little  to  one  side,  cutting  the  skin  in  its  passage ;  then 
turns  it  in  a  proper  position  to  graze  the  side  of  the  bone,  brings  it  nearer  to 
the  median  line  as  its  point  emerges  upon  the  palm,  and  concludes  the  opera- 
tion by  cutting  towards  himself  with  the  full  edge  to  the  middle  of  the  corre- 
sponding interdigital  commissure.  After  this  first  incision  he  makes  another 
exactly  similar  on  the  opposite  side,  but  in  such  a  manner  that  the  two  should 
only  form  one  in  the  rear ;  that  is  to  say,  that  the  thumb  and  fore-finger  should 
draw  the  tissues  to  the  left,  while  the  bistoury,  reapplied  at  the  beginning  of 
the  first  incision,  is  inclined  so  as  to  fall  upon  the  first  incision  in  the  palm. 
The  operator  then  cuts  the  soft  parts  which  may  remain  attached  to  the  bone, 
by  exploring  its  whole  circumference  with  the  point  of  the  instrument.  A 
small  splint  made  of  wood,  lead,  or  pasteboard,  or  a  thick  compress,  is  then 
thrust  into  the  wound,  so  that  the  fine  saw  which  is  to  divide  the  metacarpal 
bone  with  a  long  slope  from  front  to  rear,  may  not  injure  the  flesh.  The 
slope  is  to  be  replaced  on  the  cubital  side  of  the  last  two  fingers  and  <!ii  the 
radialside  of  the  first  two,because  of  the  particular  species  of  motion  which  the 
carpo-metar carpal  articulation  admits. 

When  the  bistoury  is  not  carried  too  far  outwards,  the  collateral  arterie* 


OPERATIVE   SURGERY.  189 

are  not  generally  opened  except  at  the  base  of  the  finger.  In  the  conti-ary 
case  the  operator  runs  a  risk  of  dividing  the  common  trunk  to  the  right 
(ind  left,  which  does  not  generally  prevent  him  from  dispensing  with  ligature 
or  torsion. 

At  the  time  of  the  dressing  it  is  requisite  to  keep  the  lips  of  the  incision 
somewhat  near  each  other,  by  means  of  several  circles  of  diachylon  placed 
across,  and  of  three  or  four  turns  of  a  bandage.  In  attempting  to  obtain  ? 
perfect  coaptation  the  operator  strains  the  posterior  articulation,  which  may 
give  rise  to  serious  accidents;  such  as  inflammation  of  all  the  synovial 
surfaces  of  the  carpus,  of  the  surrounding  tendinous  sheatlis,  &c.  This 
operation,  which  is  not  sensibly  more  difficult  than  the  disarticulation  of  a 
finger,  produces  a  sanguineous  surface,  a  wound  three  or  four  times  larger ; 
requires  the  division  of  soft  parts,  which  are  more  delicate  and  more 
numerous,  so  that  in  this  particular,  at  least,  it  is  really  much  more  serious, 
and  recourse  should  not  be  had  to  it  until  after  having  fully  ascertained  the 
insufficiency  of  the  other. 

§  2.  In  the  Contiguity, 

All  the  bones  of  the  metacarpus  may  be  disarticulated  separately,  and 
amputated  with  the  finger  with  which  they  correspond.  They  may  also  be 
amputated  all  together  or  only  the  four  last,  at  a  single  operation.  But  this 
kind  of  amputation  is  almost  exclusively  performed  upon  the  first  and  the 
fifth,  since  it  is  much  more  easy  to  amputate  the  others  in  continuity. 

A.  Metacarpal  of  the  Thumb. — imputation. — The  mobility  of  this  bone 
and  its  shortness  are  reasons  why  it  is  scarcely  ever  sawn,  and  why  disarticu- 
lation is  preferred  when  this  part  is  diseased.  In  all  cases  if  its  anterior 
extremity  is  alone  affected,  I  do  not  see  from  what  reason  one  could  refuse 
to  divide  it  immediately  behind.  No  particular  danger  could  attend  this 
operation,  which  would  not  be  difficult,  and  might  be  performed  by  the 
circular  or  flap  method. 

Anatomical  Remarks. — The  metacarpal  bone  of  the  thumb  lying  just 
beneath  the  skin,  behind  and  on  the  outside,  and  concealed  by  the  thickness 
of  the  thenar  eminence  in  front,  holds,  at  its  carpal  extremity,  relations  well 
worthy  of  notice.  Its  articulation  with  the  trapezium  lies  in  an  oblique  line 
drawn  to  the  root  of  the  little  finger,  and  holds  in  some  sort  a  middle  place 
between  the  ginglymus  and  the  enarthrosis.  It  is  surrounded  by  a  very  loose 
capsule,  may  be  opened  in  all  points  of  its  circumference,  but  principally  by 
the  two  posterior  or  dorsal  thirds.  The  tendons  of  the  long  abductor  and  of 
the  short  extensor  of  the  thumb,  garnish  and  support  the  part  which  is  nearest 
the  skin  ;  the  radial  artery  winds  round  the  cubital  side  in  its  progress  to  the 
palm  of  the  hand,  to  form  the  deep  palmar  arch.  As  for  the  tendons  of  the 
long  flexor  and  extensor,  their  position  in  front  and  behind  is  too  well  known 
to  require  particular  attention  here.  The  situation  of  the  joint  is  determined 
by  sliding  the  fore-finger  towards  the  wrist,  along  its  dorsal  face  or  one  of  its 
sides.     It  is  immediately  behind  the  first  tuberosity  which  is  encountered. 

Manual. — The  operator  performs  the  operation  of  disarticulation  of  the 
first  metacarpal  in  many  different  ways,  and  with  ease  by  all,  if  he  has  any 
skill  or  address. 


190  NEW  ELEMENTS   OF 

1st  Tlie  Ancient  Method, — If  the  surgeon  is  not  ambidexter,  the  hand  of 
the  patient  should  be  held  in  pronation  on  the  left  side,  and  in  supination  on 
the  right,  otherwise,  the  operator  places  the  hand  in  pronation  for  either  side. 
Whilst  the  assistant  clasps  the  wrist  with  one  hand,  and  holds  the  roots  of  the 
last  four  fingers  with  the  other,  the  operator  lays  hold  of  the  thumb,  and  holds 
it  in  a  state  of  abduction  ;  applies  the  edge  of  the  bistoury  held  in  the  first 
position  with  tlie  point  upwards  against  tlie  middle  of  the  commissure ;  divides 
the  whole  thickness  of  the  soft  parts,  grazing  the  cubital  border  of  the  bone 
as  far  as  the  carpus ;  extends  the  incision  of  the  teguments  from  four  to  six 
lines  upon  its  dorsal  and  palmar  surfaces,  towards  'die  wrist;  opens  the  joint 
with  the  bistoury  turned  outwards ;  divides  all  the  fibrous  parts  with  the  point 
rather  than  with  the  edge  of  the  instrument,  so  as  to  avoid  the  skin;  turns  the 
thumb  at  the  same  time  to  the  radial  side,  luxes  it,,  and  after  having  passed 
through  the  articulation,  cuts  the  flap  towards  himself,  grazing  the  external 
surface  of  the  bone,  and  extending  it  to  some  lines  in  advance  of  the  metacarpo- 
phalangeal articulation.  In  order  to  preserve  for  this  flap  particularly,  at  its 
base,  a  sufficient  breadth  and  thickness,  it  is  advantageous  in  passing  through 
the  interosseous  space,  to  incline  the  handle  of  the  bistoury  a  little  to  the 
hypothenar  eminence,  and  to  direct  the  edge  towards  the  os-pisiforme,  or  the 
cubital  border  of  the  carpal  extremity  of  the  radius.  By  extending  the  inci- 
sion of  the  skin  to  some  lines  beyond  the  carpo-metacarpal  articulation,  you 
secure  the  means  of  disjointing  the  bones,  without  bruising  or  cutting  the  edges 
of  the  flap  which  is  to  cover  the  wound. 

If  the  radial  artery  itself  has  been  injured,  the  use  of  the  ligature  is  requisite ; 
otherwise,  an  exact  coaptation  of  the  surfaces  will  render  this  useless.  After 
having  applied  the  adhesive  straps,  it  is  well  still  to  lay  a  quantity  of  lint,  or 
a  graduated  compress  upon  tlie  external  face  of  the  flap,  the  base  of  which 
requires  to  be  strongly  pressed  against  the  second  metacarpal  bone. 

2d.  Jlnother  Method. — An  assistant  is  charged  with  the  thumb;  the  surgeon 
seizes  with  the  first  three  fing-ers  of  the  left  hand  and  draws  outwards  as 
much  as  possible  the  soft  parts,  plunges  the  bistoury  by  puncture  from  the 
dorsal  to  the  palmar  face  of  the  thenar  eminence,  gliding  along  the  radial  side 
of  the  articulation,  cuts  a  flap  as  before  directed,  turns  it  back,  and  causes  it 
to  be  held  by  the  assistant.  He  then  takes  the  thumb  himself,  separates  the 
lips  of  the  incision,  passes  through  the  articulation  from  the  outer  to  the  inner 
side,  luxes  the  bone,  and  terminates  the  operation  by  bringing  the  bistoury  to 
the  same  point  where  the  preceding  operation  should  commence.  As  the 
definitive  result  is  exactly  the  same  in  both  cases,  and  as  by  the  latter  metliod 
it  is  always  inconvenient  to  effect  the  disarticulation,  the  former  should  be 
preferred.  Instead  of  forming  a  flap  from  within  outwards,  by  puncture,  one 
might  cut  it  in  the  opposite  direction,  that  is,  begin  by  tlie  division  of  the 
teguments,  and  then  dissect  the  flap  backwards  from  its  free  extremity  to  its 
base.  This  would  allow  it  with  more  certainty  all  possible  regularity,  and 
just  the  dimensions  required. 

3d.  New  Process. — I  have  often  amputated  the  thumb  in  the  following 
manner : — A  dorsal  incision  carried  from  the  styloid  apophysis  of  the  radius 
to  the  commissure  of  the  thumb  and  fore-finger,  dividing  the  integuments, 
the  tendon  of  the  long  extensor  with  a  part  of  the  first  interosseus  muscle 
at  once  exposes  the  articulation.    Whilst  the  assistant  separates  the  lips  of 

W 


OPERATIVE  SURGERY.  191 

the  incision,  the  surgeon  divides  the  capsule,  luxes  the  bone  which  he  then 
removes,  preserving  as  much  of  the  thenar  eminence  as  is  necessary  for  the 
immediate  closing  of  the  wound.  The  palm  of  the  hand  being  thus  respected, 
permits  a  flap  to  be  made  of  the  form  and  extent  required,  without  having 
any  special  obstacles  to  surmount. 

4th.  The  Oval  Method. — Lassus,  Beclard,  and  Richerand,  have  many  years 
ago  described  this  method  of  amputation.  The  operation  is  begun  in  the 
manner  just  described.  The  operator  turns  the  anterior  face  of  the  root  of 
the  thumb,  comes  up  upon  its  dorsal  face,  and  unites  this  second  part  of  the  in- 
cision to  the  extremity  of  the  first.  In  the  second  step  he  carries  the  point  of 
the  bistoury  upon  the  joint  through  which  he  passes  from  the  dorsal  to  the 
palmar  side,  after  which  nothing  more  remains  than  to  detach  the  bone  from  the 
flesh  which  adheres  to  it,  by  sliding  the  instrument  between  them  from  the 
wrist  forwards.  A  very  long  oval  incision  is  thus  obtained,  the  lips  of  which 
may  be  united  with  the  greatest  facility,  leaving  nothing  between  them  but  a 
simple  linea  trace.  It  is  the  most  simple  and  the  best  of  all  known  methods, 
but  is  somewhat  more  difficult  than  the  preceding,  which  gives  nearly  the  same 
results. 

Extraction. — We  may  conceive  that  this  bone  may  suffer  necrosis,  or  become 
careous,  without  affecting  the  thumb  or  the  carpus,  and  it  would  be  important 
to  be  able  to  remove  it  and  at  the  same  time  to  preserve  all  the  other  parts. 
M.  Troccon  advocates,  in  a  memoir  presented  to  the  institute  in  1816,  the 
possibility  of  this  extraction ;  but  M.  Roux  appears  to  have  been  the  first  to 
use  this  method  successfully  upon  the  living  subject.  The  thumb  of  his 
patient  which  at  first  was  rendered  entirely  useless,  recovered  by  degrees  its 
natural  functions,  so  as  to  be  able  to  execute  quite  extensive  movements.  I 
know  a  person,  in  whose  case  the  first  phalanx  was  affected  with  necrosis,  and 
extracted  by  fragments,  without  impairing  to  any  great  degree  the  motion  of  the 
thumb.  I  was  myself  ignorant,  in  1825,  of  the  fact  that  this  operation  had 
been  mentioned  by  M.  Troccon  ;  and  as  M.  Roux  has  nowhere  described  his 
operation,  I  thought  proper  to  enter  into  some  details  as  to  the  best  method  of 
procedure,  in  my  work  on  surgical  anatomy.  This  operation  having  been  per- 
formed successfully,  in  1827,  by  M.  Blandin,  may  at  the  present  period  be 
ranked  with  the  regular  operations. 

An  incision  is  first  made  parallel  to  the  radial  border  of  the  bone  to  be 
removed,  and  is  extended  at  least  half  an  inch  behind  and  before  both  its 
articulations.  The  operator  then  carefully  detaches  the  teguments  and  the 
tendon  of  the  long  extensor  from  its  dorsal  face ;  the  same  operation  is  per- 
formed upon  the  opponens  muscle  and  the  long  flexor  which  cover  its  palmar 
face.  While  an  assistant  forcibly  separates  the  two  lips  of  the  wound,  the  sur- 
geon introduces  the  point  of  the  bistoury  upon  the  external  side  of  the  carpal 
articulation ;  divides  the  tendon  of  the  long  abductor ;  does  the  same  with 
the  short  extensor,  always  cautiously  avoiding  the  long  extensor  of  the  thumb ; 
destroys  all  the  ligaments  and  fibrous  parts  which  connect  the  metacarpal 
bone  to  the  trapezium ;  endeavors  to  lux  this  bone  outwards,  either  by  a  simple 
swaying  movement  or  by  drawing  it  in  that  direction  with  the  forceps;  takes 
it  then  in  his  fingers,  passes  the  bistoury  along  its  cubital  side  to  separate  it 
from  the  flesh,  and  disarticulates  it  by  dividing  successively  the  internal  and 
external  lateral  ligaments,  and  then  the  anterior  fibrous  strata  which  unite  it 


19B  NEW   ELEMENTS   OF 

to  the  thumb,  which  is  left  supported  bj  its  long  extensor,  long  flexus,  short 
abductor,  short  flexus  and  adductor,  preserving  in  short  the  whole  thickness 
of  the  thenar  eminence.  No  artery  of  any  size  need  be  opened.  The  usual 
dressings  are  applied,  with  the  addition  of  lint  or  compresses  so  placed  as  with 
the  aid  of  the  bandage  to  keep  the  thumb  in  its  natural  position. 

B.  Fifth  Metacarpal  Bone — Amputation, — The  bone  which  supports  the 
little  finger  is  removed  by  the  same  methods  as  that  of  the  thumb.  Its  arti- 
culation with  the  os-unciform  lies  obliquely,  in  the  direction  of  a  line  which 
would  fall  in  front  of  the  articulation  of  the  trapezium  with  the  first  metacar- 
pal bone,  and  it  is  connected  with  that  which  supports  the  fourth  finger  by  a 
facet  nearly  plane,  and  two  or  three  ligamentous  bands.  Its  situation  is 
recognized  from  without,  by  following  the  dorsal  face  of  the  bone  with  the 
end  of  the  fore-finger.  Before  coming  opposite  the  os-pisiforme,  the  operator 
meets  a  slight  protuberance,  and  immediately  after  a  slight  depression,  which 
falls  exactly  upon  the  line  of  the  articulation. 

1st.  When  the  Process  of  the  Ancients  is  followed,  there  is  no  danger  (as  in 
the  case  of  operation  on  the  thumb)  of  seeing  the  bistoury  entangled  between 
bones  in  the  carpus.  It  may  therefore  be  carried  boldly  as  far  as  the  unci- 
form bone,  along  the  radial  side  of  the  bone  to  be  removed,  with  the  edge 
directed  toward  the  median  line  of  the  wrist,  in  such  a  manner  as  to  preserve 
almost  entire  the  hypothenar  eminence.  After  the  inter-metacarpal  ligament 
is  divided,  the  point  of  the  bistoury,  which  is  then  inclined  towards  the  ulna, 
easily  enters  the  articulation.  As  the  other  fibrous  tissues  are  divided,  the 
finger  should  be  bent  to  the  ulnar  side,  so  that  the  instrument  may  clear 
the  articulation,  and  isolate  the  base  of  the  flap.  This  is  cut  forwards, 
extending  beyond  the  metacarpo-phalangeal  articulation,  while  the  little 
finger  is  returned  nearly  to  its  natural  position. 

2d.  The  Second  Process,  which  is  begun  by  forming  a  flap,  by  passing 
through  the  flesh  from  one  face  to  the  other  of  the  hypothenar  eminence 
before  having  separated  the  fifth  metacarpal  from  the  fourth,  belongs,  I  be- 
lieve, to  M.  Lisfranc.  It  must  be  admitted  that  it  is  here  more  advantageous 
and  easier  of  application  than  on  the  other  border  of  the  hand.  The  soft 
parts  are  better  adapted  to  the  formation  of  a  sufficient  flap  by  this  method ; 
but  the  disarticulation  is  here,  as  there,  more  diflicult  than  by  the  preceding 
method. 

3d.  The  process  which  I  sometimes  adopt  in  amputating  the  metacarpal 
bone  of  the  thumb,  does  not  always  apply  with  the  same  advantage  to  that  of 
the  little  finger,  where  the  oval  method  is  evidently  better.  The  incision 
being  commenced  before  the  styloid  apophysis  of  the  ulna,  is  carried  obliquely 
along  the  edge  of  the  hand  as  far  as  the  root  of  the  little  finger,  and  passes  round 
the  palmar  face  of  that  member  from  the  ulnar  to  the  radial  side.  This 
incision  stops  at  the  commissure,  but  by  a  second  application  of  the  bistoury, 
is  prolonged  upon  the  back  of  the  hand,  so  as  to  meet  at  an  acute  angle  with 
the  first  part  of  the  incision.  It  would  be  equally  easy  to  begin  so  as  to  fall 
upon  the  commissure  of  the  last  two  fingers,  and  finish  by  an  internal  incision. 
The  disarticulation  has  nothing  peculiar. 

Extraction. — This  bone,  as  well  as  the  metacarpal  of  the  thumb,  may  be 
extracted  and  that  quite  easily ;  but  as  the  little  finger  is  not  of  so  much  im- 
portance as  the  thumb,  it  will  perhaps  always  go  with  its  metacarpal  bone. 


OPERATIVE  SURGERY.  1$3 

whenever  that  shall  require  to  be  removed.  But  if  this  bone  is  to  be  sepa- 
rately removed,  it  may  be  done  by  a  method  precisely  analagous  to  that  recom- 
mended for  the  extraction  of  the  corresponding  bone  on  the  other  side  of  the 
hand,  beginning  with  a  dorsal  incision  from  the  head  of  the  ulna  to  the  middle 
of  the  ulnar  side  of  the  little  finger. 

Central  Metacarpal  Bones. — jimputation. — Although  not  absolutely  imprac- 
ticable, the  disarticulation  of  these  three  bones  is,  it  must  be  confessed,  much 
more  difficult  than  that  of  the  first  two,  so  that  surgeons  generally  prefer  to 
amputate  in  continuity.  Still,  if  it  is  thought  best  to  have  recourse  to  it,  this 
operation  may  be  performed  by  means  of  the  flap  or  oval  method. 

1st.  Flap  Method. — Metacarpal  Bone  of  the  Index. — The  bistoury,  carried 
from  the  commissure  to  the  carpus,  soon  arrives  at  the  ligament  which  con- 
nects this  bone  to  the  metacarpal  of  the  medius.  It  is  then  raised  so  as  to  cut 
the  dorsal  ligament,  and  lowered  to  divide  the  palmar  ligament ;  the  finger  is 
inclined  towards  the  thumb,  the  articulation  opens,  the  point  of  the  instrument 
crosses  it,  and  the  operation  is  finished  by  forming  a  flap  on  the  radial  side, 
which  should  extend  farther  forward  than  the  metacarpo-phalangeal  articu- 
lation. 

Metacarpal  Bone  of  the  Medius. — The  bistoury  is  carried  between  the  two 
middle  fingers.  The  operator  before  attempting  the  disarticulation,  should 
extend  the  incision  in  front  and  behind  towards  the  wrist,  to  the  distance  of 
about  half  an  inch,  turning  it  somewhat  towards  the  median  line;  this  joint 
being  in  a  position  rather  oblique  from  the  ulna  towards  the  radius,  and  from 
before  backwards,  would  occasion  much  more  difficulty  if  the  operation  were 
commenced  on  the  other  side.  When  the  dorsal  and  palmar  ligaments  have 
been  divided ;  when  the  bone  which  is  to  be  removed  has  been  separated  from 
that  of  the  ring-finger,  the  surgeon  acts  upon  the  anterior  extremity,  as  if  to 
disjoint  it  at  the  other ;  he  then  endeavors,  while  the  assistant  draws  the  lips 
of  the  incision  towards  the  thumb,  to  disengage  its  carpal  extremity,  to  which 
the  tendon  of  radialis  brevior  is  attached.  This  being  done,  the  full  edge  of 
the  bistoury  is  rapidly  passed  along  the  radial  face  of  the  bone,  as  far  as  the 
commissure  of  the  index  and  the  medius. 

For  the  Fourth  Metacarpal  Bone,  the  surgeon  should  carry  the  bistoury 
through  the  same  interspace ;  prolong  the  incision  toward  the  wrist  in  the 
same  manner,  but  with  this  difference,  that  he  incline  it  toward  the  ulna,  sepa- 
rate the  two  contiguous  osseous  facets,  divide  the  ligaments  as  in  the  preceding 
case,  and  bear  in  mind  that  the  articulation  of  this  bone  with  the  magnum  and 
the  unciform,  is  oblique  from  the  radial  to  the  ulnar  side,  and  from  before 
backwards,  and  that  it  is  continuous  with  that  of  the  fifth. 

2d.  Oval  Method. — M.  Langenbeck  was  the  first  to  practise  with  success 
the  extirpation  of  one  of  these  bones  by  the  oval  method.  The  operator 
divides  the  integuments  upon  their  dorsal  faces,  beginning  half  an  inch  beyond 
the  carpal  articulation ;  extends  his  incision  to  one  of  the  digital  commissures; 
brings  it  back  on  the  otlier  side,  by  turning  the  palmar  front  of  the  root  of 
the  finger,  and  then  unites  the  two  extremities  of  the  incision,  cutting  towards 
the  wrist,  or  he  may  cut  from  the  wrist,  making  an  incision  similar  to  the 
first,  on  the  other  side  of  the  bone  which  is  to  be  removed.  Whilst  the 
assistant  separates  as  much  as  possible  the  lips  of  the  wound,  the  surgeon 
cuts  successively  and  without  violence  with  the  point  of  the  bistoury,  the  liga-' 
25 


194  NEW  ELEMENTS  OF 

inent  of  the  articulation,  and  with  the  other  hand  endeavors  to  disjoint  the 
bone.  When  at  last  this  has  been  effected,  the  bistoury,  held  in  a  flat  and 
horizontal  position,  slides  along  the  bone  so  as  to  divide  from  the  carpus 
towards  the  root  of  the  finger  all  the  soft  parts  which  are  still  attached  to 
its  palmar  face. 

Extraction. — M.  Troccon  has  not  only  advised  the  separate  extraction  of 
the  metacarpal  bone  of  the  thumb ;  he  thinks  that  the  same  operation  should 
be  attempted  upon  the  others.  I  have  frequently  practised  it  upon  the 
dead  subject,  and  I  must  say,  that  with  an  exact  knowledge  of  the  anatomy 
of  the  articulations,  it  may  be  done  without  much  difficulty.  An  incision 
is  carried  from  the  carpal  extremity  of  the  fore-arm  to  the  distance  of 
about  half  an  inch  in  advance  of  the  phalangeal  articulation,  carefully 
avoiding  the  extensor  tendon.  In  order  to  disarticulate  the  bone  at  its 
proximal  extremity,  the  operator  acts  as  in  the  preceding  cases ;  after  luxing 
it,  he  seizes  it  with  two  fingers,  or  with  the  forceps,  while  with  the  point  of 
the  bistoury  he  proceeds  to  divide  the  posterior  part  of  the  capsule,  ih^  lateral 
ligaments  and  the  anterior  ligament  of  the  other  articulations,  carefully  avoiding 
in  every  instance  the  extensor  and  flexor  tendons  of  the  corresponding  finger. 

Instead  of  beginning  at  the  proximal  extremity,  as  advised  by  M.  Troccon, 
I  think,  with  Mr.  Blandin,  who  revived  the  idea  in  1828,  that  it  would  be 
better,  first,  to  disarticulate  the  phalangeal  extremity,  and  to  close  the  ope- 
ration by  dividing  the  carpal  ligaments  ;  but  it  is  probable  that  notwithstanding 
the  success  obtained  by  Mr.  Walther,  this  operation  will  continue  to  be,  for 
a  long  time  to  come,  a  mere  project  with  the  greater  part  of  the  practitioners. 
The  division  of  the  diseased  bone,  I  think,  may  almost  always  be  advan- 
tageously substituted  for  it. 

E.  Disarticulation  of  several,  or  of  all  the  Bones  of  the  Metacarpus  together. 
When  the  whole  hand  is  found  to  be  attacked  but  in  such  manner  as  to  leave  the 
carpo-metacarpal  articulation  untouched,  is  it  necessaryto  remove  the  wrist } 
If  all  the  dogmatical  treatises  on  surgery  are  to  be  believed,  there  could  be 
no  doubt  upon  this  subject,  or  rather  it  is  a  question  with  which  their  authors 
have  not  troubled  themselves.  In  disarticulating  only  the  metacarpal  bones, 
the  operation  preserves  a  greater  length  for  the  fore-arm,  a  movable  portion 
of  the  limb,  and  undeniable  advantages  in  the  application  of  an  artificial  hand. 
M.  Larrey  affirms,  that  for  a  long  period  the  military  surgeons  have  had 
recourse  to  this  operation;  M.  Yvan  also  remarks,  that  several  soldiers  in 
the  Hospital  of  Invalids  have  submitted  to  it,  and  always  with  success.  And 
a  number  of  other  authors  might  be  cited  to  prove  the  operation  prac- 
ticable, although  they  do  not  always  consider  it  advisable.  In  every  instance 
where  it  is  possible  to  preserve  the  thumb  or  any  other  finger,  by  means  of  it, 
there  is  no  question  of  the  propriety  of  resorting  to  it.  As  a  general  rule, 
the  disarticulation  of  the  carpus  from  the  metacarpus  should  be  preferred  to 
the  amputation  of  the  wrist.  It  cannot  be  denied  that  after  the  cure  the  car- 
pus can  be  of  very  great  advantage  to  the  patient,  even  if  he  do  not  desire  to 
make  use  of  an  artificial  hand.  But  this  is  an  operation  which  requires  prac- 
tice and  very  precise  anatomical  knowledge;  so  that  if  the  surgeon  is  not  suffi- 
ciently confident  in  himself  to  perform  it  securely,  he  ought  not  to  undertake  it. 
1st.  Anatomical  Remarks, — The  relations  of  the  first  and  fifth  metacarpal 
bones  with  the  trapezium  and  the  unciform,  have  been  already  discussed. 


OPERATIVE   SURGERY.  195 

The  metacarpal  bones  of  the  index  finger  is  loosely  connected  externally 
with  that  of  the  thumb ;  more  firmly  within  with  the  third ;  and  presents  behind 
and  externally  a  tuberosity  which  extends  some  lines  towards  the  wrist  and 
gives  attachment  to  the  tendon  of  the  radialis  longior.  Its  proximal  extremity 
is  articulated  externally  to  tlie  trapezium,  and  by  its  two  internal  thirds  to 
the  trapezoides.  The  third  metacarpal  also  presents  a  tuberosity,  which  tends 
to  slide  behind  the  line  between  the  os-magnum  and  the  os-trapezoides,  and 
gives  attachment  to  the  tendon  of  the  radialis  brevior.  Its  proximal  surface 
being  oblique  from  the  radial  to  the  ulnar  side,  rests  upon  nearly  the  whole 
extent  of  the  corresponding  front  of  the  os-magnum;  while  that  of  the  fourth, 
having  a  similar  slope  inwards  and  backwards,  is  connected  with  the  radial 
half  of  the  anterior  surface  of  the  os-unciform,  then  to  a  similar  surface  pre- 
sented by  the  os-magnum,  and  forwards  and  towards  the  ulnar  side. 

All  tliese  bones  are  held  together  by  means  of  dorsal  ligaments  in  the  form 
of  longitudinal  and  transverse  bands,  by  palmar  ligaments  much  more  irre- 
gular, and  by  fibrous  fasciculi,  which  fill  the  spaces  between  the  points  of  their 
proximal  extremities  in  the  palm.  Their  synovial  cavity  is  continuous  with 
that  of  the  carpus,  and  consequently  extends  between  the  two  ranges  of  that 
part,  so  that  inflammation  of  the  osseous  surfaces  after  this  amputation 
must  indeed  be  excessively  dangerous.  Looking  at  all  these  articulations  on 
their  dorsal  face,  it  is  perceived  that  that  of  the  first  metacarpal  bone  being 
oblique  forwards  and  inwards,  terminates  one  or  two  lines  before  that  of  the 
second,  the  line  of  which  turning  at  first  almost  directly  backwards,  soon 
becomes  nearly  transverse ;  before  leaving  the  trapezium,  and  with  a  semi- 
lunar sweep,  concave  forwards,  arrives  upon  the  trapezoides.  It  then  turns 
obliquely  backwards  before  leaving  this  bone,  and  joining  the  third  metacar- 
pal. The  articulation  of  this  latter  begins  about  half  a  line  nearer  the  wrist 
than  the  termination  of  that  of  the  second,  and  proceeds  obliquely  inwards^ 
and  forwards  in  a  line  which  would  fall  upon  the  posterior  quarter  of  the  fifth 
bone.  It  terminates  two  or  three  lines  nearer  the  fingers  than  the  commence- 
ment of  the  articulation  of  the  fourth.  This  follows  at  first  such  a  direction, 
that  if  continued  it  would  be  lost  in  the  pisiforme  bone,  then  takes  a  trans- 
verse direction  on  arriving  upon  the  unciform,  and  continues  with  scarce  a 
line  of  demarcation  into  that  of  the  last  metacarpal,  which  is  also  somewhat 
oblique  to  the  rear.  The  mode  of  ascertaining  from  without  the  situation  of 
the  first  and  fifth  of  these  articulations,  has  been  already  described. 

2.  Manual  of  the  Operation. — A.  Process  adopted  by  the  Author. — An  assist- 
ant supports  the  fore-arm,  and  compresses  at  the  same  time  the  ulnar  and 
radial  arteries ;  the  hand  of  the  patient  being  turned  in  pronation  is  clasped 
by  the  operator,  who  seizes  only  the  four  fingers  when  he  wishes  to  leave  the 
thumb.  With  a  straight  bistoury  or  a  small  knife  he  makes  a  semilunar  inci- 
sion convex  forwards,  about  half  an  inch  in  advance  of  the  articular  line, 
which  has  just  been  described.  The  assistant  then  draws  the  skin  in  the 
direction  of  the  fore-arm.  With  a  second  stroke  of  the  bistoury,  the  surgeon 
then  divides  all  the  extensor  tendons,  and  immediately  proceeds  to  the  disar- 
ticulation. Beginning  on  the  radial  side,  if  he  is  operating  on  the  left  hand, 
and  on  the  ulnar,  if  he  is  operating  on  the  right,  he  draws  the  point  of  the 
bistoury  along  all  the  windings  of  the  dorsal  aspect  of  the  articular  line,  foi 
there  is  no  need  of  penetrating  it  to  divide  the  ligaments. 


196  NEW  ELEMENTS  OF 

During  this  manoeuwe,  the  operator  acts  with  some  force  upon  the  anterior 
extremity  of  the  hand,  as  if  to  disjoint  it.  All  the  articulations  being  once 
opened,  the  point  of  the  bistoury  is  reapplied,  in  order  to  divide  any  fibres 
which  may  still  connect  them.  When  they  are  completely  separated,  the 
knife  glides  by  degrees  towards  the  palm  of  the  hand,  assumes  a  horizontal 
position,  and  cuts  a  flap  in  the  shape  of  a  half-moon,  of  the  length  of  an  inch 
or  an  inch  and  a  half,  grazing  the  palmar  face  of  the  metacarpian  bones, 
which  are  to  be  removed.  The  terminating  branches  of  the  radial  and  ulnar 
arteries  have  necessarily  been  divided.  Those  of  the  former  are  found  upon 
the  dorsal  aspect  of  the  wrist,  and  near  its  radial  border;  the  second  should 
be  sought  for  on  tlie  internal  side  of  the  pisiforme  bone.  Immediate  union, 
which  is  of  the  greatest  consequence,  requires  the  same  precautions  as  are 
used  in  cases  of  simultaneous  amputation  of  all  the  fingers  at  once. 

b.  Proceeding  of  M.  Maingault. — This  author  would  have  the  surgeon  to 
begin  by  forming  the  palmar  flap  with  a  small  knife,  inserted  between  the 
bones  and  the  soft  parts  of  the  hand.  A  semicircular  incision  is  then  made 
upon  the  dorsal  face  of  the  metacarpus,  at  about  one  inch  from  the  articulation, 
and  while  an  assistant  draws  back  the  flaps,  the  operator,  leaving  his  posterior 
incision,  exposes  in  front  the  articular  line,  and  passes  through  the  joints  from 
the  palm  to  the  back  of  the  hand. 

The  experiments  I  have  made  with  this  process  have  satisfied  me  that  it  is 
not  very  difficult.  But  it  appeared  to  me,  whether  from  want  of  skill  in  me, 
or  from  real  imperfection  in  the  process,  that  the  other  was  to  be  preferred. 

If  the  first  two  or  the  last  two  metacarpals  should  require  to  be  removed  by 
themselves,  the  operation  must  be  subjected  to  some  modifications.  It  would 
be  necessary  in  the  first  case,  for  example,  to  begin  by  making  a  transverse 
incision  a  little  in  front  of  the  articulations,  then  to  make  another  parallel  to 
the  axis  of  the  metacarpal  bones  upon  the  back  of  that  which  supports  the 
little  finger,  so  as  to  make  there  a  dorsal  flap  to  cover  the  whole  ulnar  side  ©f 
the  wound  after  the  operation.  That  being  done,  and  the  disarticulation  being 
effected,  the  operation  is  finished  by  forming  a  flap  one  or  two  inches  long, 
which  must  be  detached  down  to  its  base  from  the  palm  of  the  hand,  so  that 
it  may  be  applied  upon  the  transverse  branch  of  the  wound.  The  operation  is 
nearly  the  same  for  removing  the  thumb  and  the  index,  or  the  index  and  the 
medius. 

In  case  the  operator  wishes  to  remove  at  the  same  time  some  of  the  bones 
of  the  carpus,  no  rule  can  be  laid  down  beforehand.  The  surgeon  must 
rely  upon  his  own  knowledge  and  resources  for  these  trifling  operations. 

^rt,  3.— 7%c  Wrist, 

At  the  present  day,  according  to  Percy,  it  is  only  at  Tunis  and  such  like 
places  that  they  use,  in  amputating  the  wrist,  like  the  ancients,  a  hatchet 
moved  by  a  weight  falling  from  above  between  two  grooved  uprights,  or  of  a 
strong  chisel,  whicli  the  operator  strikes  with  a  leaden  mallet.  Let  us  add 
that  there  is  no  person  who  now  believes  in  the  propriety  of  amputating  the 
fore -arm,  when  to  remove  the  disease  entirely  it  is  sufficient  to  disarticulate 
the  hand.  Amongst  the  moderns,  there  are  many  surgeons  to  be  found  who 
consider  this  latter  operation  dangerous;  the  facts  reported  by  Slotanus, 


OPERATIVE    SURGERY.  197 

Hilden,  Paignon,  Leblanc,  Audouillet,  Hoin,  Sabatier,  Brasdor,  Lassus,  M 
Gouraud,  and  others,  who  affirm  that  it  almost  always  succeeds,  have  not 
entirely  dissipated  the  fears  which  it  had  previously  inspired. 

Anatomical  Remarks. — The  radio-carpal  articulation  is  surrounded  by  nu- 
merous tendons,  sheaths,  and  synovial  membranes,  and  presents  also  this 
circumstance  worthy  of  remark,  that  it  terminates  at  both  extremities  of  its 
greater  diameter  in  the  apophyses  of  the  radius  and  of  the  ulna,  which  give  it 
the  form  of  a  half-moon,  transversely  concave,  slightly  concave  also  backwards, 
lodging  a  species  of  head  formed  by  the  scaphoides,  the  semilunare,  and  the 
trapezium ;  and  held  in  place  by  internal  and  external  posterior  and  anterior 
ligaments.  As  the  first  range  of  the  carpus  diminishes  towards  its  extremities, 
particularly  towards  the  cubital  side,  a  line  drawn  transversely  from  the  styloid 
process  would  easily  fall  between  that  range  and  the  second ;  the  pisiforme, 
the  point  of  the  scaphoides,  the  crest  of  the  trapezium,  and  that  of  the  un- 
ciform bone,  jut  out  beyond  the  level  of  the  palmar  front  of  the  radius  and 
of  the  cubitus,  far  enough  to  command  attention  at  the  time  of  operation. 
The  skin  of  the  anterior  face  of  the  wrist  presents,  almost  constantly,  three 
wrinkles,  which  may  be  of  great  use  in  directing  the  course  of  the  instruments. 
The  first,  which  is  the  most  constant,  is  found  immediately  above  the  thenar  and 
hypothenar  eminences,  and  corresponds  with  the  line  between  the  two  ranges 
of  the  carpal  bones :  the  second,  which  is  perceived  from  four  to  six  lines  in 
the  rear,  falls  upon  the  radio-carpal  articulation,  and  the  third,  still  higher 
towards  the  elbow,  commonly  corresponds  with  the  junction  of  the  epiphyses 
with  the  shafts  of  the  radius  and  ulna.  When  these  wrinkles  are  imperfectly 
developed,  bending  the  hand  is  generally  sufficient  to  display  them  more 

Manual. — The  amputation  of  the  wrist  is  only  practised  by  the  circular  or 
flap  method  :  the  disposition  of  the  articular  surfaces,  and  the  thinness  of  the 
soft  parts,  render  the  oval  method  inapplicable. 

A.  Circular  Method. — The  surgeons  of  the  last  century  contented  them- 
selves with  saying,  that  the  amputation  of  the  wrist  should  be  effected  in  the 
same  manner  as  that  of  the  fore-arm  or  of  the  leg,  without  entering  inf »  any 
further  details  on  the  subject,  so  that  it  may  be  concluded  that  they  used  the 
circular  method,  which  has  been  clearly  described  by  J.  L.  Petit,  the  only  one 
indicated  by  Lassus,  and  Sabatier,  and  that  which  still  presents  the  greatest 
advantages  and  the  greatest  facility.  The  assistant  who  has  charge  of  the 
fore-arm,  draws  the  teguments  forcibly  backwards ;  the  surgeon  seizes  the  hand 
of  the  patient,  holds  it  in  a  flexed  posture,  while  he  cuts  upon  the  dorsal 
face ;  inclining  it  towards  the  radius,  while  he  cuts  on  the  inside ;  towards 
the  ulnar,  when  on  the  outside ;  and  in  extension,  the  moment  the  instrument 
is  passed  below.  In  this  manner  he  makes  an  incision  regularly  circular,  a 
full  finger's  breadth  in  front  of  the  apophyses  of  the  fore-arm,  through  the  skin 
only,  which  it  is  then  easy  to  push  back  to  the  vicinity  of  the  articulation.  A 
second  stroke  divides  all  the  tendons  at  the  edge  of  the  retracted  teguments. 
He  then  enters  the  articulation  by  one  or  the  other  of  its  sides,  taking  the  cor- 
responding styloid  apophysis  as  a  guide,  and  passing  the  bistoury  in  a  line 
convex  towards  the  arm. 

The  radial  and  cubital  arteries,  which  are  easy  to  find  and  to  tie  or  twist, 
have  often  been  left  in  the  wound  without  precaution  and  without  occasioning 


\ 


198  NEW   ELEMENTS  OF 

subsequent  hemorrhage.  As  to  the  interosseal  artery,  it  is  too  trifling  to  merit 
any  attention.  If  the  operation  has  been  properly  performed,  there  will  remain 
enough  of  the  integuments  to  enable  the  operator,  without  much  effort,  to  bring 
them  forwards,  and  to  cover  completely  the  articular  surfaces.  It  is  here  par- 
ticularly, that  Garengeot  and  Le  Blanc  recommend  incision  of  the  tendinous 
sheaths  to  the  extent  of  one  or  two  inches,  in  order  to  avoid  purulent  collec- 
tions. It  is  here  too,  that  the  depending  posture  of  the  stump  seems  to  me  to 
be  particularly  indicated. 

B.  Flap  Method. — 1st.  Old  Process. — The  surgeons  of  the  army  have  for  a 
long  time,  it  appears,  practised  an  operation,  described  by  M.  Gouraud  in 
1815,  which  consists  in  making  upon  the  dorsal  face  of  the  wrist  a  semilunar 
incision  convex  towards  the  fingers,  and  corresponding  by  its  extremities  with 
the  apophyses  of  the  radius  and  the  ulna.  An  assistant  then  withdraws  the 
cutaneous  envelope.  The  operator  divides  the  filaments  which  connect  it  with 
the  subjacent  tissues,  and  with  a  second  incision  in  the  direction  of  the  articu- 
lation, severs  all  the  extensor  tendons  and  the  posterior  radio-carpal  ligament. 
He  then  cuts  the  lateral  ligaments,  the  ten-dons  of  the  posterior  radialis,  and 
ulnaris  muscles,  if  it  has  not  already  been  done.  It  now  remains  to  pass 
through  the  joint  with  a  narrow  knife,  which  is  brought  in  front  of  the  carpus, 
so  as  to  finish  by  forming  a  flap  of  about  an  inch  in  length.  Some  surgeons 
advise  that  this  flap  should  be  extended  about  two  inches  from  its  base,  and 
consequently  cut  it  forwards  at  the  expense  of  the  thenar  and  hypothenar 
eminences.  When  enough  of  the  skin  has  been  preserved  at  the  commence- 
ment, this  precaution  would  be  more  disadvantageous  than  useful.  In  order 
to  cut  the  flap  wdth  facility,  and  to  give  it  all  possible  regularity,  the  operator 
should  early  incline  the  edge  of  the  instrument  towards  the  integuments,  so  as 
to  avoid  coming  in  contact  with  the  osseous  protuberances  of  the  carpus,  and 
to  remove  the  pisiforme  at  the  same  time  with  the  hand.  As  the  flexor  tendons 
form  here  a  considerable  bundle,  the  operator  should  not  hesitate,  in  case  of 
resistance,  to  pass  the  instrument  beneath  them,  and  to  divide  them  trans- 
versely. The  coaptation  of  the  lips  of  the  incision  cannot  fail  to  be  rendered 
more  easy.  This  process,  equally  prompt  and  simple,  possesses  the  advantage 
of  permitting  us,  in  case  the  soft  parts  behind  are  disorganized,  to  preserve 
a  sufficiency  in  front  to  close  the  whole  division.  It  is  still,  however,  subject 
to  the  inconvenience  of  exposing  the  osseous  angles  to  denudation,  and  oc- 
casioning sometimes  an  overlapping  of  the  lips  of  the  wound ;  for  it  is  precisely 
at  the  concave  and  least  salient  point  of  the  articulation,  that  the  thickest 
and  broadest  parts  of  the  flaps  are  applied. 

2d.  Process  of  M.  Lisfranc. — The  hand  and  the  fore-arm  are  placed  in 
supination,  and  held  so  by  the  assistant,  who  at  the  same  time  compresses  the 
radial  and  ulnar  arteries.  The  operator  being  provided  with  a  narrow  knife 
pierces  the  tissue  from  the  radius  towards  the  ulna,  or  vice  versa,  according  as 
he  may  have  to  do  with  the  right  or  the  left  wrist,  opposite  the  styloid  apo- 
physes, passing  thus  between  the  soft  parts  and  the  anterior  face  of  the  carpus, 
draws  the  instrument  towards  the  hand,  and  cuts  as  in  the  preceding  case  a 
semi-elliptical  flap,  about  two  inches  long.  This  being  drawn  up,  or  turned  back, 
permits  the  surgeon  to  make  immediately  a  semicircular  incision  upon  the 
dorsal  face  of  the  wrist,  something  like  that  which  I  have  just  described;  to 
divide  at  the  same  time  the  extensor  tendons,  almost  to  a  level  with  the  joint; 


OPERATIVE    SURGERY.  199 

then  to  disarticulate^  by  passing  under  the  point  of  one  of  the  styloid 
apophyses,  and  to  finish  as  in  the  circular  method. 

In  attempting;  to  describe  the  process  of  Lisfranc>,  the  editors  of  Sabatier 
have  unwittingly  introduced  a  slight  modification.  After  having  formed  the 
palmar  flap,  instead  of  carrying  the  knife  behind  the  wrist  in  order  to  divide 
the  integuments,  they  advise  to  pass  at  once  through  the  joint  from  the  palmar 
side,  and  finish  by  dividing  the  tissues  which  cover  the  back  of  the  carpus, 
f  n  either  way  this  method  presents  nearly  the  same  inconveniences  and  the 
same  advantages  as  the  flap-method  generally  followed,  from  which  it  only 
differs  in  circumstances  too  trivial  to  merit  here  a  further  discussion* 


Art.  4. — The  Fore-arm. 

Anatomical  and  Surgical  Remarks. — The  law  which  requires  us  to  am 
putate  at  the  greatest  possible  distance  from  the  trunk,  which  is  applicable  to 
every  amputation  performed  on  the  thoracic  member,  is  especially  so  in 
regard  to  the  fore-arm.  J.  L.  Petit,  Le  Blanc,  Bertrandi,  and  more  recently, 
M.  Larrey,  founding  their  opinions  upon  false  appearances  and  upon 
positions  badly  sustained,  have  however  advanced  the  contrary.  According 
to  them,  the  inferior  third  of  that  part  is  not  sufficiently  fleshy,  encloses  too 
many  fibrous  tissues  to  permit  the  bone  to  be  easily  covered  after  amputation, 
and  a  thousand  dangers  are  incurred  by  making  incisions  there.  The  supe- 
rior half,  on  the  contrary,  being  furnished  with  numerous  muscles,  and 
without  tendons,  presents  the  most  advantageous  conditions  whicli  could  be 
desired  for  the  success  of  such  operations,  and  should  consequently  be  pre- 
ferred at  the  risk  of  sacrificing  some  inches  of  tissue,  which  might  perhaps  be 
otherwise  preserved.  To  this  reasoning  it  may  be  replied  that,  all  circum- 
stances being  alike,  the  farther  you  operate  from  the  root  of  the  member  the 
less  the  fl^sh  is  divided,  the  less  extensive  the  bleeding  surface,  the  less 
violent  the  general  reaction,  the  fewer  the  accidents  to  be  apprehended: 
that  the  most  meagre  part  of  the  fore-arm  and  the  most  completely  devoid  of 
the  muscular  fibres,  will  always  permit  the  operator  to  preserve  a  sufficiencr 
of  skin  to  meet  and  completely  close  the  wound.  I  will  repeat  that  when  it 
comes  to  the  proof,  it  is  always  the  integuments  that  form  the  cicatrix,  and 
that  they  are  even  better,  more  pliant,  and  more  firm,  when  they  are  farthest 
removed  from  tendons  or  muscles.  But  this  is  a  question  which  experience 
seems  to  have  already  and  finally  decided,  for  I  do  not  see  that  any  person 
thinks  of  again  bringing  it  under  discussion. 

Besides  the  twenty  muscles  and  their  tendons,  the  radial,  cubital,  and  inter- 
osseal  arteries,  with  the  corresponding  nerves,  and  the  median  and  the  aponeu- 
rosis and  superficial  veins,  which  are  presented  over  its  whole  extent,  the 
fore-arm  offers  for  consideration — 1st.  Its  two  bones,  movable  one  upon  the 
other,  separated  by  a  space  diminishing  as  you  approach  either  extremity,  and 
which  by  the  assistance  of  a  species  of  membraneous  diaphragm,  form  the 
floors  of  the  anterior  and  posterior  excavations  or  fossae.  2d.  A  series 
of  fibrous  intersections  and  an  abundance  of  lamellar  tissue  between  the  two 
fleshy  strata,  the  attachments  of  which  permit  but  an  inconsiderable  retraction, 
at  the  same  time  that  the  whole  collection  of  these  different  objects  could 


lie  NEW    ELEMENTS    OF 

hardly  have  been  made  more  favorable  to  the  development  of  phlegmonous 
inflammation  and  of  purulent  collections. 

Manual — A.  Circular  Method. — All  the  varieties  of  the  circular  method, 
that  of  Celsus,  of  Wiseman,  and  Pigraj,  those  of  Petit,  of  Le  Dran,  or  Louis, 
of  Alanson,  and  of  Desault,  have  been  or  are  still  used  in  the  amputation  of 
the  fore-arm.  That  most  generally  followed  at  the  present  day,  and  in  my 
opinion,  the  best,  is  practised  thus : — 

1st.  Process  adopted  by  the  Author. — The  patient  is  supported  on  the  edge 
of  his  bed,  or  upon  a  chair,  if  he  is  not  too  much  enfeebled.  An  assistant 
stationed  behind  his  shoulder  presses  the  brachial  artery  against  the  humerus 
below  the  arm -pit,  with  the  four  fingers  of  one  hand,  either  directly  or  by  the 
intervention  of  a  pledget  or  rolled  bandage,  whilst  the  thumb  gives  a  counter- 
support  beneath,  unless  the  operator  should  prefer  the  use  of  the  tourniquet 
or  of  the  garot.  A  second  assistant,  or  even  the  same  if  circumstances  require 
it,  holds  the  fore-arm  turned  in  pronation,  and  is  ready  at  the  proper  moment 
to  draw  the  skin  towards  the  elbow.  The  member  to  be  removed,  wrapped 
in  a  linen  bandage,  should  be  supported  by  a  tliird  assistant.  With  the  left 
hand  the  operator,  placed  in  front,  takes  hold  of  the  fore-arm  above  tl^tj  point 
where  the  skin  is  to  be  incised  if  it  be  upon  the  left  side,  below,  if  on  the^i&ght, 
unless  the  operator  be  ambidexter.  He  then  divides  circularly  the  external 
envelope  to  the  aponeurosis,  two  or  three  fingers'  breadths  below  the  place 
where  the  section  of  the  bone  is  to  be  made.  If  any  cellulo-fibrous  filaments 
hinder  the  retraction  of  the  integuments,  the  operator  divides  them  rapidly, 
and  immediately  returns  the  knife  with  a  circular  sweep,  as  in  the  first 
instance,  upon  the  external  and  posterior  face  of  the  radius,  cuts  the  whole 
thickness  of  the  flesh  as  near  as  possible  to  the  retracted  skin,  first  on  the 
dorsal  region,  then  on  the  palmar,  and  in  the  third  place  on  the  radial.  In 
order  to  prevent  their  yfelding  or  slipping,  instead  of  being  cut  it  is  necessary 
that  the  instrument  divide  them  with  a  sawing  movement,  without  leaving  the 
surface  of  the  radius  until  it  rest  fairly  upon  the  ulna,  which  it  should  also 
carefully  graze  as  it  passes  round  to  the  palmar  side,  if  the  operator  desires 
that  no  portion  should  escape  him  and  present  itself  again  behind.  I  need 
not  say  that  the  same  precaution  is  equally  necessary  for  the  rest  of  the  cir- 
cumference of  the  limb.  The  divided  muscles  retract  more  or  less :  the  knife 
is  brought  backwards  upon  the  dorsal  face  of  the  cubitus,  and  then  drawn 
towards  the  operator ;  its  point  glides  upon  the  posterior  interosseous  fossae, 
through  which  it  is  plunged  deeply,  and  returns,  dividing  every  thing  it  meets, 
upon  the  posterior  face  of  the  radius  around  which  it  turns.  It  is  then  car- 
ried beneath,  in  order  to  effect  in  front  what  has  just  been  done  on  the  back 
of  the  member ;  nothing  then  remains  around  the  bones.  The  middle  head 
of  the  three-headed  compress  is  immediately  carried  with  the  forceps  through 
the  interosseous  space,  from  the  palmar  to  the  dorsal  side.  The  fleshy  fai^ 
being  thus  protected  and  drawn  back,  the  surgeon  proceeds  to  divide  tl^ 
bones ;  begins  with  the  radius,  continues  by  operating  at  the  same  time  upon 
the  radius  and  the  ulna,  but  in  such  a  manner  as  to  finish  with  the  latter. 
After  the  removal  of  the  part  the  triple  compress  is  taken  off",  and  the  assistant 
charged  with  the  retraction  of  the  soft  parts  immediately  relaxes  them.  The 
surgeon  then  occupies  himself  in  searching  for  the  arteries,  one  after  the  other, 
in  the  midst  of  the  tissues ;  the  anterior  interosseal,  accompanied  by  a  iierve 


OPERATIVE    SURGERY.  201 

which  it  is  well  to  avoid,  is  found  nearly  upon  the  middle  of  the  palmar  face 
of  the  ligament  of  the  same  name.  The  radial,  situated  more  to  the  outside 
and  more  superficially,  is  seen  between  the  supinator  longus,  the  flexor  radi- 
alis,  and  the  flexor  longus  pollicis.  It  is  so  far  removed  from  the  nerve  as 
not  to  require,  in  this  respect,  any  particular  precaution  in  tying  it.  The 
ulnar  artery  lies  towards  the  inner  side,  between  the  flexor  ulnaris,  the  flexor 
sublimis,  and  the  flexor  profundus,  having  the  nerve  on  its  internal  side.  As 
to  the  posterior  interosseal  artery,  which  is  distributed  throughout  the  fleshy 
mass  of  the  extensors,  it  needs  no  attention,  unless  the  amputation  have  been 
performed  towards  the  superior  half  of  the  fore-arm.  The  wound  should  be 
closed  from  behind  and  before,  and  it  is  in  this  direction  that  the  adhesive 
strips  are  to  be  applied.  A  transverse  linear  wound  is  thus  formed,  the  angles 
of  which  cover  the  bones  and  give  exit  to  the  remaining  paits  of  the  corre- 
sponding ligatures,  whilst  that  of  the  centre  should  be  immediately  brought 
directly  out  at  the  middle  of  the  wound. 

2d.  Process  of  Alanson, — If  the  skin  were  diseased,  or  had  contracted 
morbid  adhesions  with  the  subjacent  tissues,  it  would  be  better,  after  having 
made  the  incision,  to  dissect  it  up  and  turn  it  back  upon  its  external  face  like 
a  rufile,  after  the  manner  of  Alanson. 

3d.  Process  of  M.  /.  Cloquet. — When  there  is  reason  to  apprehend  soma 
difficulty  in  dividing  the  muscles  and  tendons  which  lie  in  the  interosseous 
fossae,  the  surgeon  may  pass  the  knife  flat  between  the  bones  and  the  flesh, 
and  immediately  turn  the  edge  so  as  to  cut  transversely  outwards  all  the 
soft  parts  on  a  level  witli  the  retracted  integuments,  and  that  upon  both 
aspects  of  the  limb  successively.  M.  Hervez  de  Chegoin,  I  believe,  first 
published,  in  1819,  the  idea  of  this  modification,  which  M.  J.  Cloquet  assures 
us  that  he  has  applied  many  times  with  success;  and  which,  through  inad- 
vertence no  doubt,  the  editors  of  Sabatier  have  appropriated  to  themselves. 

Remarks. — When  all  the  muscles  have  been  divided,  some  may  desire  to 
cause  them  to  retract  so  as  to  admit  of  sawing  the  bones  at  a  higher  point. 
In  this  case  they  should  detach  for  a  few  lines  with  the  point  of  the  knife,  or 
with  the  bistoury,  the  two  edges  of  the  interosseus  membrane.  Here,  as 
upon  all  the  other  parts  of  the  member,  we  should  preserve  an  extent  of  tegu- 
ments the  more  considerable  the  higher  we  perform  the  operation;  or  rather, 
the  greater  the  volume  of  the  part.  It  should  be  remembered  too,  that  the 
deep  muscles  which  are  attached  to  nearly  the  whole  extent  of  the  bones, 
retract  but  little  towards  the  elbow,  and  that  we  must  depend  principally 
upon  the  skin  for  closing  the  wound  and  covering  the  stump. 

B.  Flap  Method. — History  and  Appreciation. — The  circular  amputation  of 
the  fore-arm  generally  succeeds  extremely  well,  and  admits  of  a  cure  in  three 
or  four  weeks ;  yet  surgeons  have  advised  replacing  it  by  the  flap  method. 
M.  Graefe,  has  in  our  own  day  performed  it  according  to  the  advice  of  Ver- 
duin  and  Lowdham,  and  as  Ruysche  declares  that  he  had  seen  it  performed 
in  his  presence ;  that  is,  by  cutting  a  flap  upon  the  palmar  front  of  the  limb, 
and  concluding  the  operation  according  to  the  circular  method.  Vermale, 
Le  Dran,  Klein,  Hennen,  and  Guthrie,  prefer,  on  the  contrary,  to  make  two 
flaps,  one  in  front,  and  one  behind.  In  this  respect  we  can  hardly  refuse  pre- 
ference to  the  method  followed  by  Vermale,  over  that  of  Verduin.  I  have  tried 
it  myself,  and  have  caused  it  to  be  performed  by  many  of  my  pupils,  upon 
26 


202  NEW  ELEMENTS  OF 

the  dead  subject.  I  have  twice  operated  in  the  same  way  upon  the  living 
subject,  and  remain  convinced  that  it  is  generally  less  advantageous  than  the 
circular  method,  although  the  operation  is  more  easy  and  more  quickly  finished. 
It  is  very  ti'ue,  that  it  gives  fleshy  fibres  to  cover  the  ends  of  the  bones.  The 
flaps  are  thick  and  abundantly  furnished  with  cellular  tissue,  to  fit  together 
exactly,  and  to  provide  with  certainty  for  all  the  exigencies  of  immediate 
union.  Two  inches  are  sufficient  for  each,  in  order  to  enable  them  properly 
to  meet ;  if  the  disease  extends  farther  upon  one  side  than  the  other,  it  is 
easy  to  make  but  one  flap,  or  two  of  unequal  length  ;  so  that  it  cannot  at  first 
be  seen  why  this  method  would  not  permit  amputation  as  low  as  the  circular 
method.  Unfortunately,  in  looking  more  closely,  it  will  sw)n  be  perceived, 
that  these  advantages  are  illusory ;  all  the  muscles  are  cut  obliquely,  and 
this  necessarily  increases  the  traumatic  surface.  They  are  preserved  in  the 
thickness  of  each  flap,  only  to  increase  the  danger  of  inflammations  which 
may  then  develop  themselves.  The  bones  a^e  not  the  less  exposed  to  escape 
by  the  angles  of  the  solution,  and  the  slightest  reflection  will  show,  that  by 
a  circular  incision  an  inch  of  teguments  will  close  with  more  exactness  a 
wound  two  inches  across,  than  flaps  half  as  long  again,  because  of  the  open- 
ing which  the  flaps  are  so  prone  to  leave  upon  each  side  of  their  base :  never- 
theless, here  is  a  manual  of  the  operation. 

2d.  Manual. — The  limb  is  turned  in  pronation,  and  held  in  a  convenient  posi 
tion.  The  operator  cuts  the  palmar  flap,  by  passing  his  knife  from  one  side  of 
the  fore -arm  to  the  other  between  the  bones  and  the  soft  parts,  which  he 
divides  obliquely  towards  the  wrist.  In  order  to  form  the  dorsal  flap,  he  draws 
the  lips  of  the  wound  backwards,  returns  the  point  of  the  knife  to  the  supe- 
rior part  of  the  first  incision,  passes  it  behind  the  bones,  and  finishes  with 
the  same  precautions  as  before.  He  then  directs  the  assistant  to  turn  back 
immediately  all  the  fleshy  parts,  cuts  around  the  radius  and  the  ulna,  and 
with  the  assistance  of  the  divided  compress  divides  these  bones  as  directed  in 
tlie  circular  operation. 

3d.  Remarks, — Cutting  the  anterior  flap  first  allows  a  greater  thickness  to  the 
dorsal,  and  as  the  palmar  side  of  the  fore-arm  is  turned  downwards,  the  blood 
which  at  first  escapes  does  not  at  all  interfere  with  the  rest  of  the  operation ; 
but  this  precaution  is  far  from  being  indispensable.  The  important  point  is  to 
obtain  two  flaps  of  nearly  equal  dimensions,  and  to  avoid  cutting  them  out  too 
much  at  the  angles.  The  operator  may  also  leave  the  limb  in  supination 
instead  of  turning  it  after  the  first  stroke  into  pronation,  but  then  the  division 
of  the  bones  will  produce  a  greater  degree  of  motion  in  the  joints,  and  cannot 
be  so  easily  effected.  It  is  recommended  to  saw  the  radius  and  the  ulna  toge- 
ther, so  as  to  finish  upon  the  latter,  because,  in  being  connected  more  firmly 
to  the  humerus,  the  ulna  gives  a  better  support  to  the  action  of  the  saw.  In 
advising  the  operator  to  place  himself  in  front  between  the  limb  and  the  trunk, 
I  have  not  intended  to  establish  a  general  rule.  Garengeot  positively  advises 
the  contrary ;  and  Bertrandi  adds,  that  in  case  the  patient  is  in  bed,  the  opera- 
tor would  be  improperly  situated,  at  least  on  the  right,  if  he  did  not  place 
himself  on  the  outside.  The  English  and  German  surgeons,  Mr.  Guthrie 
amongst  others,  are  wrong  in  saying,  that  amputation  by  flaps  is  only  appli- 
cable to  the  superior  part  of  the  fore-arm;  it  is  applicable  to  any  point  of  its 
length.   Le  Dran  remarks  that  a  subject  upon  whom  he  operated  in  this  manner. 


OPEilATrVE   SURGERY.  SOS 

was  cured  in  twenty  days,  whilst  by  the  circulai*  method  he  did  not  obtain 
cicatrization  until  the  expiration  of  two  or  three  months;  but  there  is  nothing 
astonishing  in  this,  since  they  did  not  in  his  time  attempt  union  by  first  inten- 
tion after  circular  amputation. 

Art.  5.-^The  Elbow, 

History  and  Appreciation. — Some  surgeons  of  the  last  century,  founding 
their  opinions  upon  a  passage  of  Pare,  who  says  that  he  had  ventured  to  dis- 
articulate a  fore-arm  gangrened  after  fracture,  have  thought  that  this  operation 
would  be  of  considerable  advantage  in  practice ;  amongst  others,  that  of  pre- 
serving to  the  limb  three  or  four  inches  more  in  length  than  by  amputating 
the  arm  itself.  Many  of  the  moderns  have  objected  that  this  advantage  is 
one  of  too  slight  importance  to  be  purchased  at  the  price  of  such  numerous 
difficulties  and  dangers  of  every  description  which  accompany  such  a  disar- 
ticulation. If  it  is  possible  to  cut  in  the  soft  parts  a  flap  long  enough  to 
cover  completely  the  articular  extremity  of  the  humerus,  circular  amputation 
immediately  before  the  joint  must  be  equally  practicable.  In  the  contrary 
case,  say  these  objectors,  one  could  not  decide  upon  leaving  such  a  large  carti- 
laginous surface  uncovered,  and  the  amputation  of  the  arm  becomes  indispen- 
sable. These  arguments  are  less  conclusive  than  they  at  first  appeared  to  be ; 
even  if  the  fleshy  parts  are  in  such  a  state  that  they  can  be  preserved,  it  does 
not  follow  that  the  bones  are  sound  to  the  point  where  the  saw  must  be  applied  to 
preserve  the  smallest  fragment.  Necrosis,  caries,  comminutive  fractures, 
&c.  may  extend  themselves  as  far  as  the  articulation,  without  the  surrounding 
tissues  losing  entirely  their  primitive  characters;  the  diseased  bones  then 
being  once  removed,  who  does  not  know  that  the  soft  parts  the  most  deeply 
affected,  often  return  at  last  to  their  natural  state.  Besides,  the  operation  which 
is  in  fact  less  dangerous  in  itself  than  the  amputation  of  the  arm,  is  far  from 
being  so  difficult  as  some  have  imagined.  Dr.  Rodgers,  of  New  York,  has  prac- 
tised it  with  success,  and  M.  Dupuytren  has  foand  no  reason  to  condemn  it. 
For  my  own  part,  I  believe  it  to  be  indicated  in  every  instance  where  the  alter- 
ation of  the  bone  approaches  within  an  inch  or  two  of  the  articulation. 

Manual. — Ambroise  Pare,  who  was  conducted  by  circumstances,  or  pressed 
by  necessity  to  the  performance  of  this  operation,  has  not,  or  has  at  least  but 
very  vaguely  described  his  method,  supposing  no  doubt  that  every  one  could 
guess  it  and  imitate  it. 

A.  Flap  Method. — 1st.  Process  of  Brasdor. — After  several  trials  Brasdor 
came  at  last  to  the  following  precepts : — An  incision  in  shape  of  a  half-moon 
with  its  convexity  downwards  compressing  the  posterior  half  of  the  circum- 
ference of  the  member,  is  first  made  a  few  lines  beneath  the  summit  of  the 
olecranon,  so  as  to  admit  of  the  division  of  the  latter  ligaments  and  the  ten- 
don of  the  triceps,  and  to  open  freely  into  the  articulation  of  the  radius.  The 
knife  being  passed  flatwise  from  one  side  to  the  other,  between  the  anterior 
face  of  the  bones  and  the  fleshy  parts,  then  forms  a  large  flap,  of  which  the 
base  corresponds  with  the  joint,  and  the  free  end  comes  about  three  or  four 
inches  below.  Finally  the  operator  concludes  by  disarticulating  the  ulna  in 
the  direction  from  the  coronoid  process  to  the  olecranon,  and  by  the  division  of 
the  triceps  when  it  has  not  been  effected  before. 


204  NEW   ELEMENTS   OF 

2d.  Process  of  M,  Vacquier, — M.  Vacquier  proposes  to  modify  as  follows, 
the  process  of  Brasdor : — With  a  two-edged  knife  he  begins  by  cutting  the  ante- 
rior flap  from  below  upwards,  as  far  as  the  articulation ;  cuts  tlie  ligaments 
which  unite  the  radius  and  the  ulna  to  the  humerus ;  luxes  the  fore-arm ;  and 
closes  by  detaching  the  olecranon  from  the  large  tendon  to  which  it  gives 
attachment,  and  from  the  teguments,  so  as  to  leave  a  flap  some  lines  in  length 
behind. 

3d.  Process  of  Sabatier. — Sabatier  ascribes  to  M.  Dupuytren  the  suggestion 
that  it  is  much  better  to  saw  off"  the  olecranon  and  leave  it  attached,  to  form 
the  flap  after  the  manner  of  Faye,  in  amputation  of  the  shoulder,  or  that  of 
Verduin,  for  the  amputation  of  the  leg,  than  to  follow  to  .the  letter  the  advice 
of  M.  Vacquier. 

4th.  Process  of  M.  Dupuytren. — According  to  M.  Sanson  and  Begin,  M. 
Dupuyti'en  has  in  seven  or  eight  instances  practised  the  amputation  of  the 
elbow  with  success,  according  to  the  manner  of  Verduin  ;  that  is  to  say,  by 
plunging  a  two-edged  knife  in  front  of  the  articulation,  from  one  condyle  of 
the  humerus  to  the  other ;  between  the  bones,  which  he  grazes  with  the  knife, 
and  the  soft  parts,  which  he  holds  up  in  the  left  hand,  and  then  divides  them 
from  above  downwards.  The  disarticulation  being  eff*ected,  M.  Dupuytren 
completes  the  operation  by  sawing  or  removing  the  olecranon. 

5th.  Process  of  the  Author. — I  do  not  see  any  advantage  in  preserving  the 
olecranon,  as  advised  by  Sabatier  and  frequently  done  by  M.  Dupuytren.  The 
triceps  has  no  occasion  for  it  in  order  to  move  the  humerus,  and  it  is  evident 
that  its  presence  cannot  favor  in  any  degree  the  success  of  the  operation.  In 
order  that  the  saw  may  act  upon  its  anterior  face,  it  is  necessary  that  the  arti- 
cular surfaces  should  be  completely  dislocated.  There  can  then  be  no  diffi- 
culty in  detaching  it  from  the  teguments  which  cover  it  behind.  But  supposing 
that  the  operator  is  bent  on  preserving  it,  the  following  modification  appears 
to  me  to  offer  some  advantages  ; — An  anterior  flap  is  formed  after  the  manner 
of  M.  Dupuytren,  but  a  little  lower  down  than  directed  by  that  operator.  The 
integuments  which  remain  behind  are  then  divided  as  in  the  circular  method, 
at  about  an  inch  below  the  epicondyles.  The  operator  then  cuts  the  external 
lateral  lijijament  and  disarticulates  the  radius,  and  after  having  exactly  incised 
all  the  soft  parts  which  surround  the  ulna,  he  saws  through  it  immediately 
beneath  the  coronoid  process  as  near  as  possible  to  the  joint,  in  the  line  of  the 
humero-radial  articulation.  He  thus  avoids  all  the  difficulties  of  the  disarti- 
culation of  the  elbow ;  the  operation  is  as  prompt  as  that  by  any  other  method  ; 
there  is  no  occasion  to  exert  any  traction  or  wrenching  upon  the  bones  ;  and 
the  wound,  which  is  sensibly  less,  is  necessarily  less  disposed  to  suppurate,  and 
admits  more  easily  of  immediate  union. 

B.  Circular  Method. — I  have  arrived  at  the  conviction  that  the  circular 
mode  of  amputation  here  off*ers  undeniable  advantages.  An  inch  of  inte- 
guments preserved  below  the  elbow  would  suffice  to  cover  the  humeral  trochlea, 
while  by  the  flap  method  three  or  four  are  required  in  front.  As  all  the 
muscles  are  removed,  the  incision  must  in  reality  be  much  smaller  and  less 
exposed  to  profuse  suppuration,  and  would  not  occasion  such  a  lively  reaction. 
After  having  divided  the  skin  circularly,  I  dissect  it  and  turn  it  back  as  far  up 
as  the  joint,  after  which  I  cut  the  anterior  muscles,  then  the  lateral  ligaments, 
in  order  to  disarticulate  from  front  to  rear,  and  close  with  the  division  of  the 


OPERATIVE  SURGERY.  205 

triceps.  The  humeral  artery  is  the  only  one  that  requires  to  be  tied  or  twisted, 
and  the  ruffle  of  skin  may  be  turned  forwards  without  the  least  difficulty  to 
close  the  wound. 

Art,  6.-^The  Arm. 

As  the  amputation  of  the  arm  is  most  frequently  required  by  a  disease  of  the 
humero-cubital  articulation,  it  is  generally  performed  below  the  middle  of  the 
limb.  But  other  aifections,  such  as  injuries  to  the  arm  itself,  sometimes 
require  this  operation  to  be  performed  nearer  to  the  shoulder. 

Anatomical  Remarks. — The  only  bone  which  enters  into  the  constitution  of 
the  arm  is  cylindrical  in  its  centre ;  slightly  turned  upon  its  own  axis ;  flat- 
tened so  as  to  present  its  edges  bare  beneath  the  skin,  near  the  elbow ;  and 
surrounded  by  numerous  muscles.  The  deltoides,  the  coraco-brachialis,  the 
long  heads  of  the  triceps  and  the  biceps  which  are  also  attached  to  the  scapula, 
the  pectoralis  major,  and  the  latissimus  dorsi,  form  a  distinct  system,  the  re- 
traction of  which  should  be  expected  when  amputation  is  performed  above  the 
deltoidean  muscles.  As  they  are  all  inserted  below  the  head  of  the  humerus, 
M.  Larrey  has  concluded  that  in  amputating  at  the  surgical  neck  of  the  bone, 
the  fragment  which  is  preserved  can  be  of  no  avail ;  that  it  is  even  incon- 
venient, since  the  supra  and  infra  spinati  muscles  hold  it  in  a  state  of  permanent 
extension.  Below  the  deltoid  muscle,  the  biceps  which  extends  without  inter- 
mediate attachment  from  the  shoulder  to  the  fore-arm,  is  the  only  one  which  can 
retract  itself  to  any  considerable  extent,  after  having  been  cut.  The  others,  the 
brachial  and  the  three  connected  portions  of  the  triceps,  having  their  fibres 
attached  to  the  humerus  itself,  can  withdraw  themselves  but  very  slightly  from 
the  point  where  they  have  been  divided  by  the  knife. 
Manual. — A.  Circular  Method. — If  with  Petit,  after  having  incised  and  raised 
the  skin,  we  content  ourselves  with  dividing  all  the  muscles  at  a  single  stroke 
on  the  point  where  the  saw  is  to  be  applied  in  the  inferior  half  of  the  arm,  the 
biceps  muscle  will  rarely  fail  by  its  consecutive  retraction  to  produce  the 
denudation  of  the  bone.  The  teguments  are  too  movable  upon  the  aponeu 
rosis  to  require  that  we  should  dissect  and  turn  them  out,  as  advised  by  Alan 
son.  There  remain  for  choice  then,  the  process  of  Celsus  or  of  Louis,  modified 
by  M.  Dupuytren,  and  that  of  Desault. 

The  patient  being  placed  and  the  artery  compressed  as  for  the  amputation 
of  the  fore-arm,  an  assistant  holds  the  limbs  apart  from  the  trunk  at  nearly 
aright  angle.  The  rule  requires  that  the  surgeon  should  place  himself  on  the 
outside,  but  when  he  operates  on  the  left  arm,  there  is  some  advantage  to  be 
gained  by  placing  himself  on  tlie  inside.  The  left  hand  of  the  surgeon  is  thus 
still  enabled  to  draw  the  skin  as  the  instrument  divides  it.  The  section  of  the 
integuments  is  then  performed  as  near  as  possible  to  the  elbow.  In  incising 
the  muscles  circularly  at  the  edge  of  the  retracted  skin,  it  is  very  important 
to  traverse  the  whole  thickness  of  the  biceps  muscle.  It  might  even  be  cut 
alone  in  the  first  instance,  as  is  done  by  Mr.  S.  Cooper,  so  as  not  to  touch  those 
of  the  deep  stratum,  except  at  a  few  lines  from  the  point  where  the  section  of 
the  bone  is  to  be  made.  When  the  humerus  has  been  exposed,  it  can  do  no 
harm  to  separate  from  it  the  fleshy  fibres  parallel  to  its  length  to  the  extent 
of  one  or  two  inches,  as  advised  by  Bell,  Mid  as  now  practised  by  M.  Graefe. 


in* 

206  NEW  ELEMENTS  OF 

M.  Hello  contends  that  these  deep  fibres,  thus  preserved,  are  the  only  ones 
which  can  really  apply  themselves  to  the  end  of  the  bone.  I  would  add  the 
necessity  of  dissecting  the  skin,  according  to  Alanson,  if  all  the  other  tissues 
are  to  be  cut  perpendicularly  upon  the  bone  at  a  single  stroke.  In  every  way 
care  should  be  taken  that  the  radial  nerve  do  not  escape  the  edge  of  tlie  knife. 
The  lasf  fleshy  stratum  should  be  divided  about  three  inches  above  the 
incision  in  the  skin ;  the  retractor  and  the  division  of  the  bone  present  nothing 
peculiar. 

The  humeral  artery  is  found  between  the  biceps  and  the  internal  portion  of 
the  triceps  muscle,  closely  attached  to  the  median  nerve,  and  between  its  two 
attending  veins.  Two  or  three  branches  which  here  merit  some  attention, 
discover  their  position  by  the  blood  wliich  jets  from  them.  Above  the  deltoid 
depression,  the  biceps  muscle  being  brought  nearer  to  its  origin,  cannot  with- 
draw itself  to  the  same  extent,  but  as  the  volume  of  the  muscles  is  much  more 
considerable,  it  is  not  less  indispensable  here  than  below  to  preserve  as  much 
of  the  skin,  and  to  favor  the  retraction  of  the  muscles  as  much  as  possible 
before  sawing  the  bone. 

De  la  Faye  had  before  advanced,  and  Le  Blanc  had  already  disputed  the 
opinion  defended  by  M.  Larrey  in  his  Memoirs  of  Military  Surgery,  that  it 
is  more  advantageous  to  disarticulate  the  humerus,  than  to  divide  it  above  the 
muscles  by  which  it  is  connected  with  the  chest.  But  the  question  has  been 
decided  in  favor  of  Le  Blanc  and  of  M.  Richerand.  Experience  has  proved 
that  after  the  cure,  the  deltoid,  the  pectoralis  major  and  latissimus  dorsi,  the 
teres  major  and  coraco-brachialis  muscles,  are  not  without  action  upon  this 
little  end  of  hone,  as  it  is  termed  by  De  la  Faye,  and  that  they  can  impress 
different  motions  upon  the  stump.  The  little  which  is  left  of  the  arm  in- 
creases at  least  the  projection  of  the  shoulder,  opposes  the  sliding  of  the 
clothes,  preserves  the  hollow  of  the  axilla,  most  frequently  enables  the  subject 
to  hold  against  the  breast  some  foreign  bodies,  such,  for  instance,  as  a  cane, 
a  port-folio,  or  the  like ;  besides  it  is  not  necessary  to  open  the  articulation, 
nor  to  fill  up  the  large  cul-de-sac  which  exists  between  the  acromion  process 
and  the  scapular  tendon  of  the  triceps  muscle. 

J  B.  Flap  Method, — The  arm  is  the  limb  which  appears  to  be  the  least 
adapted  to  the  flap  method,  inasmuch  as  its  round  form,  the  disposition  and 
the  small  size  of  its  bone,  tend  greatly  to  the  success  of  the  circular  method. 
Klein  and  M.  Langenbeck  have  nevertheless  endeavored  to  bring  it  into  vogue. 
I  have  myself  had  recourse  to  it  twice  upon  the  living,  and  have  practised  and 
caused  it  to  be  practised  many  times  upon  the  dead  subject.  At  the  first 
glance  it  seems  as  if  the  operator  would  be  enabled  to  derive  from  it  a  great 
advantage  in  reference  to  immediate  union.  By  it,  it  is  not  only  the  skin,  as 
in  the  circular  method,  but  the  muscles  besides  that  cover  the  extremity  of  the 
bone  and  close  the  wound.  The  operator  has  then  nothing  to  fear  from  the 
retraction  of  fleshy  fibres  nor  from  the  isolation  of  the  skin  :  three  strokes 
with  the  knife,  one  for  each  flap  the  other  to  denude  the  bone,  and  one  with 
the  saw,  suffice  to  complete  the  operation.  Of  all  these  advantages,  promp- 
titude and  facility  are  the  only  ones  of  real  value.  The  mass  of  muscles  to 
which  80  much  consequence  is  attached,  only  favors  the  development  of 
phlegmonous  inflammation  in  the  stump,  tends  continually  to  slide  to  one  side 
or  the  other,  and  upon  the  slightest  suppuration  to  expose  the  bone  at  one  of  the 


OPERATIVE   SURGERY.  207 

angles  of  the  wound.  In  no  other  place  are  the  inconveniences  of  the  flap 
method  so  manifest :  but  Sabatier  himself  recommends  it  when  it  is  necessary 
to  amputate  near  the  shoulder. 

1st.  Process  of  Klein. — A  narrow  knife  plunged  through  from  the  radial  to 
the  cubital  side,  grazing  the  bone,  cuts  a  semilunar  flap  of  about  three  inches 
in  length.  After  having  formed  a  second  in  the  same  manner  on  the  opposite 
side,  the  operator  causes  the  two  to  be  held  back,  and  incises  at  their  base 
what  few  fibres  still  adhere  to  the  bone  which  he  saws  with  the  ordinary 
precautions. 

2d.  Process  of  M.  Langenbeck. — The  assistant  forcibly  draws  upon  the 
integuments.  The  operator  being  on  the  inside,  supports  with  the  left  hand 
if  operating  on  the  right  arm,  and  vice  versa  if  on  the  left  arm,  the  inferior  part 
of  the  member;  with  the  other  hand,  armed  with  a  good  knife,  he  cuts 
with  a  blow  from  the  skin  to  the  bone  an  internal  flap,  which  should  be  as  in 
the  preceding  case  of  two  or  three  inches  in  length ;  then  passing  the  knife 
and  the  wrist  beneath  and  returning  them  to  the  front  of  the  arm,  he  is  in  a 
position  to  form  an  external  flap  similar  to  the  first.  I  have  seen  young 
German  surgeons  practise  this  operation  in  our  amphitheatres  with  the  greatest 
celerity ;  but  such  trick  of  strength  or  of  address,  can  only  be  valuable  in  the 
eyes  of  those  who,  like  the  pupils  of  Langenbeck  and  of  Graefe,  are  for  him 
that  operates  the  most  quickly,  and  who  counts  the  seconds  in  amputations. 

3d.  Process  of  Sabatier. — Sabatier  only  recommends  tlie  flap  method  where 
the  operation  is  performed  too  high  to  permit  the  use  of  the  tourniquet.  His 
process,  as  already  described  by  Le  Blanc,  consists  in  making,  by  means  of  one 
transverse  and  two  longitudinal  incisions,  a  flap  in  the  form  of  a  trapezium, 
at  the  expense  of  the  anterior  external  part  of  the  deltoides,  raising  this  flap, 
and  by  a  circular  incision  cutting  the  rest  of  the  soft  parts  before  passing  to 
the  division  of  the  bone.  It  will  suggest  itself  to  every  one  that,  in  this  case, 
as  in  all  others  where  amputation  is  performed  near  the  shoulder,  compression 
should  be  applied  to  the  artery  above  the  clavicle,  or  upon  tlie  second  rib,  in 
the  manner  which  I  will  describe  below. 

*^rt,  7. — The  Arm  at  the  Joint, 

It  is  an  error  to  believe  that,  up  to  the  commencement  of  the  last  century, 
no  one  had  dared  to  disarticulate  the  arm.  Laroque  reports  an  instance  of 
this  operation  in  1686 — the  member  had  fallen  into  gangrene :  *'  The  surgeon 
took  a  small  saw  to  amputate  the  humerus,  but  perceiving  that  it  wavered 
towards  its  articulation  with  the  shoulder,  he  gave  it  a  little  jerk  and  the  bone 
easily  came  out  of  its  socket,  after  which  the  boy  was  speedily  restored  to  his 
former  health."  Although  the  idea  must  have  frequently  presented  itself  to 
the  minds  of  the  surgeons,  the  fear  of  opening  an  articulation  of  such  mag- 
nitude, the  want  of  means  to  suspend  the  course  of  the  blood  in  the  limb 
during  the  operation,  and  the  proximity  of  the  trunk,  had  kept  off"  the  boldest 
practitioners.  Le  Dran  is  the  first  to  have  described  it :  his  father  had  had 
recourse  to  it  in  a  case  of  necrosis  of  the  humerus,  attended  with  profuse  sup- 
puration, and  effected  a  complete  cure.  It  has  been  since  pretended  that  the 
elder  Morand  had  performed  this  operation  before  Le  Dran,  but  without  suf- 
ficient proof.    At  the  present  day  the  advantages  of  this  amputation  are  rc 


208  NEW  ELEMENTS   OF 

longer  disputed,  and  it  has  been  so  often  performed  that  it  is  unnecessary  to 
discuss  its  possibility. 

Anatomical  Remarks. — The  articulation  of  the  shoulder  is  overtopped  by 
two  processes  which  pass  in  front  of  its  line,  and  which  increase  in  an  especial 
manner  its  vertical  diameter.  It  consequently  presents  a  disposition  much 
more  favorable  to  coaptation  of  the  amputatory  wound,  transversely  than  ver- 
tically. The  head  of  the  humerus  forms  a  very  obtuse  angle  with  the  body 
of  that  bone,  and  the  fibrous  capsule  is  attached  a  little  beyond  its  limits.  At 
the  time  of  amputation,  the  edge  of  the  knife  must  describe  a  circular  line 
exactly  corresponding  to  the  plan  of  this  head,  in  order  to  divide  with  ease  the 
fibrous  tissues.  The  glenoid  cavity,  crowned  with  a  fibro-cartilaginous  ridge, 
is  itself  longer  in  a  vertical  line  than  horizontally  ;  and  this  disproportion  is 
apparently  increased  by  the  fossa  formed  by  the  two  above*  mentioned  pro- 
cesses of  the  scapula.  In  proceeding  downwards  v/e  find  about  this  articu- 
lation (beneath  the  common  integuments  and  a  very  fine  aponeurotic  lamina), 
the  deltoid  muscle,  a  loose  cellular  stratum,  the  tendons  of  the  supra-spinatus, 
of  the  infra-spinatus,  of  the  sub-scapularis,  the  teres  minor,  and  inclosed  within 
them  the  fibrous  capsule  and  the  long  tendon  of  the  biceps ;  to  the  inside,  the 
coraco-brachialis  and  the  short  head  of  the  biceps  muscle;  lower  down,  the 
scapular  head  of  the  triceps;  then  the  brachial  plexus,  the  axillary  vessels, 
and  under  the  skin  the  pectoralis  major,  and  the  longissimus  dorsi  and  teres 
major.  Several  of  these  objects  may  be  easily  recognized  from  without:  thus 
the  summit  of  the  acromion  is  perceived  above  the  projection  of  the  shoulder, 
and  seems  continuous  on  the  inside  with  the  clavicle ;  and  the  coracoid,  a  little 
nearer  to  the  breast  and  more  prominent,  is  also  easily  discovered.  There 
too  is  a  triangular  space  of  which  we  may  avail  ourselves  in  practice.  It  is 
bounded  on  the  outside  and  below  by  the  head  of  the  humerus,  above  by  the 
clavicle  and  the  acromion,  on  the  thoracic  side  by  the  coracoid  process.  This 
space  leads  directly  to  the  articulation,  and  has  served  as  a  guide  to  M. 
Lisfranc  in  the  execution  of  one  of  his  operations.  The  posterior  border  of 
the  arm-pit  being  raised  and  turned  outwards  upon  the  scapula,  permits  us 
to  arrive  beneath  the  acromion  and  to  traverse  the  outer  and  upper  part  of  the 
articulation.  The  acromion  is  much  more  prominent  upon  some  subjects  than 
upon  others ;  at  times  also  its  anterior  border  is  very  low,  so  that  its  humeral 
face  presents  a  very  deep  concavity^  In  infancy  it  remains  long  cartila- 
ginous. Upon  two  adult  subjects  I  have  been  able  to  separate  it  with  a  slight 
effort,  as  an  epiphysis  of  the  spine  of  the  scapula.  These  different  anomalies 
being  capable  of  rendering  the  disarticulation  of  the  arm  either  more  easy  or 
more  embarrassing,  should  be  always  present  to  the  mind  of  the  operator,  as 
well  as  the  other  anatomical  details  which  I  have  just  given. 

§  1.  Manual, 

The  amputation  of  the  arm  in  the  articulation  is  one  of  those  which  offers 
the  greatest  number  of  operative  processes.  Every  surgeon  who  has  performed 
it,  has  believed  himself  bound  to  invent  a  new  one ;  they  have  brought  into 
use  the  circular,  flap,  and  oval  methods,  and  all  the  varieties  of  which  these 
several  general  methods  would  admit. 

A.  Circular  Method, — The  idea  of  applying  the  circular  method  to  the  dis- 


^^  OJ^ERATIVE   SUROEltY*  209 

articulation  of  the  arm  was  not,  as  M.  Blandin  believes,  suggested  by  the 
author  of  the  iEirticle  Amputation  in  the  Encyclopedia.  iSarengeot  expressly 
declares,  that  in  his  time  it  was  preferred  by  many  persons ;  Bertrandi  like- 
wise mentions  and  condemns  it.  Alanson  described  it  iil  1774 ;  and  advises 
that  the  muscles  should  be  cut  obliquely,  as  in  the  amputation  of  the  thigh. 

1st.  Old  Process. — The  phrase  of  Garengeot  implies  the  simple  circular 
method.  The  artery  being  compressed  upon  the  first  rib  and  the  fleshy 
parts  drawn  up  by  the  assistant,  the  operator  incises  successively  the  integu- 
ments and  the  muscles  as  far  as  the  bone;  coilimiencing  at  three  fingers' 
breadth  below  the  acromion.  A  final  stroke  of  the  knife  detaches  the  head  of 
the  humerus  from  the  glenoides  cavity,  and  terminates  the  operation. 

2d.  Process  described  by  Bertrandi, — A  large  convex  bistoury  divides  trans- 
versely the  mass  of  the  deltoides  on  its  dorsal  face  at  some  distance  from  the 
acromion,  arrives  upon  the  biceps  muscle,  opens  the  capsula,  passes  behind  the 
head  of  the  humerus  after  having  dislocated  it,  and  finishes  the  division  of 
the  soft  parts  with  that  of  the  posterior  half  of  the  limb. 

3d.  M.  Cornuau,  formerly  a  pupil  of  the  military  hospitals,  has  proposed 
in  his  thesis  a  process,  founded  upon  the  same  principles  as  the  preceding. 
The  skin  being  divided  at  four  fingers'  breadth  from  the  acromion,  and 
drawn  up  by  Sie  assistant,  the  operator  passes  to  the  division  of  the  fleshy 
parts,  which  he  effects  by  a  single  stroke  carried  transversely  from  the  coraco- 
brachialis  as  far  as  the  tendon  of  the  teres  major,  causes  them  to  be  drawn  up, 
opens  the  articulation  and  passes  through  it  from  above,  grazes  the  neck  of 
the  humerus,  and  terminates  by  a  second  transverse  incision  which  connects 
the  two  extremities  of  the  first,  comprehends  the  vessels,  and  completes  the 
circular  incision. 

4th.  Process  of  Alanson  and  of  M,  Grsefe. — That  of  Alanson  presents  no 
peculiar  feature.  M.  Graefe,  however,  in  order  to  form  a  hollow  cone  with 
the  base  downwards  at  the  expense  of  the  muscles,  uses  the  wide  point  of  a 
knife  terminating  in  the  point  of  a  shield. 

5th.  Process  of  the  *^uthor, — I  have  repeated  all  the  varieties  of  the  circular 
method  upon  the  cadaver,  and  I  have  found  that  no  other  is  more  prompt,  or 
affords  an  incision  more  regular,  and  more  easy  to  unite  immediately.  The 
process  which  appears  to  me  to  embrace  the  most  advantages,  consists  in  dis- 
secting and  raising  the  skin,  without  touching  the  vessels,  to  the  extent  of 
two  inches ;  then  cutting  the  muscles  after  the  manner  of  M.  Cornuau  asSp^ 
near  as  possible  to  the  articulation,  through  which  the  knife  is  immediately 
passed,  and  finishes  with  the  division  of  the  triceps  and  of  the  vascular  packet, 
the  root  of  which  has  been  previously  seized  by  an  assistant. 

B.  Flap  Method, — ^The  different  processes  which  come  under  the  flap 
method,  may  be  arranged  in  two  classes ;  from  the  one  results  a  transverse 
wound,  the  other  produces  a  wound  the  greater  diameter  of  which  is  vertical. 

1st.  Transverse  Method,— Ea.ch  of  these  two  classes  forms,  in  some  sort,  a 
particular  method,  the  respective  advantages  and  inconveniences  of  which 
should  be  carefully  appreciated.  The  first  has  been  for  a  long  time  the  only 
one  employed,  and  includes  tlie  processes  of  Le  Dran,  Garengeot,  de  la  Faye, 
M.  Dupuytren,  M.  Lisfranc,  and  others. 

a.  Process  of  Le  Dran. — The  patient  is  seated  on  a  chair ;  the  assistant 
seizes  the  arm,  and  holds  it  moderately  extended  from  the  trunk.    With  a 
27 


210  NEW  ELEMENTS  OF 

narrow  knife  the  surgeon  incises  transversely  the  deltoides,  the  two  heads  of 
the  biceps  a  little  in  front  of  the  acromion,  then  the  tendons  which  attach 
themselves  to  the  head  of  the  humerus,  and  the  fibrous  capsule.  Whilst  the 
assistant  sways  the  arm  and  disjoints  the  extremity  upwards,  the  surgeon, 
keeping  the  knife  in  a  transverse  position,  passes  through  the  articulation, 
slides  the  instrument  behind  and  cuts  a  flap  of  three  or  four  inches  at  the 
expense  of  the  fleshy  parts  of  the  posterior  portion  of  the  limb,  and  comprising 
the  nervous  plexus,  the  vessels,  the  borders  of  the  axilla,  and  various  muscles. 

b.  Process  of  Garengeot. — The  mode  of  Garengeot  differs  in  three  points 
from  that  of  Le  Dran.  Instead  of  a  straight  needle,  he  advises  a  curved  one, 
which  is  passed  from  front  to  rear  through  the  flesh,  grazing  the  neck  of  the 
humerus,  so  as  to  compress  the  artery.  He  recommends  to  make  the  first 
incision  at  three  fingers'  breadth  from  the  acromion,  in  order  to  form  an  upper 
flap  at  the  expense  of  the  deltoid.  Finally,  in  finishing,  according  to  Le  Dran, 
with  an  axillary  flap,  he  allows  it  less  length  and  cuts  it  square,  so  that  it  may 
better  fit  the  deltoid  flap. 

c.  Process  of  La  Faye. — La  Faye  makes  no  previous  ligature  and  cuts 
but  one  flap ;  but  instead  of  leaving  it  below  he  forms  it  above,  in  the  form  of 
a  trapezium.  A  transverse  incision  is  first  made  above  the  inferior  attach- 
ment of  the  deltoid  muscle,  at  about  four  fingers'  breadth  from  the  summit 
of  the  acromion.  Two  other  incisions  which  he  then  commences,  the  one  on 
the  inside,  the  other  on  the  outside  of  that  process,  are  made  in  the  direction 
of  the  fleshy  fibres  to  meet  the  corresponding  extremities  of  the  first ;  the  flap 
dissected  and  raised  up,  permits  the  opening  of  the  articulation,  the  dislocation 
of  the  humerus,  the  exposure  of  the  soft  part  of  the  axilla,  and  the  ligature  of 
the  artery,  before  detaching  the  arm  from  the  ti-unk. 

d.  Process  of  M,  Dupuytren, — In  a  thesis  sustained  in  1803,  M.  Grobois 
advises  the  following  modification  of  the  process  of  La  Faye : — With  one 
hand  the  operator  takes  up  the  whole  thickness  of  the  parts  which  should  form 
the  superior  flap ;  with  the  other  he  pierces  them  at  the  base  of  the  deltoid 
with  a  small  knife  held  horizontally,  the  edge  of  which  should  be  directed  in 
front ;  he  then  cuts  the  flap  by  drawing  the  instrument  outwards  and  forwards, 
taking  care  to  allow  it  a  suflicient  length.  M.  Grobois  speaks  of  this  modifi- 
cation as  of  a  thing  which  belonged  to  him,  and  of  which  he  had  thought  a  long 
time  before.  But  it  is  probable  that  he  derived  the  idea  from  the  lectures  of 
M.  Dupuytren,  for  it  is  under  the  name  of  this  professor  that  the  process  is 
generally  known. 

e.  Process  of  M.  Onsenort. — Instead  of  being  formed  from  the  deeper  parts 
to  the  skin,  the  deltoid  flap  may  be  cut  in  the  opposite  direction  ;  that  is, 
from  the  integuments  towards  the  articulation,  from  its  apex  towards  its  base, 
assuming  as  before  a  semilunar  form.  This  manner,  which  does  not  sensibly 
differ  from  that  of  Garengeot,  is  yet  by  some  pupils  attributed  to  M.  Dupuytren. 
I  have  seen  M.  Dubled  and  Guersent,  junior,  practise  it  upon  a  dead  body 
with  great  address,  and  M.  Onsenort  exerted  himself,  in  1825,  to  bring  forward 
its  advantages.  Mr.  Cline,  of  London,  begins  by  compressing  the  artery  upon 
the  first  rib  ;  then  with  a  narrow  knife  he  makes,  at  the  expense  of  the  deltoid, 
a  flap  capable  of  covering  the  wound,  passes  through  the  articulation,  and 
divides  at  a  single  stroke  the  muscles  which  unite  the  arm  to  the  shoulder  and 
the  trunk.    Tins  process,  which  the  surgeon  of  London  has  practised  for  a 


OPr.KATIVE    SURGERY.  211 

long  time,  is  described  by  Dr.  Smith  (ia  Dorsej's  work)  in  a  manner  ex- 
tremely obscure,  but  it  very  mucli  resembles  the  preceding ;  and  I  can  say 
that  in  practising  it  according  to  this  idea,  I  found  that  the  operation  could 
easily  be  performed  with  a  rapidity  which  it  is  difficult  to  conceive. 

/.  Process  of  M.  Lisfranc  and  Champesme. — M.  Grobois  had  already 
suggested  that  another  advantage  would  be  derived  from  his  modification 
of  the  process  of  La  Faye,  by  contriving  to  open  the  superior  part  of  the 
articular  capsule  at  the  first  stroke.  M.  Lisfranc  and  Champesme  have 
made  this  remark  the  foundation  of  a  new  process.  The  arm  with  the  elbow 
somewhat  near  the  trunk,  is  carried  in  this  position  upwards  and  outwards. 
The  operator  being  placed  in  front  of  the  shoulder,  applies  the  point  of  the 
knife  to  the  triangular  space  which  has  been  above  described,  one  of  the  edges 
being  directed  upwards  and  forwards ;  plunges  it  through  the  soft  parts  and 
through  the  articulation  outwards  and  backwards  and  downwards,  so  as  to 
bring  it  out  at  about  an  inch  beliind  the  acromion ;  seizes  the  deltoides,  raises 
it  with  one  hand,  cuts  forwards  and  slightly  upwards,  turns  round  the  supe- 
rior part  of  the  head  of  the  humerus,  and  gradually  brings  the  edge  of  the 
instrument  to  a  direction  nearly  horizontal ;  sways  the  arm  from  the  trunk 
about  fifteen  or  twenty  degrees  as  soon  as  he  has  cut  about  an  inch,  and 
finishes  the  flap  as  in  the  processes  of  M.  Grobois  and  Dupuytren. 

g.  Bell  begins  by  a  circular  incision  four  inches  below  the  joint,  then  makes 
a  longitudinal  incision  on  each  side  so  as  to  form  two  flaps  after  the  manner 
of  Ravaton,  dissects  and  raises  these  flaps,  and  finishes  with  the  disarticu- 
lation. Of  all  these  methods,  the  most  prompt  and  simple  is  that  of  Mr. 
Cline  or  Onsenort;  but  then  it  is  difiicult  to  give  to  the  superior  flap  the  full 
extent  desired.  That  of  M.  Lisfranc,  which  follows  next,  would  be  still  more 
prompt  if  in  performing  it  unpracticed  surgeons  did  not  run  the  risk  of 
striking  against  the  head  of  the  humerus  or  of  the  acromion  with  the  point 
of  the  knife :  there  is  besides  a  risk  of  forming  a  flap  much  too  narrow  at  its 
base.  It  is  evident  that  if  we  are  content  with  one  flap  aboye,  the  process 
of  Dupuytren  or  that  of  Lisfranc  is  preferable  to  the  three  incisions  of 
La  Faye. 

2d.  Vertical  Method. — To  the  second  class  belong  all  those  processes  which 
aim  to  place  the  flap  before  or  behind,  or  to  form  one  in  each  of  these  situations. 

a.  Process  of  Sharp. — The  first  process  in  the  list  which  we  are  now  to 
begin  is  that  of  Sharp.  This  author  first  incises  the  skin,  the  deltoides,  and 
tlie  great  pectoral  muscle,  from  the  summit  of  the  acromion  to  the  hollow  of 
the  arm-pit,  in  such  a  way  as  to  expose  the  vessels  and  to  afford  an  opportu- 
nity of  tying  them.  He  then  passes  through  the  articulation  from  within 
outwards,  and  finishes  by  cutting  the  soft  parts  of  the  opposite  side,  so  as  to 
preserve  as  much  of  the  skin  as  possible. 

b.  The  Process  of  Bromfield  is  too  complicated  and  too  long  to  merit  a 
description  now,  although  it  belongs  properly  to  the  vertical  method. 

c.  Process  of  Pojet. — ^Pojet,  in  a  thesis  upon  the  disarticulation  of  the 
arm,  proposes  to  make  a  longitudinal  incision  from  the  summit  of  the  acromion 
to  the  vicinity  of  the  humeral  insertion  of  the  deltoid,  to  remove  the  lips  of  the 
incision  so  as  to  cut  the  articular capsula  and  the  tendons  which  surround  it; 
to  lux  the  head  of  the  bone,  and  finish  by  sliding  the  knife  between  it  and  the 
flesh  and  cutting  downwards. 


212  NEW  ELEMENTS  OF 

A  process  nearly  analogous  to  this  has  met  with  complete  success  in  the 
hands  of  Dr.  Dorsey  of  Philadelphia. 

d.  Instead  of  belonging  to  the  circular  method,  the  process  described  by 
Petit-Radelf  in  the  Encyclopedia,  is  nothing  more  than  that  of  Bell,  modified 
in  such  a  manner  that  one  of  the  flaps  is  on  the  inside,  the  other  on  the 
outside. 

e.  Process  of  Desault. — The  member  is  held  between  the  state  of  extension 
and  that  of  flexion,  and  is  directed  slightly  forwards.  The  surgeon  clasps 
with  one  hand  the  fleshy  parts  of  the  shoulder,  traverses  them  downwards  and 
backwards  with  a  narrow  knife,  grazing  the  head  of  the  humerus ;  forms  an 
internal  lambeau  three  or  four  inches  long,  which  includes  the  anterior  side 
of  the  axilla,  the  vessels  and  the  nerves,  and  which  the  assistant  raises  imme- 
diately, so  that  the  operator  may  pass  through  the  joint  from  front  to  rear,  or 
from  within  outwards,  and  finish  by  forming  a  posterior  or  external  flap 
similar  to  the  first. 

/.  Process  of  M.  Larrey. — In  operating  according  to  Desault,  you  divide 
the  artery  at  the  first  stroke,  and  that  may  occasion'serious  accidents,  if  from 
any  reason  the  amputation  cannot  be  promptly  finished.  M.  Larrey  thought 
it  better  to  begin  with  the  posterior  flap,  to  open  the  joint  from  the  outside, 
and  to  finish  with  the  internal  flap. 

g.  Another  process  of  M,  Larrey. — ^M.  Larrey,  who  has  so  often  performed 
this  disarticulation  in  the  army,  describes  another  process  for  effecting  it,  to 
which  he  ascribes  great  advantages.  He  cuts  at  first  through  the  whole 
thickness  of  the  cushion  of  the  shoulder,  in  the  direction  of  the  fibres  of  the 
deltoid,  and  to  the  extent  of  four  inches,  as  in  the  process  of  Pojet.  He  causes 
an  assistant  to  draw  asunder  the  lips  of  this  incision,  to  the  upper  end  of 
which  he  again  applies  his  knife,  and  pushes  it  through  from  above  downwards, 
so  as  to  make  it  emerge  in  front  of  the  posterior  edge  of  the  axilla,  and  cuts 
from  this  beginning  the  posterior  flap.  He  comes  back  to  the  same  point  as  at 
first,  and  cuts  in  the  same  way  an  anterior  flap;  leaving  between  the  two  the  soft 
parts  which  fill  up  the  cavity  of  the  axilla,  so  as  to  save  as  yet  the  artery  and 
the  nervous  plexus.  He  then  divides  the  deep  seated  tendons  and  the  capsule ; 
passes  through  the  articulation,  glides  the  knife  behind  the  head  and  neck  of 
the  humerus,  and  finishes  by  dividing  the  pedicle  between  the  basis  of  the 
flaps.     Hence  results  a  wound  of  nearly  an  oval  shape. 

h.  Process  of  M.  Dupuytren. — M.  Dupuytren  forms  the  posterior  flap  by 
cutting  from  the  surface  inwards,  from  its  apex  to  its  base,  and  then  com- 
pletes the  operation  in  the  same  way  as  M.  Larrey. 

i.  Process  of  M.  Delpech. — If  you  neglect  to  form  a  posterior  flap,  or  give 
it  but  little  length  ;  if  you  fall  almost  immediately  upon  the  external  face  of 
the  articulation  to  open  it,  pass  through  it,  and  finish  by  forming  a  large  in- 
ternal flap,  you  have  the  process  of  M.  Delpech. 

j,  M.  Hello  first  cuts  a  superior  flap,  like  M.  Dupuytren,  and  then  carries 
the  knife  between  the  shoulder  and  the  chest,  to  finish  the  operation  upon  the 
principles  of  the  circular  method. 

This  process,  says  he,  which  was  followed  by  M.  Fouilloy,  is  particularly 
applicable  where  the  humerus  is  broken  up,  or  when  displaced  fragments  of 
bone  render  the  formation  of  any  kind  of  flap  by  puncture  more  difficult  than 
usual. 


OPERATIVE    SURGERY.  213 

k.  Process  of  M.  Lisfranc. — To  avoid  the  reproach  cast  upon  his  first 
process  w^ithout  sacrificing  its  advantages,  M.  Lisfranc  has  the  arm  mode- 
rately extended  from  the  trunk ;  places  himself  on  the  outside ;  applies  the 
point  of  a  long  knife  in  front  of  the  posterior  border  of  the  axilla,  as  if  to  raise 
this  border  and  push  it  back ;  passes  through  the  whole  thickness  of  the  soft 
parts,  and  through  the  articulation  upwards  and  forwards,  bringing  out  the 
point  very  near  the  anterior  edge  of  the  acromion,  between  that  process  and  the 
carocoid ;  begins  to  cut  outwards ;  raises  the  arm  a  little,  and  inclines  it  a 
little  backwards ;  turns  with  the  blade  round  the  posterior  and  superior  half 
of  the  head  of  the  humerus,  and  cuts  from  there  his  posterior  flap ;  returns  to 
the  joint,  and  finishes  like  M.  Dupuytren  or  M.  Delpech. 

C.  Oval  Method. — It  would  be  easy  to  discover  the  origin  of  the  oval 
method  in  the  processes  of  Sharp,  Pojet,  Bromfield  and  Larrey.  At  all  events, 
it  does  not  belong  to  Beclard,  to  whom  it  is  ascribed  in  this  country,  nor  to 
Guthrie,  who  was  the  first  to  describe  it  in  England.  I  have  seen  it  distinctly 
announced  in  several  theses  of  the  school  of  Strasburg,  particularly  in  that 
of  M.  Blandin,  defended  in  1803,  and  still  more  clearly  in  that  of  M.  Chasley, 
who  even  uses  the  word  ovalaire  to  designate  the  form  of  the  wound.  The 
several  processes  which  it  admits  differs  but  little  from  each  other. — Mr, 
Guthrie  forms  a  V,  by  means  of  two  incisions  extending  from  the  acromion  to 
the  opposite  sides  of  the  axilla  close  to  the  chest ;  cutting  the  skin  first  and 
the  flesh  afterwards.  Beclard  and  M.  Dupuytren  cut  at  once  to  the  bone,  but 
in  both  processes  the  incision  should  be  somewhat  convex  forwards,  and  quite 
superficial  below,  to  save  the  vessels  until  after  the  disarticulation.  Prepa- 
ratory to  this  is  the  detachment  of  the  point  of  the  V  by  a  third  stroke.  The 
base  is  cut  oft'  by  the  last  stroke.  M.  Scoutetten  varies  from  this  process  only 
in  bringing  the  internal  incision  to  the  edge  of  the  axilla,  and  with  a  continu- 
ous motion  carrying  it  across  that  space  and  up  on  the  outside  to  the  point  of 
departure,  taking  care  in  passing  the  axilla  to  cut  only  the  skin. 

Process  adopted  by  the  Author. — First  Stage. — As  the  muscular  fibres  are 
cut  near  their  origin,  and  their  retraction  cannot  be  considerable,  it  is  right  to 
imitate  Mr.  Guthrie  in  first  cutting  the  skin  alone,  and  causing  it  to  be  drawn 
back  if  tlie  shoulder  is  covered  with  much  flesh,  otherwise  it  is  well  enough 
to  cut  at  once  to  the  bone.  Second  Stage. — The  point  of  delicacy  in  the  oval 
method  is  the  opening  of  the  capsule ;  if  the  bistoury  penetrates  too  deeply,  the 
fibrous  pouch  yields  and  folds  itself  like  a  wet  cloth,  and  is  mashed  rather 
than  cut :  if  it  fall  without  the  surgical  neck  of  the  bone,  the  ligamentous 
connexions  are  but  imperfectly  destroyed.  To  obviate  this  difficulty,  the 
surgeon,  while  the  lips  of  the  wound  are  held  apart,  should  seize  the  arm  with 
one  hand  and  make  the  head  of  the  bone  project,  turning  it  inwards  at  the 
same  time  on  its  axis ;  carry  a  sharp  bistoury  flatwise  between  it  and  the  flesh, 
and  then  turn  its  edge  at  right  angles  upon  the  capsule  at  the  level  of  the  sur- 
gical neck  of  the  bone,  and  then  cut  with  the  full  edge  all  the  tendons,  begin- 
ning with  the  teres  minor  and  ending  with  the  subscapularis,  taking  care  to  let 
nothing  escape ;  to  take  the  head  of  the  bone  for  the  support  of  the  incision, 
and  to  roll  it  on  its  axis  in  one  direction  as  the  instrument  is  drawn  on  the 
other.  In  this  way  the  articulation  is  freely  opened  and  the  arm  is  easily  dislo- 
cated, permitting  the  division  of  the  rest  of  the  capsule  by  the  bistoury  car- 
ried in  front,  behind,  and  within,  as  if  to  shave  the  bone.    In  the  third  stage,  the 


214  NEW  ELEMENTS  OF 

assistant,  behind  the  shoulder,  puts  his  thumb  upon  the  artery  in  front  of 
the  glenoid  cavity,  and  compresses  it  in  the  mass  of  flesh  left  between 
the  lower  exti'emities  of  the  incisions  already  made ;  while  with  a  small  knife, 
or  even  with  the  same  bistoury  which  has  served  him  thus  far,  the  surgeon 
cuts  through  the  base  of  the  V,  and  completes  the  separation  of  the  member 
from  the  trunk. 

;§  2.  Comparison  of  the  different  Methods, 

In  all  fiiese  processes  it  is  necessary  to  suspend  for  a  time  the  course  of 
blood.  Of  the  various  modes  of  effecting  this,  that  of  Le  Dran  or  Garengeot 
is  uncertain ;  that  of  La  Faye  and  others  almost  necessarily  includes  in  the 
ligature  parts  which  should  be  avoided ;  that  of  Sharp  increases  the  sufferings 
of  the  patient  and  the  length  of  the  operation.  The  compression  upon  the  first 
rib  is  not  always  applicable,  and  if  imperfectly  applied,  endangers  fatal 
hemorrhage.  A  method  more  sure  and  simple  is  to  divide  last  of  all  the  parts 
which  contain  the  vessels.  The  preparatory  ligature  of  the  siibclavian,  which 
has  been  performed  by  Dr.  A.  H.  Stevens,  in  1821,  cannot  be  required  except 
by  very  considerable  deformity.  I  do  not  know  who  first  proposed  the  mode 
which  I  have  recommended ;  but  it  was  not  until  within  twenty  years  that  it 
was,  upon  the  recommendation  of  M.  Richerand,  generally  adopted.  The  other 
arteries  which  it  is  sometimes  useful  to  tie,  are  the  acromial,  the  external  thora- 
cics,  the  circumflexes,  and  some  branches  of  the  subscapnlaris.  These  are  not 
commonly  tied  until  after  the  axillary,  but  if  they  bleed  profusely,  or  if  any- 
tliing  prevents  the  iminediate  completion  of  the  operation,  they  may  be  easily 
tied  as  fast  as  they  are  divided. 

In  so  many  different  processes,  there  is  no  one  which  merits  an  exclusive 
preference ;  no  one  that  will  not  arrive  at  the  end  proposed ;  nor  any  which  has 
tiot  its  peculiar  cases  to  which  it  is  better  adapted  than  any  other.  The  choice 
should  be  decided  by  the  circumstances  of  the  disease ;  stich  as  its  proximity 
to  the  joint ;  its  greater  advances  on  this  or  that  side,  or  above  or  below ;  the 
degree  of  motion  it  allows  to  the  joint,  or  the  position  in  which  it  arrests  the 
limbs.  But  it  is  at  the  bedside  that  the  skillful  surgeon  should  appreciate 
these  various  exigencies. 

But  then  supposing  that  nothing  in  the  state  of  the  parts  obliges  us  to  con- 
form to  any  one  mode  rather  than  another,  what  method  presents  the  greatest 
advantages  ?  Those  which  leave  a  transverse  wound  leave  also  too  great  a 
cavity  between  the  acromion  and  the  inferior  border  of  the  glenoid  cavity. 
The  celerity  of  M.  Lisfranc's  second  method  leaves  nothing  to  be  desired  in 
that  respect.  That  of  Desault,  modified  by  MM.  Larrey  and  Dupuytren, 
requires  but  little  more  time";  but  the  oval  method,  as  furnishing  a  wound 
incomparably  more  regular,  although  it  requires  more  skill  and  more  precise 
anatomical  knowledge,  is  yet  I  think  to  be  preferred.  With  practice  it 
becomes  easy,  and  I  have  seen  Doctor  Chomet,  of  Bordeaux,  complete  it  in 
thirty  seconds  upon  the  dead  subject.  I  know  none  but  the  circular  method 
of  Cornuau  or  my  own,  which  surpasses  it,  and  can  be  substituted  for  it  with 
advantage. 


OPERATIVE   SUROERT.  S)lf  ^ 


Art,  8. — Shoulder. 

History  and  Indications. — ^Four  patients  have  been  mentioned  bj  Cheselden, 
Carmichael,  Dorsej,  and  Mussey,  who  had  the  whole  shoulder  torn  away,  and 
jei  finally  recovered.  In  the  army  M.  Larrey  several  times  took  away  with 
the  arm  a  large  part  of  the  scapula  or  of  the  clavicle,  and  success  more  than 
once  rewarded  his  boldness.  M.  Clot  and  Mr.  Brice  removed  v^dth  the  arm  a 
portion  of  the  scapula,  and  Mr.  Cuming,  at  Antigua,  the  whole,  and  all  three 
with  sftccess.  The  amputation  of  the  shoulder  may  become  necessary  for  the^ 
preservation  of  the  arm.  Janson  has  published  one  instance,  M.  Beauchene 
operated  in  another,  and  Mr.  Lucke  in  a  third. 

Sometimes  this  operation  is  required  by  a  necrosis,  a  caries,  or  a  commi- 
nutive  fracture,  with  a  disorganization  more  or  less  extensive  of  the  soft  parts, 
when  a  simple  disarticulation  will  not  completely  remove  the  disease.  Some- 
times a  tumor,  i'ormed  of  abnormal  tissues,  which  comprehends  a  part  of  the 
arm  and  extends  beyond  the  joints.  Sometimes  the  tumor  or  morbid  change 
of  structure  occupies  only  the  scapula  and  the  tissues  about  it,  so  that  the 
arm  may  still  be  preserved. 

Manual. — In  the  first  case  the  diseased  bones  are  to  be  exposed  as  far  as 
the  limits  of  the  disease.  The  flaps  are  formed  and  managed  as  in  ampu- 
tation at  the  joint,  and  cut  in  this  or  that  direction,  according  to  the  state  of 
the  parts.  If  it  is  impossible  to  avoid  the  artery,  it  should  be  compressed  on 
the  first  rib  or  previously  tied.  The  saw  commonly  used  for  dividing  small 
bones,  or  chain-saw  of  Jeffreys,  may  then  be  applied,  to  cut  off  such  portions 
of  the  scapula  or  clavicle  as  may  require  removal.  In  the  other  two  cases 
it  would  be  difficult  to  lay  down  any  precise  general  directions.  The  surgeon 
must  rely  upon  his  own  resources  of  knowledge  and  invention. 


SECTION   II. 

Inferior  Extremity. 

Upon  the  inferior  extremity  the  amputations  are  generally  more  difficult 
and  more  serious  than  upon  the  thoracic  member.  They  will  be  treated  here 
as  they  are  performed  upon  the  foot,  the  leg,  the  thigh,  in  the  continuity,  and 
in  the  contiguity. 

jirt.  l.-^-The  Toes. 

It  is  not  with  the  toes  as  it  is  witli  the  fingers.  The  uses  to  which  the  latter 
are  applied  render  their  preservation  more  important,  and  their  length  admits 
of  partial  amputation.  But  the  former,  having  an  insignificant  office  to 
perform,  and  possessing  but  slight  extent,  maybe  taken  away  all  together 
without  affecting  essentially  the  functions  of  the  foot.  For  a  similar  reason 
we  scarcely  ever  amputate  one  or  two  phalanges  of  the  toes,  nor  a  part  of  the 
metatarsal  phalanx,  except  perhaps,  sometimes  that  of  the  great  toe. 

The  processes  to  be  followed  being  exactly  similar  to  those  prescribed  for 
the  amputation  of  the  fingers,  need  not  be  here  repeated.    I  will  only  remark. 


I, 


216 


NEW   ELEMENTS  OF 


that  the  natural  cavity  which  corresponds  to  the  dorsal  face  of  the  metatarso- 
phalangeal articulation,  and  the  projection  which  forms  the  sole  of  the  foot, 
render  the  amputation  of  the  toes  severally  more  difficult  than  that  of  the  fingers, 
and  that  the  oval  method  is  still  more  advantageous  to  the  appendices  of  the 
foot  than  to  those  of  the  hand.  The  amputation  of  two  or  three,  or  of  all  the 
toes  together,  should  be  performed  as  on  the  fingers,  in  the  way  recommended 
by  M.  Lisfranc,  It  is  neither  more  complicated  nor  more  difficult,  and  there 
is  the  same  chance  of  success.  But  there  are  few  injuries  so  severe  as  to 
comprehend  all  the  toes,  without  affecting  at  the  same  time  more  or  less  of 
the  metatarsus ;  yet  some  examples,  the  result  of  frost-bite  for  instance,  have 
been  recorded.  I  have  seen  in  La  Pitie  an  invalid  who  had  been  treated  in 
this  manner  nearly  forty  years  before,  by  La  Chapelle.  M.  Chaumet  has 
recently  published  an  instance  of  the  same  thing. 

Art,  2,'^Metatarsus, 

The  metatarsal  bones,  like  those  of  the  metacarpus,  are  amputated  either  in 
the  continuity,  in  the  contiguity,  separately,  or  collectively.  They  may  also 
be  extracted,  leaving  the  corresponding  toe. 

§  1.  In  the  Continuity, 

The  amputation  of  the  three  middle  nietatarsal  bones  in  continuity,  is  prac  - 
tised  frequently,  and  always  by  the  same  rules,  as  for  the  amputation  of  the 
corresponding  metacarpal  bones.  Some  surgeons  think  that  it  ought  to  be 
preferred  to  the  simple  disarticulation  of  the  toes.  Mr.  Thomas  for  example, 
maintained,  in  1814,  that  it  is  less  difficult  and  less  dangerous,  and  that  the 
deformity  which  results  from  it  is  less  obvious.  This  is  evidently  an  error. 
To  remove  a  metatarsal  bone,  it  is  necessary  to  divide  at  two  diiferent  strokes 
the  thickness  of  the  soft  parts  of  the  sole  of  the  foot,  disturb  some  of  the  tarso- 
metatarsal articulations,  and  produce  a  very  extensive  wound ;  while  the 
amputation  of  the  toe  is  finished  in  an  instant,  and  leaves  a  solution  of  conti- 
nuity, very  simple  and  easy  to  heal.  Thus  in  the  foot  as  in  the  hand,  and  for 
the  same  reason,  the  metatarsal  bone  must  not  be  touched,  unless  it  is  impos- 
sible to  remove  the  disease  by  amputating  only  the  toe. 

First  Metatarsal  Bone, — The  first  metatarsal  bone  is  an  exception  to  this 
rule.  From  the  time  of  Le  Dran  to  this  day,  most  surgeons  have  preferred 
dividing  it  behind  its  head  to  separating  it  at  the  joint.  Dislocating  the  toe 
they  say,  gives  birth  to  a  shocking  deformity ;  the  anterior  extremity  of  the 
bones  forms  a  considerable  projection,  which  rubs  painfully  against  the  shoe, 
and  only  impedes,  instead  of  aiding  the  functions  of  the  foot.  It  is  true  that 
the  deformity  is  less  evident  after  the  amputation  of  the  metatarsal  bone,  than 
after  the  simple  removal  of  the  toe.  But  it  is  undeniable  also  that  the  standing 
posture  is  more  difficult  to  maintain,  and  less  secure  in  the  former  cases  than 
in  the  latter.  In  this  point  of  view  then,  the  simple  amputation  of  the  great 
toe  is  to  be  preferred.  Other  practitioners,  and  among  them  M.  Gouraud,  are 
of  opinion  that  it  is  better  to  disarticulate  the  first  metatarsal  bone  than  to  saw 
through  it.  Le  Dran  has  already  pointed  out  the  disadvantages  of  this  method,  in 
endeavoring  to  give  pre-eminence  to  the  other,  which  is  since  generally  adopted. 


OPERATIVE    SURGERY.  217 

M.  Richerand  advised  to  cut  the  bone  obliquely  instead  of  transversely  across. 
After  the  disarticulation,  the  base  of  the  sore  presents  a  great  L,  the  hori- 
zontal branch  of  which,  formed  by  the  cuneiform  bone,  produces  a  troublesome 
projection  on  the  internal  side  of  the  foot.  The  operation  is  besides  less  easy, 
and  the  wound  more  difficult  to  unite  by  the  first  intention.  Amputation  in 
the  continuity  leaves  no  projection  on  the  internal  side  of  the  bone,  when  care 
has  been  taken  to  carry  the  saw  obliquely  from  behind  forwards.  It  does  not 
require  the  removal  of  so  great  a  quantity  of  the  parts,  nor  the  disturbance  of 
any  joint.  I  think  it  ought  to  be  preferred  whenever  the  disease  does  not 
compel  us  to  carry  the  instrument  up  to  the  tarsus.  Three  different  cases 
have  convinced  me  of  the  justness  of  these  rules. 

Manual. — As  it  is  difficult  to  draw  the  soft  parts  inwards  from  the  sole  of 
the  foot,  and  thrust  the  bistoury  downwards  between  the  bone  and  the  flesh ; 
and  as  it  is  nearly  impossible,  especially  in  doing  this,  to  preserve  to  the  flap 
the  regularity,  breadth,  and  length  desirable ;  I  prefer  making  the  incision  from 
without  inwards,  and  tracing  its  extent  and  form  by  dividing  the  skin  from 
behind  forwards,  first  on  the  dorsal  and  then  on  the  plantar  face,  to  near  the 
anterior  extremity  of  the  first  phalanx  of  the  great  toe,  and  then  raising  this 
flap  and  dissecting  it  back  from  its  apex  to  its  base.  This  done,  the  knife 
penetrates  the  first  interosseal  space,  pressing  outwards  with  its  point  the 
adherent  lip  of  the  first  incision;  grazes  the  peroneal  face  of  the  bone,  and  in- 
clines a  little  internally  to  avoid  the  corresponding  lip  of  the  incision  on  the 
sole  of  the  foot,  which  the  operator  at  the  same  time  draws  as  much  as  possible 
oiit  of  its  way.  The  tissues  are  then  divided  with  a  full  stroke  of  the  knife, 
which  is  brought  out  at  the  commissure  of  the  first  two  toes.  Carried  imme- 
diately back,  it  divides  all  the  parts  above  and  below,  within  and  without,  that 
may  yet  adhere  to  the  metatarsal  bone.  A  splint  of  wood  or  pasteboard,  or  even 
a  simple  compress  thickly  folded,  placed  in  the  bottom  of  the  second  wound, 
protects  the  flesh  against  the  action  of  the  saw.  The  operator  seizes  with  the 
left  hand  the  toe  and  the  articular  head  which  he  intends  to  remove,  causes  the 
foot  to  be  held  outwards,  applies  his  thumb  nail  to  the  place  where  the  division 
is  to  commence,  and  then  with  his  right  hand  armed  with  a  small  saw,  he  cuts 
the  bone  very  obliquely  from  its  internal  or  tibial  to  its  external  side,  and  from 
behind  forwards.  A  dorsal  or  interosseal  artery  of  the  metatarsus  and  one  or 
two  branches  of  the  plantar  arteries,  sometimes,  but  not  always  require  ihe 
ligature.  The  flap  is  brought  back  on  the  wound,  and  exactly  applied  and 
secured  by  strips  of  adhesive  plaster  and  a  convenient  bandage. 

B.  Fifth  Metatarsal  Bone, — The  last  bone  of  the  metatarsus  may  be  ampu- 
tated like  the  rest,  in  its  continuity ;  but  the  projection  which  it  forms  behind, 
the  inutility  of  what  might  be  preserved,  and  the  facility  with  which  it  is 
disarticulated,  together  with  the  slight  deformity  which  results  from  this 
operation,  gives  to  amputation  in  the  contiguity  a  general  preference.  This 
amputation  is  not  to  be  performed  like  the  preceding.  The  oval  method  is  more 
suitable.  But  if  you  do  not  wish  to  try  that,  it  will  be  necessary  to  pass  through 
the  last  interosseal  space  backwards,  with  the  bistoury  held  vertically  from 
the  commissure  of  the  fourth  and  fifth  toes  to  the  anterior  surface  of  the  oscu- 
boides ;  then  to  disarticulate  the  bone,  pass  from  its  dorsal  to  its  plantar  surface, 
disengage  its  head,  and  cut  a  flap  from  the  soft  parts  of  the  external  side  of 
the  foot,  long  and  wide  enough  to  cover  the  bntire  surface  of  the  wound. 


NEW   ELEMENTS   OF 


'•^tii^t' '^  ■•■■  •■ ''  '^^ 

C.  Extraction, — The  extraction  of  the  middle  bones  of  the  metatarsus 
would  be  performed  as  in  the  hand,  if  it  could  be  of  any  advantage.  The 
same  may  be  said  of  thejifth.  The  preservation  of  a  corresponding  toe  is  of 
too  little  im|)ortance  to  compensate  for  the  difficulties  of  sucli  an  operation. 
M.  Blandin-,  who  has  lately  endeavored  to  show  that  it  is  otlierwise  witli  the 
first  toe,  says,  that  after  amputation,  properly  so  called,  either  in  the 
continuity  or  in  the  contiguity,  the  foot  will  be  continually  turning  upon  its 
inner  side ;  and  quoting  an  instance,  which  appears  to  confirm  his  opinion, 
asks  whether  the  amputation  of  all  the  metatarsal  bones  be  not  preferable  to 
amputating  alone  the  bone  which  supports  the  great  toe.  Will  the  simple 
extraction,  as  he  believes,  prevent  these  inconveniences  ?  The  transverse 
metatarsal  ligament  preserves  some  firmness  in  the  position  of  the  great  toe, 
after  the  extraction  of  the  bone  which  naturally  supports  it.  The  sole  of  the 
foot  maintains  its  breadth  in  front,  and  station  and  progression  suffer  very 
little  from  such  an  operation,  which  M.  Barbier  contrived  in  1795.  Kot 
being  able  to  reduce  the  luxation  of  the  first  metatarsal  bone,  this  surgeon 
undertook  to  dislocate  it  and  remove  it,  preserving  the  great  toe.  M.  Beaufils, 
who  published  this  fact  in  1797,  said  the  patient  was  conxpletely  restored  at 
the  end  of  forty  days.  It  seems  to  me,  however,  that  there  is  a  mistake  upon 
this  subject;  that  after  the  extraction  of  the  first  metatarsal  bone  the 
deformity  would  be  greater  than  after  its  amputation,  and  that  the  toe  would 
be  liable  to  turn  inwards,  to  change  its  position,  and  to  interfere  with  the 
motions  of  the  foot.  On  the  other  hand,  it  is  not  .proper  to  affirm  that  the 
ordinary  amputation  is  generally  followed  by  the  inversion  of  the  foot.  It  is 
an  accident  indeed  that  may  happen,  but  more  frequently  does  not.  This 
proposition  is  supported  by  a  crowd  of  facts.  I  was  presented  with  a  new 
proof  of  it  in  1 829,  at  the  hospital  St.  Antoine.  I  amputated  after  the  common 
method  and  the  patient  soon  recovered.  I  saw  him  frequently  afterwards ; 
he  walked  continually,  and  did  not  even  take  the  trouble  to  thicken  the  sole 
of  his  shoe  on  the  inside.  I  have  since  seen  two  more  examples  at  La  Piiie, 
Before  affirming,  therefore,  that  the  extraction  of  the  first  metatarsal  bone 
should  be  preferred  to  its  amputation,  it  is  prudent  to  wait  for  further  facts. 
This  QjMiration  has  been  indicated  by  Hey,  of  Leeds.  **  When  the  caries  is 
confined  to  the  metatarsal  bone  of  the  great  toe,"  says  this  practitioner,  ♦*  it 
is  customary,  after  having  made  a  longitudinal  and  transverse  incision,  to 
remove  the  diseased  portion  with  the  saw.  But  as  it  is  sometimes  difficult  to 
ascertain  exactly  the  extent  of  the  caries,  it  is  better  to  separate  the  whole  of 
the  bone  at  its  junction  with  the  cuneiforme."  If  the  extraction  of  the  meta- 
carpal bones  has  received  general  approbation,  it  is  because  it  preserves  the 
fingers,  and  affects  but  little  the  form  and  valuable  uses  of  the  hand,  while 
neither  the  same  advantages  nor  the  same  results  are  to  be  expected  from  a 
similar  operation  on  the  foot.  The  method  of  operating  would  be  the  same, 
unless  some  complication  should  force  us  to  imitate  M.  Barbier. 

D.  Jill  the  Metatarsal  Bones. — Though  it  was  usual  with  surgeons  up  to  the 
time  of  Chopart,  to  amputate  the  leg  for  diseases  which  did  not  involve  the 
whole  foot,  they  yet  sometimes  confined  themselves  to  a  partial  amputation  of 
the  foot,  which  it  is  now  the  rule  to  amputate  as  near  the  toes  as  possible. 

According  to  F.  de  Hilden,  de  Verdue,  &c.,  the  partial  amputation  of  the 
metatarsus  could  not  have  been  unknown  to  the  ancients,  who  performed  it 


OPERATIVE    SURGERY.  fil9 

■with  the  chisel  and  mallet,  or  else  with  the  machine  of  Botal,  and  no  doubt 
only  in  the  continuity.  Sharp  has  proposed  that  a  little  saw  should  be  used, 
and  asserts  that  he  has  seen  it  once  executed  with  success.  Hey  proposed  it 
anew  towards  the  end  of  the  last  century,  and  alleged  that  in  the  case  of  a 
young  woman,  he  had  removed  the  first  four  toes  with  a  gi-eat  part  of  the 
corresponding  metatarsal  bones,  but  complained  of  the  length  of  time  it  took 
the  wound  to  heal.  M.  Lisfranc  also  has  advised  that  the  operation  should 
be  performed  particularly  on  young  persons,  because  in  infanrcy  the  bistoury 
may  take  the  place  of  the  saw.  M.  Raoul  in  1S03,  and  Mr.  Thomas  in  1814, 
again  brought  forwards  this  proposition  in  their  theses,  supporting  it,  I  think, 
on  very  good  reasons.  M.  Pezerat  has  once  practised  it  with  success.  I  do 
not  see  indeed  why  the  transverse  section  of  the  metatarsus  should  not  be 
performed,  rather  than  its  dislocation,  when  the  disease  permits  it. 

Manual. — A  small  knife  thj'ust  through  from  one  side  to  the  other,  grazing 
the  plantar  face  of  the  bones,  cuts  a  flap  of  the  proper  length  from  the  soft 
parts  of  the  sole.  By  a  semicircular  incision  inclined  a  little  forward,  the 
skin  on  the  dorsal  face  is  next  divided,  and  tlien  the  tendons,  some  lines  in 
advance  of  the  point ^here  the  saw  is  to  be  applied.  The  flesh  being  drawn 
back  by  an  assistant,  the  surgeon  successively  denudes  the  bones  with  the 
bistoury  at  the  base  of  the  flap,  so  as  to  render  easier  the  simultaneous  or 
successive  division  from  on<i  side  to  the  other,  or  from  the  back  of  the  foot  to 
its  sole,  M.  Pezerat's  process  is  to  make  three  flaps,  ^  dorsal,  a  plantar,  and 
an  internal  one.  This  Should  never  be  followed,  unless  the  pathological  state 
renders  the  former  process  inapplicable. 

In  Contiguity. 

Historical, — ^In  cases  where  the  state  of  the  foot  does  not  permit  the  sawing  of 
the  metatarsal  bones,  or  the  surgeon  does  not  wish  to  resort  to  tliis  operation, 
it  is  possible  to  dislocate  them  and  preserve  the  tarsus,  with  the  action  of  cer- 
tain very  important  muscles.  Garengeot  says,  *•  this  amputation  is  very 
troublesome,  since  it  has  to  do  with  a  number  of  junctions  which  are  not  in 
the  same  line.  To  conduct  the  bistoury  between  the  metatarsal  bones,  &c., 
cut  the  ligaments  which  unite  them,'and  save  as  much  of  the  skin  as  possible, 
is  all  the  direction  that  can  be  given,"  Le  Blanc  is  still  more  laconic.  *'  One 
can,  in  certain  cases,  amputate  a  part  of  the  foot,  saw  the  metatarsal  bones, 
and  even  separate  them  at  their  articulation,  as  several  practitioners  have 
alleged."  It  is  the  same  with  Brasdor,  According  to  Mr.  S.  Cooper,  it  was 
practised  in  England  by  Turner,  in  1787.  Percy  performed  the  same  ope- 
ration with  a  great  deal  of  trouble,  on  a  monk  of  Elairvaux,  in  1789.  It  is 
described  in  the  thesis  of  M.  C.  Petit  (1802).  M.  Berchu  attempted  it  with 
success,  in  1814.  M,  J.  B.  J,  A.  Blandin,  who  frequently  practised  it  in  the 
army,  gives  the  following  directions :  **  Carrying  the  knife  behind,"  he  says, 
*'  I  cut  the  skin  and  the  tendons  on  the  back  of  the  foot,  holding  the  edge  of 
the  knife  backwards,  and  making  it  glide  on  the  body  of  the  bones  back  to  the 
place  of  their  a.'ticulation,  so  as  to  preserve  a  small  dorsal  flap ;  then  I  divide 
all  the  ligaments  ;  afterwards,  with  the  point  of  the  instrument  conducted 
just  below  tlie  tarsus  through  the  articulation,  I  cut  the  connexions  and  am- 
putate the  whole  at  a  single  stroke  by  a  transverse  section,  preserving  as 


380  NEW   ELEMENTS   OF 

above  a  little  of  the  sole  of  the  foot,  to  form  a  second  flap."  The  directions 
in  M.  Plantade's  thesis  (1 805)  were  very  nearly  the  same.  But  it  was  neces- 
sary that  M.  Villerme,  and  more  particularly  M.  Li^franc,  should  make  it  the 
subject  of  an  especial  work,  which  they  presented  to  the  institute  in  1815,  to 
draw  to  the  disarticulation  of  the  metatarsal  bones  all  the  attention  it  deserves. 
In  merely  saying  the  amputation  is  diflicult,  we  only  deter  from  its  execution. 
There  was  lacking  an  explication  of  the  difficulties  and  of  the  means  of  obvi- 
ating them,  and  this  deficiency  has  been  happily  supplied  by  M.  Lisfranc. 
Anatomical  Remarks. — The  three  cuneiform  bones  united,  present  in  front 
^  a  kind  of  mortise  moderately  open,  which  is  exactly  filled  by  the  posterior 
extremity  of  the  second  metatarsal  bone.  The  interior  wall  of  this  cavity, 
formed  by  the  first  cuneiform,  is  about  four  lines  in  length  and  an  inch  high, 
while  the  external  wall  which  is  formed  by  the  last,  is  only  two  lines  in  extent 
from  before  backwards.  The  articulation  of  the  first  metatarsal  bone,  which 
is  consequently  two  or  three  lines  before  that  of  the  third,  is  less  narrow  than 
any  of  the  others ;  its  surfaces  are  so  disposed,  that  that  of  the  tarsus  are  a 
little  convex  to  suit  the  slight  concavity  of  the  other,  and  that  they  present  a 
"  doubly  oblique  plane,  first  outwards,  in  the  direction  of  a  line  which  would 
fall  near  the  middle  of  the  metatarsal  bone  of  the  little  toe,  and  secondly, 
downwards  and  forwards.  The  articulation  of  the  middle  metatarsal  bone, 
placed  transversely  like  that  of  the  second,  is  two  lines  in  front  of  the  bottom 
of  the  mortise  above  described. 

The  interline  of  the  fifth  is  oblique  inwards,  in  a  line  which  would  fall  upon 
the  middle  of  the  first  metatarsal  bone,  whilst  the  fourth  is  nearly  transverse 
at  its  external  part,  but  inclines  forwards  like  the  preceding  from  where  it 
tends  to  join  the  third,  one  or  two  lines  behind  which  it  is  commonly  found. 
As  the  second  metatarsal  bone  is  cased  between  the  bones  of  the  tarsus,  so  it 
is  seldom  that  the  third  cuneiform  is  not  wedged  likewise  in  a  kind  of  mortise 
one  or  two  lines  deep,  which  is  formed  by  the  third  metatarsal  bone  in  front, 
joined  on  either  side  with  the  second  and  the  fourth.  If  the  first  cavity  did 
not  exist,  the  second  would  also  be  wanting.  Indeed,  if  the  third  cuneiform 
bone  lay  in  the  same  plane  as  the  second  (which  scarcely  projects  in  front  of 
the  cuboidal  facet  of  the  fourth  metatarsal  bone),  the  articulation  throughout 
would  be  perfectly  regular.  In  fact,  this  disposition  is  met  with  sometimes, 
and  then  the  amputation  is  generally  very  easy.  But  frequently  too,  this  bone 
projects  so  far  as  to  be  nearly  on  a  line  with  the  first  cuneo-metatarsal  articu- 
lation. In  this  case,  the  two  mortises  are  equally  difficult  to  disunite.  Other 
anomalies  frequently  occur.  I  have  seen,  for  example,  the  anterior  internal 
face  of  the  cuboides,  pass  half  a  line  or  even  a  whole  line  beyond  the  meta- 
tarsal face  of  the  third  cuneiform  bone. 

On  another  subject,  the  two  last  metatarsal  bones  united,  presented  a  ridge 
of  which  the  crest  placed  vertically  was  buried  three  lines  deep  in  the  front 
part  of  the  cuboides,  and  this  in  both  feet  of  the  same  cadaver.  At  another 
time,  I  found  the  dorsal  edge  of  the  extremity  of  the  third  metatarsal  bone 
inclined  obliquely  backwards  to  the  extent  of  a  line  and  a  half,  upon  the  cor- 
responding cuneiform  bone.  Messrs.  Lisfranc  and  Zeigler  have  remarked 
that  the  tubercle  of  the  fifth  metatarsal  bone  is  sometimes  prolonged  to  a  line 
with  calcanear  articulation,  and  I  have  noticed  a  tubercle  in  the  form  of  exos- 
.    tosis  on  the  dorsal  face  of  the  second  cuneo-metatarsal  articulation,  on  per- 


OPERATIVE  SURGERY.  221 

8ons  who  are  in  the  habit  of  wearing  tight  boots.  Lastly,  many  of  these  joints 
may  have  suffered  anchylosis. 

There  is  no  necessity  for  a  description  of  the  dorsal  ligaments  that  connect 
the  tarsus  with  the  metatarsus,  either  an tero -posterior  or  transverse,  as  they 
are  mere  fibrous  bands  fixed  under  the  tendons,  without  penetrating  between 
the  articular  surfaces.  It  is  not  exactly  the  same  with  the  plantar  surface. 
There  almost  all  the  bones  terminate  in  a  kind  of  point  or  flattened  crest, 
which  by  permitting  them  to  incline  towards  each  other,  determines  the  trans- 
verse concavity  of  the  foot,  and  leave  between  them  small  triangular  spaces, 
filled  with  fibrous  masses.  One  of  these  masses,  that  which  unites  the  exter- 
nal face  of  the  anterior  prominence  of  the  first  cuneiform  to  the  internal  sur- 
face of  the  second  metatarsal  bone,  requires  great  attention.  Besides  being 
very  thick  and  strong,  and  formed  of  fibres  oblique  in  the  direction  of  the  first 
tarso-metatarsal  articulation,  it  is  especially  remarkable  from  its  vertical  ex- 
tent bounded  by  that  of  the  articulation  itself.  There  is  nothing  important 
to  notice  respecting  the  others. 

The  tarso-metatarsal  articulation,  viewed  as  a  whole,  presents  a  line  slightly 
convex  forwards,  the  extremities  of  which  nearly  correspond  to  the  middle  of 
the  space  between  the  malleolus  and  the  base  of  the  toes.  On  the  outside  it 
is  indicated  by  the  posterior  extremity  of  the  tubercle,  which  the  last  meta- 
tarsal bone  presents  under  the  skin.  It  is  also  very  easily  discovered  in  the 
inside,  by  observing  that  under  the  tegument  and  near  the  sole  of  the  foot, 
the  first  cuneiform  and  the  first  metatarsal  bone  have  each  a  prominence, 
leaving  a  depression  between  them  which  marks  the  beginning  of  the  articu- 
lation. A  line  transversely  drawn  from  its  external  extremity  to  the  internal 
side  of  the  tarsus,  falls  a  little  in  front  of  the  scaphoides,  about  three  quarters 
of  an  inch  from  the  internal  tarso-metatarsal  articulation.  Consequently, 
there  can  be  very  little  difficulty  in  knowing  its  situation  and  direction  before 
beginning  the  operation.  As  the  tendon  of  the  peroneus  longus,  in  passing  to 
its  attachment  to  the  inferior  or  plantar  tubercle  of  the  posterior  extremity  of 
the  first  metatarsal  bone,  generally  contracts  some  adhesions  with  the  third 
cuneiform  bone,  the  simple  disarticulation  of  the  metatarsal  bones  does  not 
necessarily  destroy  the  action  of  that  muscle.  It  is  the  same  with  the  anterior 
peronei  muscles  which  are  inserted,  at  least  in  part,  into  the  dorsal  face  of 
the  cuboides ;  and  with  the  anterior  and  posterior  tibial  muscles,  the  attach- 
ment of  which  is  not  severed  by  the  operation. 

Manual, — The  disarticulation  of  the  metatarsal  bones  is  certainly  the  most 
difficult  that  can  be  met  with.  The  usual  directions  are  to  make  use  of  the 
bistoury  and  saw  at  the  same  time. 

A.  Process  of  Hey. — In  1799,  Mr.  Hey  performed  the  following  operation 
on  a  young  girl  of  eighteen : — He  made  a  transverse  incision  about  half  an 
inch  to  the  front  of  the  articulations,  and  another  on  each  side,  from  the  cor- 
responding extremity  of  the  first  to  the  roots  of  the  first  and  fifth  toe.  He 
then  detached  all  the  soft  parts  of  the  sole  of  the  foot,  and  turned  them  back, 
to  form  a  flap.  After  having  disarticulated  the  last  four  metatarsal  bones,  he 
determined  to  remove  the  projection  of  the  first  cuneiform  with  the  saw :  the 
patient  was  perfectly  restored.  This  process,  may  no  doubt,  be  imitated ;  but 
it  is  evident  that  the  lateral  incisions,  and  the  precaution  of  forming  a  plantar 
flap  before  disarticulating  the  bones,  renders  the  operation  longer  and  more 


222  NEW    ELEMENTS   OF 

difficult.  In  saying  that  the  last  four  metatarsal  bones  are  found  on  the  same 
line,  Hej  seems  to  me  to  mean  that  the  posterior  facet  of  one  projects  but 
little  beyond  that  of  the  other,  and  not,  as  he  has  been  made  to  say,  that  they 
form  a  complete  transverse  line.  As  to  the  section  of  the  first  cuneiform,  I 
do  not  think  it  merits  the  reproach  that  is  of  late  attached  to  it..  Beclard, 
M.  Scoutetten,  and  even  M.  Lisfranc,  have  practiced  it  without  any  disadvan- 
tageous result. 

B.  Process  of  M.  J.  Cloquet. — After  the  soft  parts  of  the  dorsal,  face  of  the 
foot  have  been  divided,  M.  J.  Cloquet  prefers  sawing  the  bones  transversely 
instead  of  stopping  to  disarticulate  them.  I  do  not  see  why  it  would  be  more 
dangerous  than  the  simple  disarticulation.  A  priori  it  even  seems  that  it  would 
be  less  frequently  followed  by  serious  accidents.  The  tearing,  rather  than 
cutting  of  the  ligamentous  or  fibrous  tissues,  which  some  persons  dread,  seems 
to  threaten  less  inconvenience  than  the  wrenching  which  is  inflicted  upon  the 
articulation  of  the  tarsus,  in  separating  from  it  the  metatarsus  with  the  knife. 
It  is  yet  a  question  whether  the  surface  of  the  sawn  bones  is  as  well  adapted 
as  the  cartilaginous  surface,  for  the  immediate  union  of  the  wound.  This 
advice  appears  to  have  beeix  given  by  M.  J.  Cloquet  only  for  the  use  of  those 
who  have  not  been  able  to  become  sufficiently  familiar  with  the  tarso -metatar- 
sal disarticulation^ 

C^  Process  of  M.  Lisfrant.- — I  do  not  here  notice  the  process  of  M.  Vil- 
lerme,  since  he  was  himself  the  first  to  speak  in  decided  preference  of  that  of 
M.  Lisfranc. 

First  Stage. — During  the  whole  of  this  operation  a  narrow  firm  knife  is> 
used.  A  good  bistoury  nevertheless  may  serve  until  the  plantar  flap  is  to  be 
cut.  If  the  surgeon  is  ambidexter,  the  rule  is  to  begin  always  with  the  exter- 
nal side  of  the  foot,  consequently  carrying  the  knife  with  the  right  hand  for 
the  right  member,  and  with  the  left  hand  for  the  left;  otherwise,  he  commences 
in  this  last  case  on  the  internal  side  of  the  metatarsus.  The  patient  is  placed 
on  a  table,  or  on  a  bed  properly  pillowed.  An  assistant,  holding  the  lower  part 
of  the  leg,  compresses  the  posterior  tibial  artery  behind  the  internal  malleolus 
and  the  anterior  tibial  on  the  instep,  at  the  same  time  that  he  draws  back  the 
skin  from  this  latter  part.  The  surgeon  ascertains  first,  by  sliding  his  fore- 
finger backwards  along  tlie  dorsal  and  external  side  of  the  fifth  metatarsal 
bone  and  of  the  internal  and  plantar  face  of  the  first,  the  two  extremities  of 
the  articular  line ;  he  fixes  the  thumb  and  index  finger  of  one  hand  on  the 
tubercle  of  each  of  these  bones,  embracing  the  end  of  the  foot  underneath, 
according  to  some,  or  on  its  dorsal  face  according  to  others,  and  as  I  prefer  it 
myself,  in  order  to  act  with  more  ease  on  all  the  metatarsal  bones.  With  the 
other  hand  armed  with  a  knife  he  makes  a  semicircular  incision  convex  for- 
wards, the  extremities  of  which  should  fall  upon  the  two  tubercles  indicated 
by  the  fingers,  and  which  divides  or  should  divide  only  the  skin  and  subjacent 
cellular  membrane.  The  teguments  being  drawn  back  the  instrument  is  reap- 
plied in  the  first  incision,  in  order  to  divide  the  extensor  tendons  and  other  soft 
parts  which  may  remain  over  the  bones  at  the  edge  of  the  retracted  skin,  and 
so  that  this  second  incision  may  correspond  to  the  articular  line.  It  is  import- 
ant in  arriving  at  the  side  of  the  foot,  to  be  careful  not  to  descend  too  low 
towards  its  plantar  surface,  for  fear  that  in  ending  the  operation  the  base  of 
the  flap  should  be  curtailed  of  its  necessary  breadth. 


OPERATIVE    SURGERY.  223 

Second  Stage, — If  the  cuboido -metatarsal  articulation  have  not  been  opened 
with  the  stroke  which  divided  the  tendons,  it  may  be  penetrated  by  carrying 
the  point  of  the  knife  behind  the  tubercle  of  the  fifth  metatarsal  bone,  in  the 
direction  of  a  line  which  would  fall  obliquely  in  front,  first  on  the  head,  then 
on  the  middle  part,  then  on  the  posterior  extremity  of  the  first  metatarsal 
bone,  being  placed  almost  transversely,  on  arriving  at  the  fourth,  inclined 
again  in  front  on  entering  the  articulation  of  the  third,  which  is  separated  by 
carrying  the  knife  transversely.  The  second  metatarsal  bone  generally  pre- 
vents the  knife  from  penetrating  any  further  in  that  direction.  It  is  then 
withdrawn,  and  applied  with  the  point  upwards  to  the  inside  of  the  foot,  so  as 
to  pass  obliquely  inwards  and  forwards  through  the  articulation  of  the  first 
metatarsal  bone.  The  surgeon  then  places  the  knife  perpendicularly,  with 
the  point  downwards  and  the  edge  turned  backwards,  or  on  the  internal  side 
of  the  before -mentioned  mortise ;  he  thrusts  it  towards  the  sole  of  the  foot  at 
the  angle  made  by  the  caseous  faces ;  then  pressing  on  the  handle,  so  as  to 
sway  it  back  and  forth,  divides  the  thick  ligament,  called  by  M.  Lisfranc  the 
key  of  the  articulation,  draws  it  out  again  to  seek  the  posterior  articulation  of 
the  second  metatarsal  bone.  For  this  purpose  he  places  the  point  horizon- 
tally across  the  superficial  face  of  this,  bone,  and  as  the  articulation  is  never 
more  than  three  lines  behind,  it  is  easy  to. open  into  it  by  cutting  at  every  half 
line  from  the  middle  articulation,  which  is  already  exposed,  until  it  is  found. 

After  this  has  been  done,  all  the  osseous  surfaces  separate,  and  the  point  of 
the  knife  sliding  among  them  easily  divides  the  rest  of  the  ligaments. 

Third  Part. — Nothing  more  is  to  be  done,  except  to  form  a  flap  by  grazing 
the  plantar  face  of  the  bones  as  far  as  the  metatar  so -phalangeal  articulations. 
This  flap  should  not  end  square  but  obliquely,  and  should  be  slightly  rounded 
at  its  digital  extremity  and  not  transverse,  in  order  to  correspond  to  the  semi- 
circular curve  of  the  dorsal  side  of  the  stump.  To  avoid  leaving  the  internal 
side  of  the  flap  thinner  than  the  external,  care  must  be  taken  in  cutting  it  to 
keep  the  handle  of  the  instrument  more  elevated  than  the  point ;  and  in  order 
that  the  phalangeal  head  of  the  metatarsal  bones,  especially  the  first,  should 
not  arrest  the  blade  of  the  instrument,  it  is  important  to  incline  the  edge  de- 
cidedly and  in  good  time  towards  the  skin» 

i)re.55?Vio».— ^The  arteries  divided  are  the  plantar,  internal  and  external,  the 
anterior  tibial,  and  some  other  secondary  branches  of  littie  importance.  The 
principal  flap  when  applied  against  the  articular  surface,  ought  to  cover  it 
exactly,  and  to  fit  with  its  edge  the  small  flap  preserved  on  the  dorsum  of  the 
foot.  If  in  this  last  direction  the  teguments  had  been  divided  to  a  level  with  the 
articulations,  the  bones  of  the  tarsus  would  be  found  naked  immediately  after- 
wards^ As  the  tendons  retract  less  than  the  skin,  if  they  were  to  be  sepa- 
rated at  the  same  stroke,  their  ends  would  remain  fr^e  between  the  sides  of 
the  wound  and  obstruct  its  reunion.  It  would  be  better  in  this  ease  to  cut 
them  again  with  the  scissors.  In  order  to  maintain  more  firmly  the  coaptation 
of  tlie  parts,  the  adhesive  straps  should  be  stretched  from  the  posterior  internal 
and  inferior  surface  of  the  heel,  to  the  wound,  then  along  the  back  of  the  foot, 
around  the  lower  part  of  the  leg,  or  at  least  as  far  as  the  parts  about  the  mal- 
leolus. The  patient  should  be  placed  on  his  bed,  so  that  the  leg  and  foot  on 
which  the  operation  has  been  performed  may  be  turned  on  their  external  side^ 
and  as  completely  relaxed  as  possible.    Here,  more  particularly  thaa  after 


224 

any  other  amputation  of  the  extremities,  regular  and  uniform  compression 
applied  from  the  limits  of  the  third  part  of  the  leg  down  to  the  wound,  will  be 
the  best  means  to  prevent  the  development  of  inflammation,  synovial,  venous, 
or  of  any  other  kind. 

D.  Process  of  M.  Maingault. — The  method  of  M.Maingault  in  this  case  is 
exactly  analogous  to  that  which  he  proposed  for  the  disarticulation  of  the  meta- 
carpus. Though  practicable,  it  appears  to  me  to  be  in  all  respects  less  advan- 
tageous, and  more  difficult  than  the  preceding,  and  consequently  to  be  useful 
only  in  cases  where  that  is  impracticable. 

Art,  3. — Amputation  of  a  part  of  the  Tarsus, 

Tlie  three  cuneiform  bones,  the  cuboides,  the  scaphoides,  are  generally 
removed  at  the  same  time.  Nevertheless,  if  the  cuboides  alone  is  affected, 
with  the  two  metatarsal  bones  which  it  supports,  we  may,  like  Hey,  remove 
only  the  external  third  of  the  foot.  Unless  there  is  an  absolute  necessity,  the 
whole  of  the  metatarsus  should  not  be  amputated  in  the  articulation.  The 
operation  should  be  limited  to  the  disarticulation  of  the  diseased  bones.  The 
fourth  and  fifth  metatarsal  bones,  for  example,  may  be  amputated  by  them- 
selves with  as  much  facility  as  the  corresponding  metacarpal  bones ;  it  is  the 
same  with  the  first  two.  Some  observations  published  by  M.  Miarault,  in  1824, 
and  collected  during  the  attendance  of  Beclard,  at  La  PitiCy  showing  the  just- 
ness of  these  assertions,  have  fully  confirmed  what  experiments  made  on  the 
dead  subject  had  already  rendered  probable. 

The  amputation  between  the  os-calcis  and  the  astragalus  on  one  part,  and 
the  scaphoides  and  the  cuboides  on  the  other,  is,  like  that  of  the  metatarsus,  an 
operation  of  which  no  trace  is  found  among  the  ancients;  and  which  would 
have  belonged  entirely  to  France  if  F.  de  Hilden  had  not  pointed  it  out  with 
sufficient  clearness,  since  M.  Chopart  was  the  first  that  positively  described 
it ;  and  the  operation  has  since  been  improved  only  in  France. 

Anatomical  Remarks. — The  articulation  traversed  by  Chopart,  is  much  less 
complicated  and  less  difficult  to  disunite  than  the  preceding.  The  four 
osseous  surfaces  of  which  it  consists  possess  some  mobility,  and  are  far  from 
being  so  closely  connected  as  those  of  the  tar  so -metatarsal  articulation.  The 
rounded  head  of  the  astragalus  is  retained  in  the  cavity  of  the  scaphoides  only 
by  some  loose  fibre ->cellular  bands.  Outside,  and  on  the  dorsal  face,  it  has 
the  same  kind  of  attat^hments  to  the  calcaneum  and  the  cuboides.  The  strongest 
and  most  important  ligament  of  this  articulation  is  that  which  goes  deeply 
from  the  os-calcis  to  the  peroneal  extremity  of  the  scaphoides,  and  which  may 
also  be  called  the  key  of  the  articulation.  The  articular  line  is  divided  here 
into  two  very  distinct  portions.  Its  internal  half  represents  a  half-moon,  re- 
gularly convex  forwards.  Its  external  or  calcanear  half  presents,  on  the 
contrary,  a  plane,  oblique  outwards  and  forwards,  in  such  a  manner  that  in 
connexion  with  the  other  it  forms  quite  a  deep  sinus,  that  seems  continuous 
with  the  dorsal  excavation  of  the  os-calcis,  and  into  which  it  is  easy  to  stray 
at  the  time  of  the  operation,  if  its  disposition  is  not  exactly  remembered.  Like 
that  of  the  metatarsus,  the  articulation  of  the  bones  of  the  tarsus  among 
themselves  is  very  concave  and  unequal  on  its  plantar  aspect,  where  the  sca- 
phoides and  the  cuboides  present  a  projection  which  ought  not  to  be  forgotten 


OPERATIVE   SURGERY.  2£5 

in  the  separation  of  the  soft  parts  from  those  bones.  Its  internal  extremity  is 
marked  by  a  slight  depression,  which  is  bounded  behind  by  the  tuberosity  of 
the  calcaneum,  and  in  front  by  the  corresponding  tubercle  of  the  scaphoides, 
which  last  projection  prevents  any  groping  for  the  articulation  of  the  astra- 
galus and  naviculare.  On  the  dorsum  of  the  foot  the  articulation  in  question 
is  indicated  by  a  slightly  depressed  line,  which  may  be  felt  with  the  finger  in 
front  of  the  head  of  the  astragalus.  The  tendon  of  the  tibialis  posticus  is 
attached  to  the  internal  and  inferior  tubercle  of  the  scaphoides,  and  the  tibialis 
anticus  to  the  first  cuneiform  bone. 

As  the  tendon  of  the  peroneus  longus  passes  under  the  cuboides,  the  re- 
moval of  the  last  five  bones  of  the  tarsus  necessarily  destroys  the  attachments 
of  these  three  muscles,  while  the  disarticulation  of  the  metatarsus  permits  us 
to  preserve  them.  Some  anomalies  may  change  the  value  of  these  data. 
Sometimes  the  tuberosity  of  the  scaphoides  is  scarcely  appreciable.  In  other 
cases,  there  may  be  in  the  passage  of  the  tendon  of  the  tibialis  posticus  a  sesa- 
moid bone,  which  will  in  a  great  measure  fill  up  the  articular  depression.  M. 
Prichon  has  been  remarked  that  the  calcaneo-scaphoid  ligament,  or  the  articular 
key,  mentioned  above,  is  sometimes  transformed  into  a  cartilaginous  epiphyses, 
and  afterwards  become  completely  osseous,  even  on  very  young  persons.  He 
has  met  this  frequently,  and  subjected  one  example  of  it  to  the  inspection  of 
the  professors  of  the  faculty  in  defending  his  thesis. 

We  may  conceive  the  difficulties  which  such  an  anomaly  throws  in  the  way 
of  the  operator.  It  was  this,  no  doubt,  that  produced  the  anchylosis  which  Sir 
A.  Cooper  was  obliged  to  break  in  order  to  finish  a  partial  amputation  of  the 
foot;  and  that  mentioned  by  M.  Ficher,  and  which  would  have  yielded  only 
to  the  saw,  if  it  had  been  necessary  to  amputate  during  life.  M.  Plichon  re- 
marked, and  very  justly,  that  the  head  of  the  astragalus  projects  beyond  the 
plane  of  the  anterior  face  of  the  calcaneum,  more  in  some  cases  than  in  others ; 
and  that  the  calcaneo-cuboidal  articulation  is  then  less  oblique  forwards. 

Operation. — The  modes  of  disarticulating  the  scaphoides  and  the  cuboides, 
can  vary  only  in  the  most  unimportant  details.  Chopart,  who  was  not  guided 
by  the  present  anatomical  data,  thought  it  very  difficult.  It  is  true,  that  in 
1779,  a  celebrated  surgeon  of  Paris  was  nearly  three  quarters  of  an  hour  in 
completing  it,  though  he  had  before  his  eyes  at  the  time  the  foot  of  an  arti- 
culated skeleton ;  but  since  M.  Richerand  and  Bichat  showed  that  the  pro- 
jection of  the  internal  extremity  of  the  scaphoides  may  be  felt  under  the 
skin,  the  difficulties  which  formerly  accompanied  the  operation  have  been 
removed,  and  it  is  now  one  of  the  easiest  in  surgery. 

1st.  Process  of  Chopart. — The  position  of  the  limb  and  that  of  the  surgeon 
should  be  the  same  as  for  the  preceding  disarticulation.  A  transverse  incision 
is  first  made  two  inches  in  front  of  the  malleolus.  At  the  extremities  of  this 
incision  two  smaller  ones  are  made ;  the  trapezoid  or  quadrilateral  flap  which 
results  is  dissected,  and  turned  back  towards  the  leg.  The  operator  opens 
the  articulation  from  the  internal  side  of  the  foot  towards  the  external,  and 
in  passing  through  it  divides  the  calcaneo-scaphoidean  ligament;  arrives  at 
the  plantar  face  of  the  scaphoides  and  cuboides,  and  finishes  by  cutting  the 
flap  as  far  as  the  heads  of  the  metatarsal  bones. 

2d.  Process  of  M.  Richerand. — Messrs.  Walther  and  Graefe,  still  describe 
the  partial  amputation  of  the  foot  in  the  same  manner  as  Chopart,  although 
29 


NEW  ELEMENTS  OF  . 

the  modification  proposed  by  Bichat  and  M.  Richerand  had  been  adopted  for 
some  time  in  France ;  that  is,  instead  of  forming  the  dorsal  flap  by  three  inci- 
sions, to  make  one  semicircular  incision  convex  forwards,  which  is  placed 
only  a  few  lines  in  front  of  the  articulation.  Klein  and  Lisfranc  have  pro- 
posed to  draw  it  directly  over  the  articulation. 

3d.  Process  of  M.  Maingault. — M.  Maingault  proceeds  from  the  plantar 
to  the  dorsal  face,  in  disarticulating  the  bones  of  the  tarsus  from  one  another, 
the  same  as  in  removing  the  metatarsus  and  metacarpus,  and  thinks  that  this 
process  should  be  adopted,  at  least  as  an  exceptionary  method.  On  that 
point,  I  am  entirely  of  his  opinion. 

Remarks. — It  is  superfluous  to  discuss  the  relative  importance  of  these 
varieties  of  the  general  operations.  All  may  find  their  application  in  practice, 
if,  for  example,  there  are  soft  parts  only  on  the  dorsal  face  susceptible  of  being 
preserved ;  it  is  evident  that  the  flap  should  be  taken  from  those  parts  entirely, 
or  from  the  inferior  part,  if  the  teguments  on  the  back  of  the  foot  are  disor- 
ganized up  to  the  leg.  If  there  is  not  enough  of  the  healthy  tissues,  either 
above  or  below,  singly  to  form  a  flap  capable  of  covering  the  wound,  I  do 
not  see  why  two  of  equal  extent  should  not  be  cut.  But  if  the  sole  of  the 
foot  be  not  too  far  disorganized,  Bichat's  plan  is  certainly  the  best  and  most 
rational. 

4th.  Process  adopted  by  the  Author. — 'First  Stage.-^~Wh\\e  the  assistant 
compresses  the  arteries  and  draws  back  the  integuments,  the  surgeon 
embraces  with  one  hand  the  back  of  the  foot,  in  such  a  manner  that  his  fore- 
finger presses  upon  the  tubercle  of  the  scaphoides,  and  with  a  little  knife  in 
the  other  hand  makes  an  incision  slightly  convex  in  front,  the  extremities  of 
which  correspond  to  the  extremities  of  the  articular  line,  and  which  he  carries 
from  the  internal  to  the  external  side  of  the  foot,  for  both  feet  if  he  is  ambi- 
dexter ;  otherwise,  from  the  external  to  the  internal  side  for  the  left  foot. 
After  having  caused  the  tissues  to  be  withdrawn,  and  carried  the  instrument 
back  to  the  bottom  of  the  wound,  he  divides  in  the  same  direction,  near  the 
retracted  skin,  the  tendons  and  the  other  layers  which  still  cover  the  osseous 
surfaces,  and  generally  opens  the  articulation  by  this  second  stroke : 

Second  Stage. — If  not,  then  after  again  assuring  himself  of  the  situation  of 
the  scaphoidean  tubercle,  he  cuts  from  within  outwards  all  the  ligaments  on 
the  dorsal  face  which  unite  the  scaphoides  to  the  astragalus,  without  endea- 
voring to  penetrate  the  articulation,  as  the  head  of  this  last  bone  would  prevent 
this.  He  describes  in  this  way  a  semicircle,  taking  care  not  to  prolong  the 
external  branch  too  far  behind,  but  on  the  contrary,  in  order  to  detach  the 
cuboides ;  to  incline  the  edge  of  the  knife  first  transversely,  then  a  little  for- 
wards ;  and,  as  soon  as  the  surfaces  are  sufliciently  separated,  to  divide  the 
thick  fibrous  mass  which  unites  the  calcaneum  to  the  scaphoides,  and  finally 
to  arrive  at  the  plantar  side  of  the  articulation. 

Third  Stage. — The  operator  then  directs  the  edge  of  the  knife  forwards 
along  the  inferior  face  of  the  tarsus,  and  cuts  the  plantar  flap ;  lowering  his 
wrist  for  the  left  foot  or  raising  it  for  the'right,  so  that  the  flap  may  not  be 
thinner  on  the  inner  edge  than  on  the  outer,  and  prolongs  it  more  on  the 
internal  side  than  on  the  external,  because  the  astragalus  ascends  towards 
the  leg  higher  than  the  os-calcis.  As  the  vertical  thickness  of  the  osseous 
surfaces^  here  exposed  is  much  greater  than  after  the  disarticulation  of  the 


OPERATIVE  SURGERY.  227 

metatarsus,  the  flap  ought  to  be  extended  in  front  as  fer  as  in  that  operation, 
although  this  is  commenced  nearly  two  inches  farther  back. 

Dressing,^— To  tie  the  arteries  as  fast  as  they  are  opened,  as  Chopart  has 
advised,  is  a  useless  precaution.     After  the  operation,  the  anterior  tibial  and* 
the  two  plantars  are  all  that  require  attention.     The  dorsal  integuments  are? 
also  brought  forwards. 

The  plantar  flap  is  applied  against  the  cartilaginous  surfaces,  and  retained 
there  by  long  strips  of  diachylon,  and  by  a  rolled  bandage  accurately  applied. 

*^rt.  4. — Comparison  of  the  two  partial  imputations  of  the  Foot. 

Since  skillful  surgeons  have  shown  that  it  is  possible  to  disarticulate  the 
metatarsus  as  well  a&the  anterior  range  of  the  tarsus,  it  has  been  asked  which 
of  these  two  operations  should  be  preferred.  This  question  should  not  have 
been  raised ;  they  are  not  intended  to  supersede  one  another.  Each  of  thenv 
has  its  special  applications ;  and  if  there  be  any  diff*erence  between  them  as  io.^ 
difficulty,  pain,  and  danger,  it  is  not  sufficient  to  countervail  the  rule  before^ 
laid  down — to  amputate  as  near  the  toes  as  possible. 

»^rt.  5. — Extraction  of  some  of  the  Bones  of  the  Tarsus.         ^^p 

Many  surgeons  extract  the  astra2:alus,  and  thus  preserve  the  use  of  the  foot 
and  leg.  Cases  are  related  by  Dupuytren,  Despeaux,  Fallot,  Dassit,  Charley^f^ 
Lockeman,  and  Modesti.*  But  it  is  only  in  case  of  luxation,  with  laceration 
of  the  soft  parts,  that  such  an  operation  is  necessary.  As  the  same  condition 
of  the  parts  is  seldom  found  in  two  different  cases,  it  is  impossible  to  give 
fixed  rules  for  operating.  We  must  be  governed  by  existing  circumstances  : 
observing  at  all  times  to  divide  as  few  tendons  as  possible,  and  to  operate- 
before  general  reaction  manifests  itself,  and  as  soon  as  possible  after  the  acci- 
dent. The  cuboid,  scaphoid,  and  great  cuneiform  bones,  may  each  be  removed 
when  they  cannot  be  preserved,  as  in  a  case  of  luxation  complicated  with 
caries  or  necrosis.  Here,  too,  the  surgeon  must  also  be  governed  by  the  cir- 
cumstances of  each  case. 

v^r/.  6. — Extraction  of  the  foot. 

Besides  the  rule,  in  other  respects  so  just,  that  we  should  only  remove  the 
least  possible  of  parts,  surgeons  have  asked  if  the  disarticulation  of  the  foot 
ought  not  to  be  preferred  when  it  may  prevent  the  amputation  of  the  leg  ?  if 
after  this  disarticulation  it  will  not  be  possible  for  the  patient  to  walk  with  a 
peculiar  shoe,  a  sort  of  half-boot,  which  will  conceal  his  deformity  ?  It  has  been 
performed  once  with  success  by  Sedillier.  He,  Laval,  and  Brasdor,  affirm 
that  the  cicatrix,  which  was  quickly  formed,  neyei?  reopened  during  the  twelve 
years  that  the  patient  subsequently  lived.  Hippocrates,  F.de Hilden,  and 
Scultetus  seem  also  to  have  thought  of  it,though  very  vaguely.  Since  then  others 
have  again  proposed  it,withoutsucceedinghowever  in  introducing  it  into  prac- 
tice. The  projection  which  the  tibial  malleolus  presents,  would  prevent  the 
cicatrix  according  to  some,  from  supporting  the  weight  of  the  body  after  the  cure* 

•  In  the  case  of  the  patient  treated  by  Dr.  A.  H.  Stevens,  in  1826,  the  tibio-tarsal 
articulation  remained  movable,  and  the  foot  but  slightly  disfigtired. 


2S8  NEW   ELEMENTS   OF 


m 


The  want  of  soft  parts  and  the  numerous  tendons  that  surround  the  articu- 
lation, not  permitting  us  to  expect  immediate  union,  must  beget  strong  fear  of 
serious  consequences.  But  are  not  the  most  of  the  dangers  and  difficulties 
imaginary  ?  It  is  certain,  as  Brasdor  has  already  observed,  that  the  mal- 
leolar points  soon  become  blunted,  and  the  whole  extremity  of  the  member 
rounded ;  and  that  it  is  possible  to  save  skin  enough  to  cover  a  great  part  of 
the  wound.  Some  theoretic  objections  which  have  been  advanced  are  not  a 
sufficient  basis  for  a  definite  opinion  in  such  a  case,  and  I  think  that  if  favor- 
able circumstances  should  present  themselves,  it  would  be  proper  to  make 
some  trials.  M.  Confrie  long  since  observed  an  old  soldier  at  Saint  Cathe- 
rine, who  underwent  it  in  the  Russian  campaign,  and  who  walks  very  well 
with  a  half-boot. 

Operation, — The  operation  itself  presents  no  difficulty.  Two  semilunar 
incisions,  one  passing  over  the  instep,  the  other  over  the  heel,  at  twelve  or 
fifteen  lines  before  and  behind  the  articulation,  and  uniting  so  as  to  form 
another  semilunar  one  on  either  side  at  about  an  inch  below  each  malleolas, 
constitute  the  first  step.  After  dissecting  up  the  skin,  the  tendons,  muscles, 
and  ligaments  are  to  be  divided  as  near  as  possible  to  the  articulation.  Then 
the  astragalus  can  be  separated  without  difficulty,  and  removed  with  the  rest 
of  the  foot.  The  haemostatic  means  having  been  applied,  I  would  recom- 
mend the  lips  of  the  wound  to  be  brought  together  anteriorly  and  posteriorly 
so  tliat  its  angles  should  cover  the  malleolar  points.  It  is  for  this  that  I  pro- 
pose to  divide  the  integuments  at  some  distance  from  tJie  ancles  and  the  articu- 
lation, and  not  quite  upon  them,  as  recommended  by  Brasdor,  Sabatier,  and 
others.  By  placing  the  flaps  laterally,  as  Rossi  advises,  the  malleoli  will 
render  their  coaptation  altogether  impracticable;  and  it  would  be  ridiculous 
at  this  day  to  attempt  to  hold  them,  by  passing  a  double  ligature  across  the 
articulation,  as  this  author  is  said  once  to  have  done  with  success. 


Art.  7. — •imputation  of  the  Leg, 

This  amputation  is  more  rarely  practised  than  formerly ;  but  is  even  at  the 
present  time  often  rendered  indispensable,  by  diseases  of  the  tibio-tarsal 
articulation,  complicated  fractures,  wounds  from  fire-arms,  gangi-ene,  &c. 

Place  of  Operating — of  Election. — The  rule  which  requires  that  an  am- 
putation should  be  made  as  far  as  possible  from  the  trunk,  has  scarcely  ever 
been  applied  in  this  case.  The  place  of  election  for  dividing  the  bone,  even 
when  the  disease  does  not  reach  above  the  inferior  articulation,  is  at  two  or 
three  fingers'  breadth  from  the  tuberosity  of  the  tibia.  The  tendinous 
expansion  of  the  sartorius,  the  gracilis,  and  semitendinosus,  will  be  preserved. 
The  stump,  which  will  retain  its  power  of  flexion  and  extension,  will  be 
sufficiently  long  to  allow  the  knee  to  be  fixed  firmly  and  easily  upon  the 
artificial  leg.  It  is  easy  to  save  enough  of  the  soft  parts  to  cover  the  wound. 
By  operating  too  near  the  malleolus  nothing  is  met  with  but  skin ;  the  cicatrix 
forms  slowly,  remains  tender,  and  is  easily  torn.  After  the  cure,  the  stump 
projecting  too  far  backward  and  constantly  exposed  to  injury  from  surrounding 
bodies,  must  become  more  embarrassing  than  useful ;  so  much  so,  that  some 
subjects  operated  upon  in  this  way  have  of  their  own  accord  desired  another 
operation;  of  which  Sabatier  has  given  some  examples,  and  on  which  Pare 


* 


OPERATIVE  SURGERY.  229 

has  made  some  remarks.  Higher  up  the  saw  will  divide  the  tibia  in  its 
thickest  and  most  spongy  part,  and  the  fibrous  expansion  that  propagates  the 
action  of  certain  muscles  of  the  thigh  upon  the  stump :  such  at  least  are  the 
motives  which  have  been  invoked  for  a  long  time  to  support  a  precept  which 
is  now  questioned.  However,  Soligen,  who  lived  towards  the  end  of  the 
sixteenth  century,  strongly  opposed  this  doctrine.  According  to  him  we 
should  amputate  the  leg,  like  the  arm,  as  low  down  as  possible.  With  the  aid 
of  a  shoe,  supported  by  two  thin  and  polished  plates  of  steel,  fixed  upon  the 
side  of  the  leg  by  means  of  engrenures  skillfully  arranged,  the  patient  could 
walk  with  almost  as  much  facility  as  with  the  natural  foot.  Many  foreign 
surgeons  agreed  with  him,  and  Dionis  was  not  far  from  adopting  his  opinions. 
There  had  been,  however,  nothing  further  said  about  this  when  Ravaton, 
White,  and  Bromfield,  towards  the  middle  of  the  last  century,  made  as  they 
thought  the  discovery  of  it.  Like  Solingen,  these  authors  extolled  the  em- 
ployment of  machines,  and  among  the  rest  that  of  Wilson,  which  permits  the 
flexion  and  extension  of  the  leg,  and  of  walking  in  fact  as  with  a  natural 
member.  Ravaton 's  boot,  fixed  by  means  of  straps,  had  a  vacuity  correspond- 
ing to  the  cicatrix,  in  order  to  preserve  it  from  compression.  But  Sabatier 
properly  objects  to  this,  that  the  weight  of  the  body  forcing  the  integuments 
of  the  stump  upwards,  must  strain  the  cicatrix  so  much  that  it  will  be  torn, 
M.  Larry  is  of  the  same  opinion.  Vacca,  Brunninghausen,  and  Souleraj. 
have  nevertheless  ventured  to  restore  it  to  use  at  the  present  time :  the  am-"* 
putadon  of  the  leg  at  its  inferior  part  is  a  much  less  serious  matter,  it  must 
be  acknowledged,  than  at  what  is  called  the  place  of  election,  since  there  is 
less  of  the  soft  parts  met  with  there.  The  integuments  that  are  preserved  are 
sufficient  to  produce  union  even  by  the  first  intention.  It  cannot  be  thought 
impossible  to  construct  a  machine  so  perfect  as  to  resemble  the  abstracted 
member,  and  allow  of  its  use  with  little  evident  deformity.  Solingen,  White, 
Ravaton,  Bell,  Bromfield,  and  many  German  surgeons,  report  cases  to  prove 
the  contrary.  But  if  some  patients  suffer  from  this  plan,  it  does  not  follow 
that  it  should  be  rejected  with  all  others :  success  in  such  cases  must  depend 
on  many  circumstances  which  have  not,  I  think,  been  properly  estimated. 
It  may  be  that  the  cicatrix  shall  be  more  or  less  solid,  or  placed  at  the  centre 
or  towards  the  circumference  of  the  stump.  Allowing  that  we  have  not  yet 
given  the  boot  all  the  qualities  desirable,  it  does  not  follow  that  this  is  ulti- 
mately beyond  the  reach  of  human  invention.  The  two  subjects  thus  ope- 
rated upon  that  have  been  presented  to  my  observation,  could  travel  with  a 
boot  so  imperfect,  that  I  can  hardly  believe  in  the  absolute  necessity  of  making 
the  knee  the  point  of  support  for  the  artificial  member.  Hence  I  conclude 
that  with  subjects  who  are  not  obliged  to  make  long  and  fatiguing  efforts  at 
walking,  or  who  are  desirous  of  maintaining  the  appearance  of  the  natural 
form  of  the  part,  Solingen's  method  may  sometimes  be  adopted.  If  I  am  not 
deceived,  there  would  in  that  case  be  some  advantage  in  dividing  the  integu- 
ments in  such  a  manner  that  the  cicatrix  would  form  behind,  and  not  at  the 
centre  of  the  stump. 

Some  persons  have  placed  the  point  of  election  either  higher  or  lower  than 
I  have  done.  Hey,  for  example,  places  it  in  the  middle  of  the  member.  M. 
Garigue,  on  the  contrary,  with  de  la  Motte,  and  Bromfield,  advises  us  to 
amputate  much  nearer  the  articulation,  and  even  above  the  tuberosity  of  the 


2S0  NEW  ELEMENTS  OF 

tibia.    M.  Larry  strongly  counsels  this  course,  and  M..  Guthrie  also  formally 
approves  of  it. 

The  Place  of  Necessity. — Yet  the  point  where  these  different  surgeons 
amputate,  should  be  considered  as  a  place  of  necessity  rather  than  of  elec- 
tion. On  this  subject  I  perfectly  agree  with  them,  and  would  always  prefer 
the  amputation  of  the  leg,  were  it  but  at  an  inch  below  the  articulation,  to 
the  amputation  of  the  thigh,  if  it  be  not  allowed  to  amputate  in  the  joint.  I 
even  believe,  that  as  a  general  rule  it  would  be  better  to  cut  the  bone  imme- 
diately below  the  tuberosity  of  the  tibia,  than  in  the  place  commonly  preferred. 
The  section  of  the  tendons  and  ligaments  does  not  prevent  these  and  their 
muscles  from  maintaining  their  action  upon  the  superior  extremity  of  the 
leg.  Here  there  is  no  interosseal  space.  The  popliteal  is  the  only  artery  to 
be  secured  ;  at  least  the  peroneal  and  posterior  tibial  are  tlie  only  others  that 
can  require  attention.  The  head  of  the  fibula  maybe  removed.  Then  the 
amputation  of  the  leg  resembles  that  of  any  single-boned  member  of  the 
skeleton.  The  spongy  nature  of  the  tibia,  so  far  from  being  an  inconve- 
nience, on  the  contrary  offers  the  advantage  of  an  immediate  union,  and  an 
easy  and  prompt  development  of  cellular  granulations.  But  it  must  be 
confessed  that  the  integuments  alone  exist  on  the  anterior  semi -circumferences 
of  the  member,  whilst  below  the  muscles  come  to  our  assistance ;  but  as  it  is 
the  integuments  that  ultimately  close  the  wound,  I  cannot  see  any  great  dis- 
advantage to  result  from  this  circumstance.  So  that  if  the  spongy  substance 
of  the  tibia,  in  contact  with  the  pus,  does  not  expose  the  subject  to  phlebitis 
and  the  reabsorption  of  morbific  matters ;  if  in  operating  above  the  head  of 
the  fibula  there  be  no  risk  of  opening  the  synovial  sac  of  t!he  knee  (which 
sometimes  prolongs  itself  so  far,  according  to  Berard,  who  has  communicated 
two  examples  of  it,  and  as  I  have  myself  once  seen),  I  would  approv-e  without 
reserve  of  the  doctrine  of  Garrigue  and  Larrey.  When  the  disease  reaches 
Tery  near  the  knee,  to  preserve  the  inferior  attachment  of  the  rotular  ligament, 
and  to  l-eave  untouched  the  mucous  bursae  situated  behind,  M.  Larrey  recom- 
mends that  the  saw  should  be  applied  more  or  less  obliquely  from  before 
upward,  and  backwards.  We  may  thus  remove  the  whole  of  the  fibula,  whilst 
Ave  leave  a  small  portion  of  the  tibia,  which  will  serve  equally  well  for  the  point 
'of  support  for  the  artificial  limb;  but  in  such  cases  it  seems  better  to  amputate 
in  the  joint. 

Jinatomical  Remarks. — After  the  preceding  details,  there  is  no  necessity 
here  for  a  prolonged  description  of  the  leg.  The  tibia,  much  thicker  than  the 
fibula,  and  much  more  elevated,  causes  the  greatest  thickness  of  the  member  to 
be  from  within  outward,  and  from  before  backward,  instead  of  transverse.  Its 
internal  face  is  -entirely  uncovered  by  muscles,  and  cannot  be  covered  either 
circularly  or  with  a  flap,  except  by  the  integuments.  Its  sharp  edge,  a  kind 
of  crust  which  presents  anteriorly,  gives  to  this  portion  of  its  section  a  point 
commonly  very  sharp  and  capable  ofproforating  the  skin,  if  proper  attention 
be  not  paid  to  it.  The  muscles  of  the  leg  that  fill  the  external  interosseal 
fossa,  adhering  through  almost  their  whole  extent  to  this  excavation,  are 
incapable  of  retracting  more  than  a  few  lines  after  being  divided.  It  is  the 
same  with  the  lateral  j)eroneals  that  form  the  deep  muscular  layer  of  the 
limb,  and  the  flexors  of  the  toes  which  fill  the  posterior  interosseal  fossa,  whilst 
the  gastrocnemius  and  soleus  can  retract  very  considerably  when  we  operate 


OPERATIVE    SUROERr.  231 

very  low.  The  anterior  tibial  artery  bending  at  a  right  angfe  as  soon  as  it 
gets  upon  the  interosseal  ligament,  soon  joins  the  nerve  of  the  same  name. 
The  posterior  and  anterior  tibial  arteries  which  separate  either  higher  or  lower 
from  the  popliteal,  are  rarely  wanting :  the  first  is  found  behind  the  external 
border  of  the  tibia,  on  the  posterior  face  of  the  common  flexor  and  the  tibialis 
posticus)  the  second  behind  the  fibula,  in  the  thickness  of  the  fibres  of  the 
long  flexor  of  the  great  toe.  And  the  nerve  is  almost  constantly  placed  upon 
the  fibular  side  of  the  tibial  artery. 

Manual. 
The  leg  may  be  amputated  by  either  the  circular  or  flap  method  .^ 
A.  Circular  Method. — Position  of  the  Patient,  of  the  Assistants ^  and  of  the 
Operator. — The  patient  should  be  placed  upon  a  bed  or  a  table,  and  properly 
supported.  To  guard  against  hemorrhage,  compression  must  be  made  upon 
the  femoral  artery  over  the  os  pubis,  by  the  thumb  of  an  assistant,  a  handled 
pad,  or  some  other  instrument;  or  on  a  level  with  the  lesser  trochanter 
against  the  internal  face  of  the  femur,  by  means  of  the  fingers  sunk  into  the 
groove  formed  by  the  vastus  internus  before  and  the  abductors  behind  ;  or,  in 
fine,  by  the  tourniquet  or  garot.  When  the  assistants  are  not  sufficiently 
numerous,  or  cannot  be  entirely  depended  upon,  the  garot  or  tourniquet  is 
to  be  preferred*  These  instruments  may  be  employed  with  the  greater 
security,  inasmuch  as  being  applied  upon  the  thigh  they  in  no  wise  incommode 
the  operator  during  the  amputation.  The  operator  places  himself  commonly 
on  the  inside  ;  this  is  a  long-established  general  rule ;  the  reason  assigned 
for  which  is,  that  it  is  more  easy  to  terminate  the  division  of  the  fibula  before 
having  entirely  got  through  the  tibia,  than  if  the  operator  were  on  the  out- 
side. Le  Dran  had  remarked,  however,  that  the  surgeon  could,  if  it  were 
necessary,  disregard  this  rule  without  danger  and  even  perhaps  with  advan- 
tage. M.  Grjefe  and  S.  Cooper,  maintain  that  it  is  as  well  that  the  sur- 
geon should  always  place  himself  on  the  outside ;  but  that  it  is  useless  to 
keep  this  latter  position  for  the  amputation  of  the  right  limb.  In  a  word, 
though  on  the  left,  the  corresponding  hand  turned  towards  the  head  of  the 
member  can  draw  up  the  integuments  as  they  are  divided  by  the  right,  for  the 
other  limb  this  is  not  possible,  when  the  operator  follows  the  general  rule. 
Consequently  the  precept  which  it  is  proper  to  substitute  for  the  ancient,  and 
to  which  I  have  for  a  long  time  conformed,  is  this:  the  operator  shall  place 
himself  in  such  a  manner  that  the  left  hand  can  always  embi'ace  the  limb  towards 
the  knee;  at  least  if  he  be  not  ambidexter.  But  if  he  be,  it  would  be  better 
to  place  himself  on  the  inside  for  either,  than  on  the  outside  for  both.  It 
would  be  idle  to  place  himself  on  the  outside  for  the  division  of  the  soft  parts, 
and  then  inside  for  the  bone,  as  some  German  and  English  surgeons  have 
recommended.  It  would  be  still  more  improper  to  leave  the  sound  limb 
between  the  operator  and  the  limb  that  he  wishes  to  amputate,  under  the  pre- 
text of  never  placing  himself  between  the  limbs.  The  foot  and  whole  diseased 
portion  of  the  limb  being  enveloped  in  a  cloth,  is  confided  to  the  care  of  an 
assistant. 

2d.  Ordinary  Process — First  step. — Armed  with  an  amputating  knife  the 
operator  makes  a  circular  incision  through  the  skin,  commencing  at  the  crest 


m 


2S2  NEW   ELEMENTS    OF 

and  finishing  at  the  internal  border  of  the  tibia,  uniting  by  a  second  cut  the 
two  extremities  of  this  incision ;  unless,  by  a  rotatory  motion  of  the  hand  upon 
the  handle  of  the  instrument  (a  movement  I  have  indicated  abovej,  he  should 
prefer  to  pass  over  without  stopping  the  whole  circumference  of  the  limb ; 
draws  up  with  the  left  hand  the  integuments  thus  divided ;  cuts  their  cellular 
attachments,  and  raises  them  to  the  extent  of  an  inch  or  an  inch  and  a  half;  or 
better,  seizes  them  by  their  superior  lip  between  the  thumb  and  finger,  near  the 
fibula,  dissects  them  by  rapid  strokes  of  the  knife  or  bistoury,  and  reverses 
them  quickly  upward,  so  as  to  form  a  sort  of  collar  or  ruffle. 

Second  step. — After  having  applied  the  knife  at  the  base  of  this  collar  or 
circle  of  the  skin,  and  upon  the  same  point  of  the  tibia  as  before,  the  operator 
cuts  backwards  and  outwards  so  as  to  divide  the  aponeurosis  and  all  the 
fleshy  fibres  above  the  level  of  the  anterior  interosseal  fossa.  By  depressing 
the  wrist  he  divides  the  peroneal  muscles  in  the  same  manner ;  then,  by 
bringing  it  back  gradually  inwards,  those  of  the  calf  or  posterior  face  of  the 
leg  ;  again  carries  the  instrument  in  front ;  detaches  the  aponeurosis  on  each 
side,  and  applies  the  heel  of  the  knife  immediately  upon  the  external  face  of 
the  fibula  ;  draws  it  from  heel  to  point,  and  when  the  latter  reaches  the  in- 
ternal face  of  the  bone,  obliges  it  to  pass  through  the  interosseal  space ; 
divides  all  the  deep-seated  fibres ;  divides  those  which  adhere  to  the  external 
face  of  the  tibia  whilst  withdrawing  the  instrument ;  carries  the  instrument 
under  the  limb  to  the  same  point  of  the  fibula ;  brings  it  back  upon  its  posterior 
face  ;  passes  again  through  the  interosseal  space,  drawing  it  out  in  the  same 
manner  as  before ;  divide  all  the  muscles  still  remaining  behind  the  tibia;  and 
thus  he  will  find  that  he  has  traced  out  the  figure  8  by  his  movements,  as  has 
already  been  observed  in  the  amputation  of  the  fore-arm.  It  is  well,  as  in  this 
latter  member,  to  make  a  second  incision  with  the  bistoury  upon  each  edge  of 
the  interosseous  membrane.  Then  pass  from  behind  forwards  the  middle 
strip  of  a  three-headed  bandage  between  the  bones.  The  pieces  of  this  bandage 
suitably  applied  and  brought  together,  are  given  to  an  assistant  to  draw  up  the 
soft  parts. 

Third  step. — The  surgeon  fixes  the  nail  of  the  thumb  at  the  point  to  which 
the  tibia  has  been  denuded ;  applies  the  saw  upon  this  point  and  gives  it  a 
few  limited  movements,  then  elevates  the  wrist  so  as  to  cut  the  fibula  com- 
pletely first,  and  finish  upon  the  bone  on  which  he  had  commenced  ;  because 
the  fibula  alone  would  not  offer  sufficient  resistance  to  the  action  of  the  saw, 
and  its  superior  articulation  would  be  exposed  to  a  serious  concussion.  This 
second  reason  appears  to  me  none  the  less  conclusive,  although  the  first  is 
sufficient  to  justify  the  precept.  As  soon  as  the  fibula  is  divided,  the  assist- 
ant holding  the  inferior  part  of  the  limb,  and  the  operator  holding  the  superior 
part  with  his  left  hand,  must  compress  it  enough  to  prevent  its  being  touched 
or  moved  by  the  saw.  M.  Roux  recommends  it  to  be  divided  higher  up  than 
the  tibia.  It  is  for  this  reason  that  he  inclines  the  saw  obliquely  upwards  and 
outwards.  By  this  means  M.  Roux  proposes  more  surely  to  guard  against  the 
consecutive  projection  of  the  fibula.  It  is  of  little  importance.  The  section 
of  the  two  bones  on  a  line  is  not  sensibly  less  advantageous.  I  see  still  less 
reason  to  imitate  some  surgeons  who  saw  them  separately.  In  fine,  if  the 
surgeon  should  choose  to  operate  on  the  outside  instead  of  the  inside,  after 


OPERATIVE  SURGERY.  233 

having  formed  a  groove  of  a  certain  depth  upon  the  principal  bone,  it  will  be 
sufficient  to  direct  the  assistants  to  pronate  the  limb,  and  then  depress  the 
wrist  a  little  to  render  the  division  of  the  fibula  more  easy. 

The  anterior  angle  of  the  tibia  upon  which  the  skin  rests,  and  against  which 
it  is  pressed  by  the  force  of  the  muscles  of  the  calf  which  tends  to  draw  it 
backward,  sometimes  produces  a  perforation  of  this  membrane.  The  surgeon 
should  have  in  his  mind  the  means  of  combating  such  an  accident,  of  which 
the  amputation  of  the  limb  at  a  high  point  is  ordinarily  a  successful  one.  I 
have  seen  MM.  Richerand  and  Cloquet,  at  the  Hospital  Saint  Louis,  prevent 
it  when  it  was  threatning,  by  applying  upon  the  posterior  face  of  the  stump  a 
piece  of  pasteboard  en  forme  d^atdles.  A  much  more  certain  means  is  to 
remove  the  angle  or  osseous  edge  itself  by  a  cut  of  the  saw.  It  is  not  known 
to  whom  belongs  the  first  idea  of  such  an  improvement.  It  has  been  used  for 
a  long  time  by  military  surgeons. 

Process  of  Sabatier. — The  metliod  of  Sabatier  differs  from  the  foregoing 
only  in  this ;  he  advises  the  operator  to  divide  the  anterior  half  of  the  integu- 
ments of  the  member ;  first,  to  draw  them  upwards  and  continue  then  the 
circular  incision  behind  somewhat  higher  up.  The  reason  that  he  gives  is, 
that  upon  the  calf  of  the  leg  tlie  skin  retracts  with  the  muscles,  whilst  befor*». 
upon  the  tibia  and  anterior  aponeurosis,  this  does  not  take  place.  This  modi- 
fication, although  not  bad,  is  generally  neglected. 

Process  of  Dr.  Physick. — C.Bell  claims  the  honor  of  the  invention  of  a 
method  which  Dorsey  gives  to  Dr.  Physick.  It  is,  to  divide  first  the  skin  and 
then  the  muscles  of  the  calf  very  obliquely  from  below  upward,  so  as  to  com- 
plete the  section  much  nearer  the  knee,  upon  the  anterior  half  of  the  member, 
and  terminate  the  operation  as  in  the  ordinary  manner. 

Process  of  M.  Baudens,  or  B.  Bell. — After  dividing  the  soft  parts  circularly, 
M.  Baudens  advises  us  to  detach  all  the  muscles  to  the  extent  of  one  or  two 
inches,  with  the  point  of  the  knife  held  parallel  to  the  axis  of  the  bone.  This 
advice,  given  by  B.  Bell  for  amputation  of  the  arm  or  thigh,  for  amputation 
in  general  may  be  useful,  and  accords  with  that  recentl}^  given  by  M.  Hello. 

Dressing. — In  the  place  of  election  the  operator  successively  seizes  the 
anterior  tibial  artery,  which  is  in  contact  with  the  nerve,  from  which  it  is 
necessary  to  separate  it ;  the  posterior  tibial,  the  peroneal,  and  some  branches 
of  the  gastrocnemials ;  and  sometimes,  the  nutritive  artery  of  the  tibia.  Very 
often  the  first  of  these  vessels  retracts  far  into  the  flesh ;  the  reason  of  which, 
M.  Ribes  says  is  the  double  curvature  which  it  undergoes  to  get  before  the 
interosseous  ligament.  M.  Gensoul,  on  the  contrary,  thinks  that  this  retraction 
appears  to  occur  because  the  fleshy  fibres  surrounding  it  are  too  adherent  to 
contract;  thus  making  the  contraction  of  the  artery  appear  much  greater  than 
it  really  is,  and  much  more  so  here  than  in  the  posterior  parts,  w^here  the 
muscles  draw  them  up  much  higher.  Witliout  rejecting  entirely  the  first  of 
these  two  explications,  I  freely  adopt  the  second. 

When  the  section  of  the  bone  is  made  immediately  below  the  tuberosity  of 
the  tibia,  a  single  trunk  replaces  the  posterior  tibial  and  peroneal  arteries,  but 
then  the  nutrient  artery  presents  a  considerable  volume.  Higher  still  the  an- 
terior tibial  itself  may  not  be  separated  from  the  popliteal,  which  in  this  case 
requires  only  one  ligature,  with  the  inferior  articulating  and  gastrocnemial 
arteries. 

30 

f 


234  NEW    ELEMENTS   OF 

Surgeons  do  not  all  agree  upon  the  mode  of  uniting  the  wound.  In  France 
it  is  almost  always  done  from  within  outward  and  from  before  backward. 
Many  English  operators,  Mr.  Hutchinson  among  many  others,  still  close  as 
formerly,  e.  e.  directly  from  before  backward,  thereby  hoping  to  escape  the 
stagnation  of  the  fluids,  and  the  pressure  of  the  point  of  the  tibia  against  the 
skin.  Again,  there  are  others  who,  after  the  advice  of  ,Mr.  Guthrie,  unite  it 
transversely:  but  it  is  indisputable  that  when  the  operator  has  taken  the 
precaution  of  paring  the  bone,  as  it  is  called,  the  method  of  M.  RicKerand  is 
the  best ;  that  this  alone  permits  the  bringing  together  of  the  flesh  into  the 
smallest  space,  and  that  this  alone  opposes  in  no  way  the  flow  of  the  pus. 

If  the  amputation  has  been  made  very  low,  the  limb  must  be  supported  upon 
a  cushion  lightly  flexed,  and  inclined  upon  its  external  edge ;  sometimes  the 
stump  is  placed  upon  pillows,  which  very  much  relieves  the  ham,  and  prevents 
the  wound  from  coming  in  contact  with  the  matrass. 

The  Flap  Operation. — It  was  on  the  leg  especially,  that  Lowdham,  Verduin, 
Sabourin,  &c.  wished  their  method  applied.  It  was  also  on  this  part  that 
Garengeot,  de  la  Faye,  and  Le  Dran  made  their  first  attempts.  But  the  ex- 
ertions of  Louis,  Lassus,  and  Sabatier  to  disseminate  the  circular  method, 
and  the  apparently  greater  pain  and  difficulty  of  the  flap  operation,  caused 
the  latter  to  be  almost  entirely  renounced.  M.  Roux  and  Dupuytren,  however, 
again  introduced  it  amongst  us  about  twenty  years  ago.  Dr.  Hey  in  England, 
Klein  and  Benedict  in  Germany,  have  also  succeeded  in  introducing  it  among 
some  of  their  countrymen.  It  appears  to  have  been  rejected  by  the  moderns, 
especially  on  account  of  the  volume  of  the  tibia,  ih^  internal  face  of  which, 
whatever  plan  may  be  pursued,  can  only  be  covered  by  the  skin.  The  ne- 
cessity of  making  the  flap  chiefly,  if  not  entirely  from  behind,  is  another 
motive  for  its  rejection.  However,  as  there  may  be  cases  that  render  it 
indispensable,  I  feel  bound  to  point  out  here  the  principles  upon  which  it  is 
to  be  performed. 

1.  Process  of  Verduin,  A  two-edged  knife,  entered  a  little  below  the 
point  at  which  the  saw  is  to  be  applied,  is  made  to  form  a  semilunar  flap  at 
the  expense  of  the  calf,  about  four  inches  long ;  bringing  it  in  front  you  im- 
mediately divide  the  integuments  and  muscles,  as  in  the  circular  method,  to 
the  base  of  the  elevated  flap;  the  interosseal  parts  are  cleared,  and  the  bone 
sawn  as  in  the  ordinary  method. 

2.  Process  of  Hey. — To  be  more  certain  of  the  length  of  the  flap.  Dr.  Hey 
advises  us  to  make  one  circular  line  at  half  lieight  of  the  tibia,  a  second 
an  inch  below,  and  a  third  four  inches  below  the  first ;  then  two  others  parallel 
to  the  axis  of  the  member,  one  on  each  side,  and  which  stretch  from  the  union 
of  the  two  anterior  thirds,  with  the  posterior  third  of  the  superior  circular 
line,  as  far  as  the  last.  The  first  line  indicates  where  the  bone  is  to  be 
divided  with  the  saw,  the  second  where  the  integuments  are  to  he  divided 
anteriorly,  and  the  third  the  place  where  the  knife  must  be  stopped;  whilst 
the  two  lateral  lines  trace  the  form  and  extent  of  the  flap,  whicli  Hey  in  other 
respects  formed  like  Verduin  and  Lowdham.  No  operators  at  present,  I  ima- 
gine, will  be  tempted  to  use  these  architectural  delineations  and  geometrical 
rules. 

3.  Process  of  Ravaton. — The  circular  incision,  made  at  four  inches  from 
the  place  where  the  amputation  should  be  performed,  admits  of  another  on 


OPERATIVE    SURGERY.  335 

the  face  and  near  the  internal  edge  of  the  tibia,  then  a  tJiird  upon  the 
external  edge  of  the  limb,  which  must  fall  at  right  angles  upon  the  first. 
The  two  square  or  trapezoid  flaps,  one  anterior  and  the  other  posterior, 
that  result,  are  then  dissected  upwards  and  raised;  nothing  more  remains 
but  to  free  the  interosseal  space,  pass  the  compress,  and  saw  the  bone. 

4.  Process  of  Vermale. — To  form  the  first  flap,  Le  Dran,  who  is  said  to 
have  used  the  methods  of  Ravaton  and  Vermale  successfully,  pushed  the 
knife  from  the  internal  to  tlie  external  face  of  the  limb,  and  began  by  forming 
the  anterior  flap ;  nothing  is  then  more  easy  than  to  force  back  the  flesh  and 
make  the  posterior  flap. 

5.  Process  of  M,  Dupuytren, — Instead  of  beginning  with  the  anterior  flap, 
M.  Dupuytren  passes  the  instrument  between  the  posterior  face  of  the  bone 
and  the  soft  parts,  taking  care  to  leave  more  flesh  than  Le  Dran,  behind  the 
fibula. 

6.  Process  of  M,  Roux. — As  it  is  almost  impossible  to  presei-ve  as  much  of 
tlie  tissues  before  as  beliind,  M.  Roux  first  conceived  the  idea  of  makinp; 
upon  the  internal  face  of  the  tibia,  an  incision  about  two  inches  long,  obliquely 
forwards  and  downwards,  beginning  at  the  internal  and  ending  at  the  anterior 
edge  of  the  bone ;  when  the  posterior  flap  has  been  formed,  tliis  incision  admits 
of  the  bringing  back  of  the  edge  of  the  wound  easily  to  the  level  of  iY.^  crest 
of  the  tibia;  thus  making  the  anterior  flap  more  regular  and  thicker. 

All  of-  these  methods  may  be  reduced  to  that  of  Lowdham  and  that  of 
Vermale;  one  by  a  single  flap,  the  other  by  two.  When  the  skin  is  disor- 
ganized much  higher  before  than  behind ,  and  the  amputation  must  be  performed 
very  near  the  knee,  the  first  is  necessary.  I  have  seen  it  used  with  success 
by  M.  J.  Cloquet,  at  the  Hopital  de  Perfectionnement,  on  a  subject  who 
without  it  must  have  lost  his  thigh.  In  all  other  cases  the  double  flap  method 
appears  to  me  most  proper,  although  a  little  more  difticult.  When  there  is 
only  one  flap,  it  must  necessarily  be  bent  at  a  right  angle  at  its  base  to  apply 
it  upon  the  bone.  Immediate  and  complete  union  is  almost  impossible.  It 
is  rare  that  it  is  not  succeeded  by  very  lively  pains.  The  consequences  that 
may  result  from  it,  justify  to  a  certain  extent  the  fears  of  some  surgeons,  and 
their  repugnance  to  its  performance.  W^ith  two  flaps,  on  the  contrary,  the 
wound  closes  very  easily;  the  parts  are  neither  bent  nor  stretched,  and  are 
thus  in  the  most  favorable  condition  possible  for  immediate  reunion. 

7.  Process  of  the  Author — In  trying  upon  the  dead  subject  the  method  of 
'ttermale,  which  I  have  once  performed  upon  a  living  one  at  the  Hopital  St. 
jQntoine,  I  neglect  the  little  preparatory  incision  of  M.  Roux,  but  I  take  care 
to  embrace  both  sides  of  the  limb  with  my  left  hand,  and  to  draw  as  much  of 
the  integuments  as  possible  forwards.  The  point  of  the  knife  is  then  applied 
upon  the  internal  face  of  the  tibia;  brought  to  the  level  of  the  crest  of  this 
bone,  pushing  the  skin  before  it;  slipped  behind  the  interosseous  ligament; 
raised  a  little  to  pass  behind  the  fibula, and  again  inclined  backwards;  whilst 
the  tissues  are  drawn  towards  the  body  of  the  operator  until  the  moment  it 
passes  through  the  external  edge  of  the  member.  This  flap  finished,  a  similar 
one  is  formed  behind,  and  the  rest  of  the  operation  performed  without  variation 
from  M.  Dupuytren's  method.  By  every  method  it  is  necessary  that  the  in- 
ternal angle  of  the  wound  should  be  a  little  lower  than  the  external,  if  we 
would  not  expose  the  bone  to  denudation  or  necrosis. 


236  NEW   ELEMENTS    OF 

2.  In  the  Articulation,— History  and  Value. — Although  vaguely  indicated  by 
Hippocrates  and  Guy  de  Chauliac,  a  little  more  clearly  mentioned  by  F.  de 
Hilden,  the  disarticulation  of  the  leg  never  attracted  much  attention  until  tlie 
latter  part  of  tlie  last  century.  At  the  present  time,  notwithstanding  the 
efforts  of  J.  L.  Petit,  Hoin,  and  Brasdor,  who  endeavored  to  restore  it,  it  is 
not  now  recommended  by  any  one :  and  M.  Blandin  is  almost  the  only  person 
who  has  dared  to  reproduce  the  arguments  of  Brasdor  in  its  favor.  The 
operation  therefore  at  first  view  seems  to  deserve  to  be  erased  from  modern 
siu-gery.     Is  tliis  a  judgment  without  appeal  ?  I  think  not. 

De  la  Roche  tells  us  that  a  young  girl,  aged  seventeen  years,  underwent  an 
amputation  in  the  knee,  and  that  she  was  perfectly  cured.  In  one  case  men- 
tioned by  J.  L.  Petit,  the  disarticulation  of  the  leg  appeared  only  to  have  been 
prefeiTed  because  of  the  want  of  instruments  to  amputate  in  the  continuity  of 
the  limb.  Another  was  that  of  a  young  man,  who  had  both  bones  of  the  leg  exos- 
tosed  and  carious  throughout  their  whole  extent.  We  have  every  reason  to 
believe  that  these  two  cases,  of  which  Petit  was  only  a  witness,  were  amply  suc- 
cessful. ,  A  slater  who  had  fallen  nineteen  days  before  from  a  height  of  one  hun- 
dred and  thirty-two  feet,  was  taken  to  the  Hospital  of  Dijon,  July  26, 1764. 
His  leg  was  gangrened  to  the  knee.  Hoin  disarticulated  it,  and  although 
tliere  were  not  soft  paiis  enough  to  permit  immediate  union,  this  man  was 
ultimately  cured.  'In  the  month  of  July,  1771,  he  was  still  alive,  used  his 
wooden  leg  freely,  and  could  mount  the  scaffold  or  roof  as  before  the  accident. 
Gignoux,  of  Valence,  speaks  of  a  young  woman  who  had  had  the  leg  separated 
from  the  thigh  by  gangrene,  and  whose  health  was  entirely  restored  in  four 
years.  Sabatier  is  said  to  have  seen  a  boy  whose  leg  was  carried  away  by  a 
ball  without  injury  to  the  patella,  and  who  suffered  nothing  serious  from  the 
accident.  In  1824,  Dr.  Smith,  Professor  of  Yale  College,  in  America,  had 
recourse  to  disarticulation  in  the  case  of  a  lady,  who  since  has  never  ceased  to 
be  able  to  walk  witli  a  wooden  leg.  A  scrofulous  subject,  aged  nineteen  years, 
was  operated  on  in  the  same  way  at  the  Hopital  de  St.  Louis,  in  1824,  by  M. 
Richerand.  Various  accidents,  some  abscesses,  and  purulent  fistulre  of  the 
thigh,  at  first  alarmed  the  surgeon,  but  the  wound  nevertheless  ultimately 
cicatrized.  A  man,  amputated  at  the  knee,  was  met  with  in  the  streets  of 
Paris  by  M.  Dezeimeris,  in  1829.  This  man  walked  freely,  but  with  a  cuissart, 
and  without  using  the  stump  as  a  point  of  support  for  the  artificial  member. 
Dr.  Bourgeois  informs  me  that  he  has  seen  a  similar  case  at  Etampes.  Rossi 
regards  it  as  the  most  simple  method,  and  is  said  to  have  twice  performed  it 
successfully.  Finally,  a  case  of  disarticulation  of  the  leg  is  mentioned  in  the 
first  volume  of  the  Dictionnaire  de  Medecine  et  de  Chirurgie  Pratique.  The 
patient  operated  upon  at  the  Hospital  Beaujon  died  the  sixteenth  day  after 
the  operation,  from  the  consequences  of  phlebitis. 

Here  then  are  fourteen  well  authenticated  cases  of  amputation  of  the  leg 
in  the  articulation,  and  of  this  number  thirteen  incontestable  examples  of 
cure.  It  cannot  be  denied  that  these  first  results  are  very  encouraging. 
Amputation  in  the  continuity  has  certainly  never  given  more  satisfactory 
ones.  To  those  who  would  object  that  in  Gignoux  and  Sabatier's  patients  the 
operation  having  been  performed  as  much  by  nature  as  by  surgery,  nothing 
can  be  concluded  in  favor  of  ordinary  cases ;  that  gangrene  had  also  per- 
formed part  of  the  amputation  in  Hoin's  subjects;  that  that  of  M.  Blandin 


OPERATIVE    SURGERY.  QS7 

ultimately  succumbed ;  that  they  were  all  young  subjects,  and  that  with  all  it 
was  a  long  time  before  they  could  use  the  stump ;  it  may  be  replied  :  1st.  That 
if  tlie  wound  closes  well  after  tlie  spontaneous  separation  of  the  limb,  or  when 
gangrene  had  already  attacked  the  tissues,  there  is  no  reason  why  it  should  be 
otherwise  in  consequence  of  an  artificial  operation.  2d.  That  the  accident, 
of  which  one  of  the  patients  became  the  victim,  belongs  no  more  to  disarticula- 
tion than  to  the  simple  operation  for  amputation  of  the  leg,  and  that  his  death 
eight  months  after  was  the  result  of  his  primitive  affection.  Sc\,  That  there 
is  no  evidence  that  there  should  be  less  to  hope  for  in  this  operation  with 
adults  than  with  adolescents.  4th.  That  the  length  of  the  cure  must  be 
attributed  to  the  peculiar  circumstances,  and  not  to  the  operation.  5th.  In 
fine,  that  Dr.  Smitli  did  not  complain  of  any  of  these  inconveniences.  But 
let  us  contiuue  the  exposition  of  facts. 

In  the  month  of  January,  1 8  ?0, 1  received  at  the  hospital  Saint  Antoine,  an 
orphan,  aged  nineteen  years,  who  was  sent  to  me  by  M.  Kapeler,  chief  physi- 
cian of  the  house.  The  operation  was  fixed  for  the  14th  of  the  same  month. 
As  there  were  not  soft  parts  enough  behind,  I  thought  it  proper  to  preserve 
enough  in  front  for  a  flap  of  a  given  extent.  The  wound  united  but  incom- 
pletely. Noaccident  followed;  and  although  there  remained  a  transverse 
surface  of  about  an  inch  in  width  antero-posteriorly,  which  the  flap  did  not 
cover,  the  cicatrix  nevertheless  was  completed  by  the  end  of  two  months.  At 
present  this  subject  enjoys  sound  health ;  the  stump  supports  the  weight  of 
the  body  upon  a  wooden  leg  with  the  same  facility  as  if  it  had  been  subject- 
ed to  an  amputation  in  the  continuity  of  the  limb.  A  man,  aged  twenty-nine, 
well  made,  born  in  the  colonies,  was  sent  to  me  in  tlie  hospital  Saint  Jin- 
toine,  the  24th  of  the  following  May,  by  Dr.  Thierry,  to  be  treated  for  a 
comminuted  fracture  of  the  left  leg.  Gangrene  soon  manifested  itself. 
An  ichorous  suppuration  more  and  more  abundant,  an  excessive  pain  at 
dressing  and  even  during  the  intervals,  and  almost  continual  fever,  diar- 
rhoea, &c.,  soon  supervened,  and  took  away  all  hope  of  preserving  the 
limb.  I  tlien  decided  to  amputate  in  the  knee  joint,  and  performed  this 
operation  on  the  4th  of  June.  The  fever  of  reaction,  which  continued  high, 
obliged  me  to  bleed  on  the  first  and  second  day.  Nothing  of  importance  fur- 
ther occurred  up  to  the  fifteenth  day.  On  the  sixteenth  and  seventeenth  an 
erysipelas  supervened,  and  returned  the  fever.  Notwithstanding  this,  in- 
tercurrent phlegmasia,  together  with  two  purulent  collections  which  afterwards 
formed  at  tlie  angles  of  the  condyles,  and  derangements  produced  by  errors 
in  diet — a  true  indigestion  in  fact — the  cure  was  completed  towards  the 
sixtieth  day.  At  present  this  patient  uses  a  limb  of  wood  with  the  same 
fiicility  as  the  preceding  patient.  In  the  month  of  July,  1830,  I  had  to  ex- 
amine, at  the  central  bureau  of  the  hospital,  a  young  man,  aged  nineteen, 
who  had  undergone  an  amputation  seven  years  before,  and  who  came  to  re- 
quest a  renewal  of  his  wooden  leg.  He  informed  me  that  it  was  at  the  Ho- 
pital  des  En/ants,  to  which  he  had  been  sent  for  grangrene,  that  he  had  sub- 
mitted to  the  operation  in  the  knee.  The  cicatrix  is  behind,  and  although 
the  internal  condyle,  an  inch  longer  than  the  other,  is  the  only  part  that  presses 
upon  the  artificial  member,  yet  he  moves  about  as  well  as  if  he  had  been 
operated  upon  below  the  articulation.  Since  then  it  has  been  performed  once 
successfully  by  Mr.  Nivert  of  Azai-le-Rideau,  in  a  male  adult  who  had  had 


238 


NEW   ELEMENTS   OF 


the  limb  fractured  by  a  gun-shot.  I  have  been  told,  liowever,  that  two  other 
operators  have  not  had  the  same  success.  But  I  know  from  M.  Blandin,  that 
the  state  of  his  patient  scarcely  left  any  hope  before  the  operation,  and  I  am 
ignorant  of  the  details  of  the  other  case.  It  was  not  so  with  tv/o  subjects 
upon  whom  I  operated  this  year  at  La  Pitie  ;  the  one  an  old  man,  affected  wdth 
senile  gangrene,  died  the  28th  day,  the  mortification  having  renewed  itself 
upon  the  stump.  The  other  a  woman  extremely  ftit,  with  the  limb  suffering 
from  an  enormous  cerebroid  cancer,  w^hich  did  not  permit  me  to  preserve  any 
thing  but  the  integuments  on  the  inner  side,  was  taken  with  a  suppuration  of 
the  entire  thigh  and  a  large  ulceration  on  the  sacrum.  She  died  the  sixty- 
second  day,  without  showing  any  thing  wrong  about  the  wound. 

Instead  of  opposing  experience,  this  gives  high  evidence  in  favor  of  this 
operation.  And  what  reason  can  there  be  opposed  to  it  ?  Will  some  object, 
1st.  That  by  uncovering  such  large  osseous  or  cartilaginous  surfaces  it  exposes 
to  very  formidable  consequences.^  As  the  continuity  of  the  bone  is  not  af- 
fected, nor  the  periosteum  destroyed,  there  is  nothing  to  fear  from  the  contact 
of  the  air.  The  cartilaginous  plate  which  envelopes  the  condyles  is  a 
protection,  quite  insensible,  that  may  remain  for  weeks  entirely  naked 
without  the  least  inconvenience.  The  synovial  membrane  that  Bichat  has 
given  it,  does  not  exist.  2d.  That  it  will  produce  an^ enormous  wound, 
which  it  will  be  almost  impossible  to  cover  with  the  adjoining  soft  parts  ? 
This  is  an  error.  This  wound,  so  vast  in  appearance,  is  reduced  by  analysis 
to  the  division  of  the  integuments,  several  fibrous  laminae,  and  some  muscles. 
Provided  the  skin  can  be  saved  for  the  extent  of  two  or  three  inches,  it  will 
always  suffice  for  immediate  reunion.  Sd.  That  it  is  concerned  with  tissues 
which  do  not  readily  inflame  or  admit  of  a  ready  and  firm  cicatrization,  as 
in  the  fleshy  parts  of  the  limbs  ?  There  is  an  error  prevalent  on  this  point  as 
upon  the  other.  Nothing  is  better  than  a  tegumentary  couch ;  it  is  all  that  is 
absolutely  necessary  to  the  formation  of  a  good  cicatrix.  As  it  covers  the 
whole  synovial  surface  of  the  femoral  condyles,  it  will  adhere  as  well,  and 
even  more  exactly,  it  may  be  said,  than  upon  a  divided  bone  and  muscles. 
4th.  That  it  will  be  more  painful,  and  attended  with  a  less  speedy  cure  than 
the  ordinary  amputation  This  is  not  a  more  solid  objection  than  the  preced- 
ing ;  the  facts  above  stated  give  suflacient  proof  of  this  ;  and  the  more  as  the 
subjects  of  it  were  certainly  not  all  in  the  best  condition  for  a  prompt  cicatriza- 
tion of  the  wound.  5th.  It  is  accused — and  this  reproach  is  the  one  upon 
which  objectors  most  insist— of  leaving  the  patient  in  the  same  state  after 
the  cure,  as  those  who  have  been  operated  on  at  the  thigh ;  that  is,  of  being 
obliged  to  make  use  of  a  cuissart  instead  of  a  wooden  leg  in  walking .  I 
confess  that  this  apprehension  for  a  long  time  arrested  me.  But  it  is  useless 
to  refute  it  here ;  the  three  patients  upon  whom  I  have  already  remarked,  are 
placed  there  to  reduce  it  to  its  just  value. 

Why  then  should  it  be  proscribed  ?  After  the  amputation  of  the  thigh,  no 
matter  how  low  down,  the  point  of  support  for  the  artificial  limb  must  be 
taken  upon  the  ischium.  The  movements  of  the  haunch  are  almost  entirely 
annihilated.  Progression  is  performed  as  if  the  coxo-femoral  articulation 
had  been  anchylosed.  On  the  contrary  after  disarticulation  of  the  leg 
the  point  of  support  is  the  extremity  of  the  femur.  The  thigh  preserves  all 
its  movements,  and  tjie  patient  is  in  the  same  condition  as  if  he  had  a  simple 


OPERATIVE    SURGERY.  239 

consolidation  or  anchylosis  of  the  knee.  If  it  be  true  that  as  to  the  functions 
of  the  member  it  is  inlinitelj  better  to  amputate  in  the  continuity  of 
the  leg  than  in  that  of  the  tiiigh,  the  advantages  of  disarticulation  of  the  knee 
must  be  equally  beyond  dispute,  for  ihe^  weight  of  tlie  body  is  transmitted  to 
the  artificial  member  in  the  same  manner  after  the  latter  as  the  former.  The 
wound  appertains  almost  exclusively  to  the  skin,  comprehending  neither  bone 
nor  aponeurosis ;  the  surface  to  be  covered  is  convex,  regular,  deprived  of  every 
kind  of  asperity,  and  there  is  no  reason  to  apprehend  muscular  contrac- 
tion. In  the  thigh,  on  the  contrary,  the  solution  of  continuity  comprehends 
a  great  aponeurotic  envelope,  and  all  its  concentnc  plates;  muscles  nu- 
merous, and  of  very  considerable  thickness ;  of  a  bone  which  divides  itself 
with  great  facility,  and  the  division  of  which  produces  a  concussion  which  is 
in  itself  not  without  danger ;  and,  in  fine,  of  all  the  cellular  tissues  that  unite 
these  various  parts.  At  the  knee  only  one  artery  of  considerable  size  is  di- 
vided ;  torsion  and  compression  secure  it  almost  as  Certainly  and  as  easily  as 
the  ligature.  At  the  thigh  there  are,  besides  the  principal  trunk,  numerous 
secondary  branches,  all  requiring  to  be  tied  with  care. 

Thus,  in  theory  as  in  practice,  the  amputation  at  the  knee  evidently  offers 
less  danger  than  amputation  at  che  thigh ;  perhaps  even  than  in  the  continuity 
of  the  leg  itself.  I  would  say  further,  that  the  proofs  indicate  it  to  be  less 
dangerous  than  most  other  disarticulations,  althougli  up  to  the  present  time 
it  has  been  practised  mostly  after  very  vicious  methods,  or  under  verj  disad- 
vantageous circumstances- 

Mamial, 

The  patella  which  J.  L.  Petit  recommends  to  be  removed,  should  always  be 
preserved;  the  contraction  of  its  muscles  elevates  and  soon  fixes  it  above  the 
condyles,  where  it  can  interfere  with  neither  the  cicatrization  of  the  wound 
nor  the  use  of  the  stump  after  the  cure. 

1.  Process  of  Hoin. — The  process  of  Hoin,  carefully  described  by  Brasdor, 
and  which  consists  in  cutting  through  the  articulation  from  before  backward 
below  the  patella,  and  finishing  with  a  large  flap  made  from  the  calf  of  the 
leg,  presents  more  than  one  inconvenience.  The  anterior  lip  of  the  wound, 
drawn  by  the  action  of  the  muscles  and  the  natural  contractility  of  the  tis- 
sues, often  mounts  above  the  cartilaginous  surfaces.  Its  angles,  separating 
by  the  lateral  projection  of  the  condyles,  in  spite  of  all  that  can  be  done, 
soon  leave  a  part  of  the  bone  uncovered.  The  flap,  always  thinner  at  its 
root  than  towards  its  point,  adapts  itself  badly  to  the  parts  it  has  to  cover. 
Besides  which,  the  state  of  the  tissues  prevents  us  sometimes  from  giving  it 
sufficient  size  to  reach,  with  ease,  the  retracted  edge  of  the  patella.  In  fine, 
it'is  rare  that  the  cicatrix  will  be  formed  so  high,  that  in  walking  or  standing 
it  will  not  be  exposed  to  pressure. 

2.  Process  of  Leveille. — In  following  the  advice  of  Leveille,  to  form  the 
flap  at  the  expense  of  the  anterior  soft  parts,  the  operator  can  but  rarely  give 
it  sufficient  extent  to  throw  the  cicatrix  far  enough  from  the  resting  point 
of  the  condyles.  This  manner  of  operating  has  not  been  reproduced  in  any 
other  work  of  surgery  than  that  of  Monteggia,  who  barely  mentions  it. 

3.  Process  of  M,  Blayidin, — Nor  can  I  see  what  more  is  to  be  gained  by 


S40       "  NEW   ELEMENTS   OF 

commencing,  instead  of  finishing  bj  the  formation  of  a  flap  behind,  nor  the 
advantage  to  be  derived  from  making  a  counter-opening  in  the  hollow  of  the 
ham  for  the  passage  of  the  ligatures  and  pus,  as  proposed  bj  M.  Blandin. 

4.  Process  of  Mr.  Smith, — With  the  two  flaps  of  Mr.  Smith,  or  rather  of 
M.  Beclard,  I  am  assured  bj  M.  Belmas,  who  assisted  at  the  operation  on  the 
cliild  of  whom  I  have  spoken,  it  is  not  necessary  to  preserve  so  much  of  the 
flesh  in  the  calf  of  the  leg.  Being  forced  to  pursue  this  method  with  my  first 
patient,  I  was  convinced  that  it  offered  at  least  as  many  advantages  as  those 
of  Petit,  Hoin,  and  Brasdor.  However,  whetlier  by  one  or  two  flaps,  nothing 
can  prevent  them  from  contracting  in  extent  as  they  increase  in  thickness, 
and  consequently  leaving  a  portion  more  or  less  considerable  of  the  condyles 
entirely  uncovered ;  so  that  the  cicatrix  can  only  be  completed  by  a  tissue  of 
new  formation. 

Process  ofPossi. — Rossi's  method,  which  consists  in  making  one  flap  inside 
and  another  on  the  outside,  instead  of  before  and  behind,  although  still  more 
vicious,  should  not  be  entirely  rejected,  especially  when  the  skin  is  less  altered 
upon  the  sides  than  elsewhere, 

New  Process. — In  the  process  that  I  have  adopted,  the  skin  is  divided  cir- 
cularly at  three  or  four  fingers'  breadth  below  the  patella,  witliout  touching 
the  muscles.  In  dissecting  it  away  to  elevate  and  evert  it,  care  must  be  taken 
to  preserve  on  its  internal  face  all  the  cellulo-adipose  layer  with  which  it  is 
naturally  thickened,  and  not  to  destroy  its  smaller  blood  vessels.  An  assist- 
ant immediately  draws  it  up  toward  the  knee,  until  in  dividing  the  rotular 
ligament,  the  instrument  can  fall  upon  the  inter-articular  line;  tlie  sur- 
geon then  divides  the  lateral  ligaments ;  separates  the  osseous  surfaces  by 
flexing  the  leg  a  little;  detaches  the  semilunaj*  cartilages ;  divides  the  cru- 
cial ligaments ;  goes  through  the  joint,  and  finishes  by  dividing  at  a  single 
stroke,  the  vessels,  nerves,  and  muscles  of  the  ham,  in  a  direction  perpendi- 
cular to  their  length,  and  on  a  level  with  the  elevated  integuments. 

Dressing. — After  having  tied  or  twisted  the  popliteal  artery  and  the  less 
important  branches  that  may  require  it,  the  operator  turns  down  the  whole  of 
the  dissected  skin,  cleans,  and,  if  he  intend  immediately  to  unite  them,  brings 
the  two  sides  together  so  that  the  angles  of  the  division  may  be  tranverse. 
But  if  the  union  should  not  be  at  once  attempted,  a  fine  piece  of  linen,  covered 
with  cerate  and  pierced  with  holes,  should  be  applied  over  the  whole  solution 
of  continuity,  which  is  then  filled  with  lint,  and  the  whole  covered  with  soft 
pledgets,  and  enveloped  in  an  ordinary  bandage. 

By  this  method  the  integuments  represent  a  kind  of  purse  or  nifile,  which 
envelopes  and  covers  the  condyles  as  well  at  the  sides  as  before  and  behind. 
As  it  is  a  little  smaller  at  the  mouth  than  in  its  depth,  it  is  similar  to  a  sleeve 
somewhat  tight  at  the  wrist ;  and  consequently  offers  some  impediment  of 
itself  to  its  retraction  upon  the  thigh.  The  muscles  are  divided  squarely,  and 
where  they  are  very  small,  present  but  a  very  small  bleeding  surface ;  leave 
the  skin  free,  and  cannot  aggravate  the  traumatic  inflammation  or  excite  any 
just  fear  of  too  abundant  a  suppuration,  as  in  other  methods.  In  fine,  the 
ligatures,  if  they  are  used,  are  easily  applied;  and  collected  at  a  point  so 
<listant  from  the  vessels  which  they  secure,  and  in  such  a  manner  as  to  irritate 
but  little  the  interior  of  tlie  wound. 

I  would  not  however  conclude  from  these  data,  that  all  otlier  methods 


OPERATIVE    SURGERY.  241 

should  be  henceforth  abandoned  as  useless.  If  the  skin  be  too  much  altered 
before,  whilst  it  is  otherwise  behind,  it  would  be  better  to  use  Petit's  method. 
Smith's  process  will  be  in  some  sort  necessary,  if  the  disorganization,  being 
liigher  on  each  side  towards  the  condyles  than  an tero -posteriorly,  has  already 
traced  the  limits  of  the  flap.  But  in  other  cases,  whenever  circumstances 
admit  of  choice,  I  will  venture  to  say  that  the  circular  method  offers  the 
greatest  advantages,  and  should  be  generally  preferred. 

Art.  9.— Thigh. 
§  1.  In  the  Continuity. 

Place  of  Election. — It  is  not  with  the  thigh  as  with  the  leg;  here  the  ampu- 
tation should  be  as  low  as  possible.  The  greater  the  length  of  the  stump,  the 
more  easy  is  it  to  apply  the  substituted  apparatus.  The  operation,  already 
one  of  the  most  dangerous  class,  is  still  more  dangerous  the  nearer  we  approach 
the  trunk.  It  is  then  astonisliing,  that  M.  Langenbeck  should  recommend  it 
never- to  be  performed  below  six  fingers'  breadth  above  the  knee;  alleging,  as 
the  pretext,  that  lower  down  the  artery  is  confined  in  the  sheath  of  the  abduc- 
tors, and  that  it  will  be  difficult  to  draw  it  out  for  ligature.  As  the  femoral 
artery  may  be  reached  above  or  below  the  fibrous  canal  which  it  traverses,  or 
even  in  the  canal  itself,  it  can  in  no  case  be  difficult  to  seize,  nor  require  an 
after-division  of  the  sheath  which  encloses  it.  On  the  other  hand,  as  it  is  rare 
that  the  disease  permits  the  division  of  the  integuments  at  less  than  two  or 
three  inches  above  the  patella,  the  section  of  the  femur  must  almost  always 
be  more  than  five  inches  above  the  articulation,  and  therefore  the  precept  of 
M.  Langenbeck  is  useless. 

Anatomical  Remarks. — In  the  thigh,  as  in  the  arm,  tliere  are  found  two 
beds  of  muscles,  one  superficial,  composed  of  the  rectus,  the  sartorius,  the 
gracilis,  the  semitendinosus,  the  semimembranosus,  and  the  long  portion  of  the 
biceps ;  the  other  deep-seated,  comprehending  the  three  parts  of  the  triceps  and 
the  abductors.  The  first  extend  from  the  pelvis  to  the  leg,  eacli  one  in  a  sort  of 
distinct  cellular  sheath,  which  permits  them  to  move  easily  beside  each  other, 
and  consequently  enjoying  very  great  contractility.  The  intimate  connexion 
of  the  others  with  the  bone,  on  the  contrary,  allows  them  but  slight  retractile 
power ;  hence  it  is  the  superficial  layer  only  which  contracts  after  amputation, 
so  as  sometimes  to  leave  the  femur  uncovered  and  projecting.  Near  the  pel- 
vis, we  find,  besides  the  psoas  and  iliacus,  the  great  gluteal,  and  the  pecti- 
neus ;  then  quite  high  up  the  other  two  glutei,  the  obturatores,  the  gemini,  the 
pyriformis,  and  the  quadratus,  which,  by  the  great  separation  of  their  points 
of  origin,  tend  much  more  to  enlarge  the  wound  than  to  denude  the  bone,  if 
the  amputation  be  performed  between  the  lesser  trochanter  and  the  hip  joint. 

The  femur,  bending  slightly  forwards  near  its  middle,  is  enveloped  at  this 
point  by  a  bed  of  soft  parts  less  thick,  and  by  muscles  much  less  retractile  be- 
fore than  behind.  From  which  it  happens  that  the  cicatrix  forms  almost  al- 
ways more  or  less  inwards  or  backwards,  and  that  the  extremity  of  the  bone 
never  corresponds  to  the  centre  of  the  stump  in  those  amputated  at  the  thigh. 
The  crest  which  the  bone  presents  posteriorly,  easily  splinters  under  the 
action  of  the  saw,  and  consequently  requires  much  care  during  that  part  of, 
the  operation. 

31 


242  NEW   ELEMENTS    OF 

The  femoral  artery  is  the  only  one  of  importance  met  with  in  the  lower 
part  of  the  thigh.  As  it  is  covered  by  the  sartorius,  it  is  always  easy  to 
find.  However,  the  anastomotica  magna  must  not  be  forgotten.  It  is  some- 
times enveloped  by  the  tendinous  fibres  of  the  great  adductor,  the  direction 
of  whicli  it  follows,  and  it  is  in  such  cases  very  difficult  to  isolate.  The  deep- 
seated  muscular  or  perforantes,  and,  nearer  the  pelvis,  the  superficial  muscu- 
lar and  circumflex  arteries,  must  be  added  to  the  crural ;  the  first  over  the 
anterior  of  the  adductor  muscles,  or  in  the  midst  of  them ;  the  second  under 
the  rectus ;  the  other  tvVo,  inside  and  outside,  a  little  above  the  lesser  tro- 
chanter 

The  femoral  vein  is  connected  with  the  artery  in  such  a  manner  that  the 
precautionary  compression  of  the  latter  prevents  the  return  of  blood  by  the 
former;  thereby  often  producing  hemorrhage.  The  great  sciatic  nerve,  loose 
at  tlie  posterior  part  of  the  thigh  and  anterior  to  tlie  superficial  muscles,  devoid 
of  all  contractility  in  itself,  sometimes  hangs  out  from  the  wound,  beyond 
which  it  may  project  more  than  an  inch,  and  thereby  render  the  dressings  very 
painful.  In  such  a  case  the  best  thing  to  be  done  is,  as  recommended  by  M. 
Discot,  to  cut  it  oft*  at  once.  Another  branch  of  the  nerve  that  requires  some 
attention,  is  that  which  attends  the  crural  artery.  Its  diminutive  size  prevents 
it  from  being  readily  distinguished.  Yet,  by  remembering  that  it  is  always 
upon  the  anterior  and  internal  face  of  the  artery  or  vein,  an  operator  will  not 
be  much  embarrassed  in  finding  and  putting  it  aside. 

Manual. 

A.  Circular  MetJtod. — All  that  has  been  said  of  the  circular  method  in 
general  applies  particularly  to  this.  As  it  is  of  all  amputations  in  continuity 
the  most  serious  and  alarming,  it  is  to  this  that  F.  dfe  Hilden,  Wiseman, 
Pigray,  J.  L.  Petit,  Le  Dran,  Louis,  Pouteau,  Valentin,  Alanson,  Hey, 
Desault,  &:c.  have  particularly  referred,  in  their  discussions  upon  the  ablation 
of  the  members. 

Position  of  the  Assistants. — Placed  upon  the  foot  or  edge  of  his  bed  or  a 
table,  with  the  thigh  free  to  its  root,  the  patient  is  held  by  four  or  five  assist- 
ants ;  one  for  the  head  and  arms,  another  for  the  pelvis,  a  third  for  the  sound 
limb,  a  fourth  for  the  leg  of  the  affected  side,  and  a  fifth  to  draw  up  the  tissues. 
The  tourniquet,  or  the  garot,  which  some  persons  still  use,  and  every  kind  of 
bandage  m  hich  was  formerly  applied  above  the  point  of  division  of  the  flesh  to 
prevent  hemorrhage,  should  be  rejected,  as  preventing,  or  at  least  lessening  tlie 
contraction  of  the  muscles.  The  practice  of  Girardeau,  adopted  by  almost 
all  modern  surgeons,  and  wliich  consists  in  compressing  the  artery  upon  the 
body  of  the  pubis,  since  it  does  away  with  this  objection,  merits  the  prefer- 
ence that  it  has  generally  received.  It  will  be  inexcusable  to  follow  the  an- 
cient method,  unless  under  special  circumstances  in  the  case,  or  for  want  of 
sufficient  assistance.  In  every  case  the  tourniquet  should  be  placed  as  high 
as  possible.  According  to  S.  Cooper,  in  order  that  the  left  hand  may  always 
embrace  the  thigh  on  the  side  next  its  origin,  it  is  the  practice  in  England  for 
the  operator  to  place  himself  always  on  the  right  of  the  patient ;  so  that  in  the 
amputation  of  the  left  thigh  the  sound  member  is  placed  between  him  and  the 
one  to  be  removed.    I  need  not  assign  the  value  of  such  a  precept ;  every 


OPERATIVE   SURGERY.  243  . 

surgeon  amongst  us  will  give  it  what  it  merits.  In  France  the  operator 
places  himself  on  the  outside  for  both  limbs,  and  consequently,  when  operating 
on  the  left,  he  must  leave  tlie  retraction  of  tlie  integuments  to  an  assistant. 

The  first  incision,  which  comprehends  as  nearly  as  possible  the  whole 
thickness  of  the  integuments,  is  begun  above  the  knee  at  four  or  five  fiihgers' 
breadth  from  the  point  at  which  the  division  of  the  bone  is  to  be  made.. 
Whether  the  aponeurosis  and  the  subjacent  muscular  fibres  be  reached  or  not,^ 
is  of  little  importance;  the  chief  matter  is  the  complete  division  of  the  skin." 
In  endeavoring  to  favor  its  retraction,  it  should  be  remembered  that  it  adheres 
much  more  firmly  to  the  aponeurosis,  on  the  anterior  part  of  the  thigh,  than 
elsewhere. 

Second  Step, — Tlie  knife,  again  placed  at  the  edge  of  tlie  retracted  integu- 
ments, is  made  to  cut  the  muscles,  if  not  to  the  bone,  at  least  through  the  super- 
ficial bed.  After  the  retraction  of  this  part,  the  surgeon  again  applies  the 
instrument  upon  the  base  of  the  cone  formed  by  these  divided  parts,  and  with 
another  cut  divides  the  remaining  fleshy  fibres;  he  then  denudes  the  bone, 
applies  the  defensive  compress,  crossing  the  strips  anteriorly,  incises  any 
tissue  that  may  yet  remain  attached  to  the  bone,  and  then  finishes  with  the 
saw. 

Above  the  middle  of  the  limb  the  muscles  contract  much  less ;  but  as  the 
volume  of  the  member  is  more  considerable,  it  is  equally  necessary  to  com- 
mence three  or  four  inches  below  the  point  at  which  the  saw  is  to  be  applied. 
Perhaps  there  would  be  some  advantages  when  the  operation  is  nearer  the 
hip,  in  using  M.  Graefe's  knife,  in  order  to  make  a  kind  of  funnel  of  the  soft 
parts,  or  else  divide  them,  as  Alanson  and  M.  Dupuytren  do,  by  inclining  the 
edge  of  the  instrument  upwards.  In  fact,  a  perpendicular  division  produces 
a  wound  so  square  or  level,  that  it  is  sometimes  very  difficult  to  bring  its 
parts  in  contact.  But  this  inconvenience  is  easily  obviated,  by  taking  the 
precaution  to  dissect  the  skin  for  two  inches,  and  evert  it,  instead  of  merely 
dividing  the  cellular  filaments  that  connect  it»with  the  aponeurosis,  as  in 
the  process  of  Desault.  I  have  seen  M.  J.  Cloquet,  in  the  case  of  a  young 
subject  at  the  Hopital  de  Perfectionnemenf,  on  whom  he  was  obliged  to  operate 
at  a  short  distance  from  the  great  trochanter,  unable  to  produce  immediate 
union,  from  having  neglected  this  precaution.  The  same  thing  has  happened 
to  myself. 

The  arteries  to  be  tied  or  twisted  in  the  lower  part  of  the  thigh,  are  the 
femoral,  the  great  anastomotic,  and  some  articular  branches,  or  those  of  the 
last  perforating.  The  number  augments  as  we  go  up ;  so  that  in  the  hig;her 
parts  there  are  the  profound  femoral,  the  superficial  muscular,  some  branches 
of  tlie  circuiafiex,  the  obturator,  and  the  ischiatic.  To  give  easy  escape  to 
the  matter  formed,  French  surgeons  give  the  wound  such  a  direction,  that  one 
of  its  angles  presents  anteriorly,  wliilst  the  other  is  immediately  behind. 
Some  of  the  operators  of  Great  Britain  blame  this  plan  as  vicious,  because  the 
posterior  angle  must  necessarily  come  in  contact  with  the  cushions  or  matrass. 
Among  others,  Dr.  Hennen  recommends  an  antero -posterior  coaptation  of  the 
tissues,  thus  giving  the  wound  a  transverse  direction.  But  without  being 
absolutely  necessary,  the  French  method  is  best.  For  the  position  of  the  stump 
after  dressing,  I  refer  to  what  has  already  been  said  a.bov^ 

Flap  Operation. — As  by  the  modern  processes,  the  circ^r  amputation,  well 


244  NEW  ELEMENTS  OF 

performed,  generally  admits  of  the  coaptation  of  the  lips  of  the  wound,  and 
of  immediate  union,  the  flap  operation  has  not  been  tried  in  such  a  variety  of 
ways  above  as  below  the  knee.  In  spite  of  the  advantages  which  Ravaton, 
Vermale,  Le  Dran,  and  Desault  are  said  to  have  obtained  from  it;  notwith- 
standing those  which  Paroisse  obtained  from  it  on  the  field  of  battle ;  although 
the  seven  individuals  spoken  of  by  Kleim,  were  almost  completely  cured  in 
ten  days ;  and  although  many  other  surgeons,  both  English  and  German,  have 
used  it  of  late  with  much  success,  still  it  is  but  very  little  employed.  It  is 
objected,  that  it  is  longer  and  more  painful — which  objection,  in  my  opinion, 
has  to  be  proven  ;  that  it  requires  a  greater  extent  of  sound  parts — an  objection 
perhaps  a  little  more  correct ;  and  that  it  exposes  the  patient  to  more  serious 
consequences — and  this  again  is  perhaps  just.  I  have  never  attempted  it  but 
once ;  the  bone  escaped  by  the  superior  angle  of  the  wound,  and  the  patient 
died.  Some  surgeons,  Mr.  Guthrie  for  instance,  who  prefer  the  circular 
operation  under  other  circumstances,  have  yet  recourse-to  tlie  flap  operation 
when  it  is  necessary  to  amputate  in  the  superior  third  of  the  thigh.  It  then 
certainly  offers  incontestable  advantages  for  the  approximation  of  the  lips  of 
the  wound. 

1.  Process  of  Vermale. — Nothing  could  induce  us  at  the  present  day  to 
practise  the  three  incisions  of  Ravaton,  to  form  the  flaps  that  may  be  needed. 
It  is  infinitely  more  simple  to  cut  at  once  through  the  whole  thickness  of  tlie 
member,  as  advised  by  Vermale.  The  patient  and  assistants  being  disposed 
as  before,  the  operator  places  himself  on  the  outside  for  the  right,  and  on  the 
inside  for  the  left  limb  (this  position  however,  he  is  not  bound  rigidly  to 
follow );  seizes  the  flesh  with  liis  left  hand,  and  draws  more  or  less  from  the 
bone ;  plunges  in  a  long  knife  till  it  reaches  the  anterior  face  of  the  femur  at 
some  lines  below  the  point  where  it  is  to  be  divided ;  inclines  the  point  of  the 
instrument  slightly  so  as  to  graze  the  external  side  of  the  bone ;  then  immedi- 
ately after  gives  it  its  original  direction,  so  as  to  pass  it  out  at  a  point  dia- 
metrically opposite  the  one  at  which  it  entered;  and  then,  by  cutting 
downwards  and  outwards,  forms  the  external  flap,  of  about  three  or  four 
fingers'  breadtli  in  length,  which  the  assistant  immediately  raises.  The 
knife  is  again  brought  to  the  anterior  angle  of  the  wound,  and,  the  fleshy  parts 
forced  away  from  the  axis  of  the  body,  it  is  made  to  glide  along  the  internal  face 
of  the  femur,  care  being  taken  to  carry  it  behind  this  bone  without  cutting 
the  soft  parts  a  second  time ;  and  the  operation  is  finished  by  making  a 
second  flap  of  the  same  size  and  form  as  the  first.  If,  to  adopt  Dr.  Hennen's 
ideas,  the  operator  wishes  to  give  the  incision  a  transverse  direction,  the  flap 
operation  may  still  be  used ;  but  it  will  be  necessary  to  make  one  of  these 
flaps  anterior  and  the  other  posterior,  instead  of  internal  and  external.  I 
prefer  to  begin  with  the  external  flap,  because,  there  being  less  to  divide  on 
this  side,  it  is  necessary  to  draw  them  out  as  much  as  possible,  that  there  may 
not  be  too  much  difference  in  the  thickness  of  the  two  flaps,  and  especially 
because,  in  this  way,  we  may,  if  necessary,  dispense  with  the  compression  of 
the  artery  at  the  inguinal  space,  since  it  is  not  divided  until  the  very  moment 
of  the  completion  of  the  flap. 

2.  Process  of  M.  Langenbeck. — Instead  of  commencing  the  operation  by 
puncture,  and  then  cutting  outwards  the  skin,  Langenbeck  cuts  from  the 
tegumentary  tissulP  towards  the  bone.     The  operator  places  himself  on  the 


OPERATIVE    SURGERY.  245 

inside  for  the  right  limb,  and  the  outside  for  the  left  member,  unless  he  be 
ambidexter;  has  the  skin  drawn  upward  by  an  assistant ;  seizes  the  knee  him- 
self with  one  hand,  and,  with  a  knife  of  moderate  length  in  the  other,  divides 
with  a  single  stroke  all  the  soft  parts  which  cover  the  inner  face  of  the  femur 
from  below  upward,  and  from  the  superficial  towards  the  deeper  parts,  so  that 
his  instrument  may  reach  the  bone  at  not  less  than  three  inches  above  the  point 
at  which  the  incision  in  the  integuments  was  commenced.  An  assistant 
then  elevates  this  flap.  The  operator  passes  the  fore-arm  behind,  then  out- 
side, and  then  before  the  thigh,  and  by  a  second  incision  cuts  externally  an- 
other flap  similar  to  the  first,  taking  care  to  connect  its  semilunar  extremities 
with  those  of  the  internal  incision. 

In  both  these  processes  it  is  necessary,  after  making  the  two  flaps,  to  carry 
the  knife  to  their  base,  and  divide  the  soft  parts  that  may  yet  remain  attached 
to  the  bone,  so  that  the  saw  m.ay  be  applied  as  high  up  as  the  point  to  which 
the  knife  has  reached. 

It  is  evident  that  the  operator  may  content  himself  with  one  flap,  either 
internal  or  external,  anterior  or  posterior,  if  the  state  of  the  skin  does  not 
allow  room  for  a  second  opposite  the  first,  and  that  all  the  peculiarities 
belonging  to  the  flap  operation  in  general  apply  to  that  of  the  thigh  in  parti- 
cular. M.  Baucel,  who  is  said  to  have  followed  the  process  of  Vermale  in 
every  particular,  is  affirmed  to  have  been  sixty  times  successful.  M.  Hello, 
%vho  at  the  suggestion  of  M.  Fouilloy  made  but  a  single  flap  out  of  the  anterior 
soft  parts,  maintains,  with  justice  in  my  opinion,  that  his  method  has  the 
advantage  of  more  decidedly  opposing  the  projection  of  the  bone  than  any 
other,  because  the  parts  are  drawn  by  their  own  weight  over  the  whole  extent 
of  the  wound.  I  doubt,  however,  if  the  circular  method,  well  performed,  may 
not  be  preferable  to  all  these,  which  should  be  preserved,  as  I  think,  only  as 
exceptionary  methods. 

In  Contiguity. 

History  and  Value. — Morand  appears  to  have  had  the  first  idea  of  amputat- 
ing the  thigh  at  the  articulation,  and  to  have  been  the  first  to  conceive  the 
possibility  of  success  in  this  formidable  operation.  Two  young  practitioners^ 
eleves  of  Wolher,  surgeon  to  the  horse-guards  of  the  King  of  Denmark,  that 
surgeon  himself,  Puthod  de  Nyon,  in  Switzerland,  made  the  first  formal 
proposition  of  it  to  the  Academy  of  Surgery,  the  3d  of  March,  1739,  and 
obtained  a  favorable  report  the  26th  of  July,  1740,  from  Le  Dran  and  Guerin. 
Ravaton  would  have  put  it  in  practice  in  1743,  if  some  of  his  compeers, 
called  in  consultation,  had  not  opposed  it.  The  7th  of  March,  1748,  Vallum 
sustained  a  thesis  of  Lalouette's  upon  the  subject,  which  Morand  succeeded 
in  opening  to  a  concoiirs,  in  1756 ;  and  again  in  1759,  the  academy,  not  having 
found  any  w^ork  the  first  time  worthy  the  prize  proposed,  thirty-four  memoirs 
were  received,  and  that  of  Barbet  crowned.  Goursault,  Moublet,  Le  Febure, 
Puy,  and  Le  Compte,  also,  have  each  published  a  work  on  the  disarticulation 
of  the  thigh.  Almost  all  came  to  the  conclusion  that  it  was  practicable; 
some  after  attempting  it  upon  the  dead  subject,  others  from  experiments  made 
on  dogs.  Barbet  sustained  its  practicability  from  analogy,  and  upon  its 
result  upon  an  infant,  aged  four  years,  affected  with  gangrene  from  the  use  of 


246  ,  NEW    ELEMENTS    OF 

ergot,  who  first  had  the  right,  and  then,  four  days  after,  the  left  tliigh  ampu- 
tated by  Lacroix  d'Orleans,  in  the  presence  of  Le  Blanc,  and  who  appeared  to 
be  on  the  point  of  being  cured,  but  eventually  died  fifteen  days  after  the 
operation.  Perrault  of  Saint-Maure,  in  Tourain,  was  obliged  to  imitate 
Lacroix,  in  1774,  on  a  subject  named  Gois,  who  had  had  the  thigh  crushed 
between  a  wall  and  the  pole  of  a  coach,  and  rendered  grangrenous  almost  to 
the  hip.  This  patient,  of  whom  Sabatier  gives  us  the  history,  was  cured, 
and  for  a  long  time  continued  to  be  a  cook  in  an  inn,  at  Saint-Maure,  where 
I  myself  saw  his  son,  in  1815.  Kerr,  according  to  S.  Cooper  performed  the 
same  operation,  but  unsuccessfully,  about  the  same  time,  upon  a  girl  aged 
fourteen  years.  Pott  and  Callisen  having  reprobated  it,  Bilguer,  Tissot,  &c., 
in  vain  defended  it;  and  at  the  commencement  of  the  present  century  it  was 
considered  almost  out  of  the  question  in  England  and  Germany.  It  was  in 
the  French  armies  that  it  was  subjected  to  sufficient  proof.  M.  A.  Blandin 
cites  three  cases  of  it.  He  operated  on  the  first  of  his  patients  in  the  month 
of  Fructidor,  year  III,  and  completely  succeeded.  The  second  was  equally 
successful,  and  the  third  did  not  die  until  the  fifty-eighth  day.  At  the  same 
time  M.  Perret,  another  military  surgeon,  performed  one  successful  ope- 
ration. In  1798,  Mulder  was  not  less  happy  with  a  girl  aged  eighteen  years. 
In  1803,  M.  Larrey  had  already  disarticulated  the  thigh  several  times,  and 
his  memoirs  contain  two  well -authenticated  cases  of  success;  one  upon  a 
Russian  at  Witepzk,  the  other  upon  a  French  soldier  at  Mojaisk.  According 
to  M.  Gouraud,  Dr.  Millengen  had  two  successful  cases,  which  he  published 
in  London.  M.  Baifos  attempted  it  in  1812,  at  the  Hopital  des  Enfants,  upon 
a  subject  aged  seven  years,  who  was  cured  of  the  operation,  although  it  died 
some  months  after,  from  the  continuance  of  the  scrofulous  affection  of  the 
joint.  A  soldier,  wounded  at  Merida,and  operated  upon  by  Mr.  Brownrigg, 
so  far  recovered  that  he  returned  to  England,  where  many  persons  have  since 
seen  him.  M.  Cloquet  saw  a  French  prisoner,  in  1815,  at  Val  de  Grace,  who 
had  been  operated  upon  in  the  same  manner,  by  Mr.  Guthrie.  Another 
successful  case  in  France  was  produced  by  M.  Delpech,  and  two  others  in 
England,  one  by  Sir  A.  Cooper,  in  1824,  the  other  by  Mr.  Orthon,  in  1826. 
Dr.  Mott,  of  New  York,  published  another,  in  1827,  and  M.  Wedemeyer 
still  another.  Mr.  Lyme's  patient,  in  1825,  was  cured  in  thirty-four  days. 
Mr.  Bryce's,  in  1825,  who  was  near  perisliing  from  hemorrhage,  was  met 
some  months  after  by  this  surgeon,  at  Poros,in  perfect  health.  So  that  up  to 
the  present  time,  this  operation,  which  M.  Richerand  for  ten  years  would 
scarcely  admit  as  possible,  counts  near  twenty  well-authenticated  cases  of 
success.  But  during  the  same  time,  how  often  has  it  been  followed  by  death? 
Thompson,  Kerr,  A.  Blandin,  A.  Cooper,  Broocke,  Cole,  Walther,  Larrey, 
Guthrie,  Emery,  Dupuytren,  Blicke,  Krimer,  Gensoul,  Clot,  Roux,  &c.,  have 
each  had  the  misfortune  to  see  at  least  one  of  their  patients  succumb  to  it. 
The  second  operated  upon  by  M.  Delpech,  died  in  about  two  months.  One  of 
those,  of  Mr.  Pelikan,  of  Wilna,  died  in  ten,  the  other  in  sixty  days.  M. 
Dieffenbach's  survived  but  ten  hours.  I  performed  it  once  myself,  and  the 
patient  died  on  the  fourteenth  day.  We  should  then  only  decide  upon  this 
amputation,  when  it  is  difficult  to  amputate  with  some  chances  of  success  in 
the  continuity  of  the  limb.  M.  Larrey  seems  even  to  prefer  it  when  it  would 
be  possible  to  saw  the  bone  between  the  lesser  trochanter  and  the  articulation . 


OPERATIVE    SURGERY.  247 

I  am  entirely  of  his  opinion  upon  this  point.  The  case  I  have  spoken  of  as 
occurring  to  myself,  and  two  amputations  of  the  latter  kind  which  I  was 
forced  to  perform,  have  convinced  me  that  he  is  right.  My  patient  was  in 
such  a  state  of  exhaustion  when  he  submitted  to  the  operation,  and  the  disorder 
had  extended  so  far  towards  the  pelvis,  that  I  could  scarcely  comprehend  how 
he  could  have  existed  even  for  a  few  hours  under  so  many  lesions.  The  cases 
of  Barbet,  Kerr,  Baffos,  and  Delpech,  failed  from  the  progress  of  the  primary 
affections,  and  not  in  consequence  of  the  operation.  In  the  other  cases  the 
disease  was  so  serious,  that  the  simple  amputation  of  the  thigh  in  continuity 
would  probably  have  been  followed  by  the  same  fate,  had  that  onei-ation  been 
performed. 

Hence,  a  comminuted  fracture,  necrosis,  caries,  osteo -sarcoma,  spina- 
ventosa,  or  any  incurable  alteration  of  the  femur  extending  to  the  head  of 
the  bone ;  gangrene  ;  every  disease,  in  a  word,  which  may  attack  the  hip,  and 
be  sufficiently  serious  to  require  amputation,  calls  for  this  operation,  provided 
the  articular  cavity  and  the  bones  of  the  pelvis  are  not  affected.  Wounds 
from  fire-arms,  with  lesion  of  the  bone  in  the  superior  third  of  the  thigh,  give 
the  most  formal  indication.  As  it  is  then  necessary  to  use  the  knife  at  a 
certain  distance  above  the  disease,  I  can  see  no  reason  to  hesitate  in  attempt- 
ing it.  Reason,  and  the  facts  already  known,  lead  to  the  belief  that,  all  other 
things  being  equal,  it  is  not  more  dangerous  than  amputation  in  the  upper  fifth 
of  the  femur.  It  is  more  easily  performed  and  much  more  prompt.  The  sur- 
face of  the  wound  is  not  larger.  The  same  muscles  and  the  same  vessels  are 
divided,  and  there  is  less  of  the  tissues  necessary  to  obtain  co-aptation  of  the 
parts.  If  practised  in  cases  less  desperate,  I  am  convinced  it  will  be  attended 
with  very  considerable  success. 

Anatomical  Remarks. — The  head  of  the  femur,  forming  more  than  a  hemi- 
sphere, is  enveloped  in  such  a  way  in  its  fibrous  capsule,  that  it  will  continue 
to  be  held  by  it  unless  the  capsule  be  divided  near  the  edge  of  the  socket.  The 
circumference  of  its  transverse  plane,  upon  which  the  axis  of  the  neck  of  the 
femur  falls  obliquely  outward,  downward,  and  backward,  having  to  be  traced 
round  with  the  knife  at  the  moment  of  the  operation,  should  never  be  lost 
sight  of.  The  position  of  the  internal  ligament  is  such  that,  by  turning  the 
limb  outwards,  it  presents  itself  at  once  to  the  edge  of  the  knife.  If  the  ope- 
ration be  commenced  on  the  external  side  of  the  articulation,  it  is  true  that 
this  ligament  becomes  relaxed  in  proportion  as  the  thigh  is  inclined  inwards  ; 
but  as  it  in  no  wise  prevents  the  luxation,  it  is  very  easily  divided  on  the 
inner  edge  of  the  cavity. 

Covered  by  the  psoas  and  iliacus  muscles,  a  little  on  the  outside  by  the  rectus 
internus,  by  the  pectineus,  the  vessels  and  nerves  on  the  inside,  the  coxo-fe- 
moral  articulation  is  more  superficial  before  than  in  any  other  direction,  and 
corresponds  to  the  junction  of  the  middle  with  the  external  third  of  Poupart's 
ligament.  Behind,  it  is  separated  from  the  skin  by  a  considerable  space, 
which  is  filled  by  the  third  abductor,  the  quadratus  femoris,  semitendinosus, 
semimembranosus,  biceps,  the  obturators,  the  gemini,  and  pyriformis  muscles, 
of  the  cellular  tissue,  the  great  sciatic  nerve,  and  some  vessels.  A  triangu- 
lar space,  filled  by  the  gluteal  muscles  and  facia  lata,  limited  by  the  great 
trochanter  below,  and  by  the  external  iliac  fossa  above,  removes  its  external 
side  from  the  skin,  whilst  the  great  trochanter  itself  is  almost  naked  beneath 


248  NEW  ELEMENTS   OF 

the  integuments.  Internally  there  is  found  a  kind  of  gorge  or  hollow, 
formed  by  the  concavity  of  the  neck  of  the  femur,  which  descends  as  low  as 
the  lesser  trochanter,  filled  by  the  principal  mass  of  the  abductors,  the  gra- 
cilis, the  end  of  the  psoas  and  ilacus,  and  which  obliges  us  to  seek  the  cap- 
sule on  a  plane  much  nearer  the  symphysis  pubis,  and  much  higher  than  the 
axis  of  the  member  would  seem  to  indicate. 

The  lines  drawn  from  the  anterior-superior  spinous  process  of  the  ileum,  from 
the  great  trochanter  or  spine  of  the  pubis,  to  measure  the  distance  whicji  sepa- 
rates these  difierent  points' of  the  articulation,  and  upon  which  M.  Lisfranc 
especially  insists,  should  not  be  neglected  in  an  embarrassing  case ;  but  the 
preceding  indications  will  generally  suffice  for  a  surgical  anatomist.  The 
great  and  little  trochanters,  and  even  the  head  of  the  femur,  continuing  carti- 
laginous until  the  tenth  or  fifteenth  year  of  age,  may  if  necessary  be  divided 
by  the  knife,  if  there  be  any  difficulty  in  turning  their  prominences  in  such 
young  subjects.  The  anomalies  presented  by  the  cotyloid  cavity,  the  tube- 
rosity of  the  ischium  or  the  neck  of  the  femur,  and  the  projections  near  its 
base,  regard  only  the  length,  projection,  or  inclination  of  these  different 
objects ;  so  that  they  rarely  cause  any  real  difficulties  at  the  moment  of  dis- 
articulation. 

§  1.  Manual. 

A.  Circular  Method. — 1.  English  Process. — Abernethy  appears  to  have 
been  the  first  to  think  that  the  amputation  of  the  thigh  in  the  articulation 
could  be  performed  by  the  circular  method.  This  surgeon  compresses  the 
artery  on  the  body  of  the  pubis ;  divides  first  the  skin  and  then  the  muscles  at 
some  inches  below  the  joint;  separates  the  flesh  from  the  great  and  little  tro- 
chanter; opens  the  capsule ;  divides  the  inter-articular  ligament ;  dislocates 
die  bone ;  ties  the  different  arteries,  and  concludes  by  uniting  the  lips  of  the 
wound  antero -posteriorly  with  adhesive  plaster,  to  maintain  them  in  contact. 
Mr.  CoUes  is  not  the  only  one  who  has  practised  Mr.  Abernethy's  method 
upon  the  living  subject.  M.  Krimer  has  also  followed  it.  Dr.  Weitch,  who 
also  prefers  it,  exposes  the  femur  before  seeking  the  articulation  for  two  or 
three  inches  downward,  below  the  incision  of  the  soft  parts,  in  order  to  use  it 
afterward  as  a  lever  to  disengage  it  from  its  cavity ;  a  useless  precaution,  for 
it  is  always  possible  to  move  the  member  with  sufficient  force  in  any  direction 
after  dividing  the  capsule. 

2.  Process  of  M.  Grsefe. — The  circular  method  is  equally  praised  by  M. 
Graefe,  who  also  applies  it  to  almost  all  disarticulations,  and  claims  the  honor 
of  its  invention.  At  the  thigh,  as  at  the  shoulder,  he  makes  use  of  his  large 
knife  to  divide  the  flesh,  and  penetrates  from  below  upward  from  the  skin  to 
the  head  of  the  bone,  in  such  a  manner  as  to  scoop  out  a  hollow  cone'  as  regu- 
larly as  possible.  Having  remarked  that  the  head  of  the  femur  is  sometimes 
difficult  of  dislocation,  M.  Grsefe  recommends  the  incision  of  the  cotyloid 
cartilage  upon  the  notch  of  the  same  name ;  but  if  the  operator  takes  care  to 
divide  the  fibrous  capsule  exactly  over  the  largest  circle  of  the  joint,  there 
will  be  no  danger  of  the  inconvenience  that  he  apprehends,  and  which,  accord- 
ing to  S.  Cooper,  detained  a  celebrated  operator  of  London  nearly  half  an 
hour  in  the  disarticulation  of  the  thigh. 

B.  Flap  Operation. — The  method  by  the  flaps  has  almost  always  been  pre-    , 


OPERATIVE  SURGERY.  249 

ferred  for  thi s  amputation.  A  variety  of  different  methods  have  been  invented. 
I  shall  not  speak  of  those  of  Ravaton,  Moublet,  or  of  Petit  Radel,  because 
they  are  too  difficult  or  too  complicated.  Barbet,  Penault,  and  M.  Baffos, 
having  as  it  were  only  finished  what  nature  had  begun,  do  not  present  us  with 
a  process  to  be  described. 

1.  Process  of  Lalouette. — In  a  thesis  sustained  under  the  Presidency  of 
Lalouette,  we  find  indicated  one  of  the  best  processes  that  can  be  followed. 
It  should  be  commenced,  says  Louis,  who  reproduced  it,  by  a  section 
almost  sfemicircular  at  the  external  part  of  the  thigh,  in  order  to  disarticulate 
the  femur  before  any  thing  else,  and  then  to  finish  by  an  incision  of  the  inter- 
nal part,  preserving  a  flap  of  four  or  five  fingers'  breadth.  The  candidate  M. 
de  Vallun,  described  it  as  follows :  the  artery  is  compressed  with  a  tourniquet ; 
the  patient  placed  upon  the  healthy  side,  the  operator  makes  a  semicircular 
incision,  commencing  over  the  great  trochanter,  ending  at  the  tuber  of  the 
ischium,  and  penetrating  to  the  articulation.  With  a  second  cut  he  opens  the 
capsule,  whilst  the  assistant  carries  the  member  inward ;  luxates  the  femur ; 
divides  the  rest  of  the  capsule,  and  terminates  by  making  a  greater  or  smaller 
internal  flap,  adapted  to  the  embonpoint  of  tlie  patient.  M.  Lenoir,  assistant 
anatomist  to  the  faculty  of  Paris,  who  has  recently  reintroduced  this  prac- 
tice, employs  an  assistant  to  compress  the  artery,  who  compresses  it  in  tlie 
flap  with  the  thumb  as  soon  as  the  incision  is  completed.  The  rest  of  his  de- 
scription is  so  exactly  similar  to  that  of  Vallun  and  Louis,  tliat  I  think  it  use- 
less here  to  repeat  it. 

2.  Process  of  M.  Plantade. — Many  persons  have  thought  that  it  would  be 
better  to  place  the  flap  altogether  in  front,  than  upon  the  inner  side  of 
the  thigh.  M.  Plantade,  who  was  one  of  the  first  to  suggest  it,  recommends 
the  making  of  three  incisions  after  the  manner  of  the  scapulo -humeral  flap 
of  de  la  Faye,  opening  the  articulation  by  its  internal  face,  and  finish  by 
forming  a  very  small  posterior  flap. 

3.  Process  of  M.  Manec, — In  April,  1831,  M.  Manec  showed  me,  on  a 
dead  subject,  a  modification  of  the  method  of  M.  Plantade.  The  knife,  placed 
upon  the  centre  of  the  space  that  separates  the  iliac  spine  from  the  great  tro- 
chanter, is  carried  downwards  and  inwards,  between  the  flesh  and  the  anterior 
internal  face  of  the  neck  of  the  femur,  so  as  to  pass  out  before  the  ischium, 
and  at  once  form  a  large  flap,  the  free  edge  of  which  presents  in  a  semilunar 
form  downwards  and  outwards.  The  assistant  immediately  seizes  this  flap 
and  elevates  it,  taking  care  to  compress  the  artery,  if  the  operator  should  not 
prefer  to  tie  it  before  proceeding  further.  To  conclude,  M.  Manec  divides 
the  external  and  posterior  soft  parts,  by  means  of  the  semicircular  incison  of 
Moublet,  before  disarticulation,  or  he  first  opens  the  joint,  and  make  this  in- 
cision last.  M.  Lenoir,  who  also  praised  this  method,  recommends,  and  I  think 
correctly,  that  after  the  formation  of  the  flap  we  should  always  finish  the 
division  of  the  soft  parts,  as  in  performing  the  circular  operation,  before  pro- 
ceeding to  the  disarticulation. 

4.  Process  of  Dr.  Ashmead, — A  distinguished  young  surgeon  of  Philadel- 
phia, Dr.  Ashmead,  also  imparted  to  me  in  the  montli  of  April,  1831,  a  pro- 
cess founded  upon  the  same  ideas  as  the  preceding.  Like  M.  Manec,  he  gives 
his  flap  a  semilunar  form.  Like  M.  Plantade,  he  cuts  from  the  skin  towards 
the  deeper  parts.     After  dividing  the  integuments  at  the  point  indicated,  he 

32 


250  NEW  ELEMENTS  OF 

seeks  the  arterj,  and  ties  it.  Relieved  from  the  apprehension  of  hemorrhage, 
he  proceeds  to  the  section  of  the  muscles ;  having  reached  the  capsule,  he  dis- 
articulates the  femur,  and  finishes  like  Plantade  or  Manec. 

5.  Process  of  M.  Delpech. — M.  Delpech's  manner  of  operating,  is  one  which 
gives  a  result  almost  exactly  similar  to  that  of  Lalouette.  This  professor  ties 
the  femoral  artery  at  its  escape  from  under  the  crural  arch ;  then  makes  an 
inner  flap,  by  plunging  the  knife  at  once  from  before  backwards  between  the 
neck  of  the  femur  and  the  soft  parts,  and  bringing  it  downwards  in  the 
direction  of  the  skin,  with  greater  or  less  rapidity.  The  flap  thus  formed,  is 
seized  and  elevated  by  an  assistant.  The  operator  makes  a  semilunar  incision 
at  the  base ;  reaches  tlie  inner  side  of  the  articulation ;  divides  the  capsule  and 
inter-articular  ligament;  brings  back  the  thigh  to  its  natural  position ;  makes 
a  semicircular  incision  below  the  external  iliac  region,  and  thus  unites  the 
anterior  and  posterior  extremities  of  the  flap ;  divides  the  three  glutei,  the 
obturator  intemus,  the  pyriformis,  and  the  gemini  muscles,  and  the  external 
face  of  the  capsule.  The  tying  of  the  arteries  and  dressing,  concludes  the 
operation.  M.  Delpecli  insists,  tliat  with  a  single  flap  immediate  union  is  more 
easy  and  sure.  Slight  pressure,  he  says,  obliges  the  flesh  to  mould  itself  to  the 
cotyloid  cavity,  thus  preventing  inflammation,  suppuration,  exfoliation  of  the 
cartilage,  and  fistulas.  Moreover,  as  the  flap  presents  a  very  oblique  cut,  he 
recommends  that  the  section  of  the  integuments  towards  Hie  outside  should 
be  made  a  little  higher  than  that  of  the  other  parts,  in  order  that  there  may  not 
be  too  much  skin,  and  that  the  coaptation,  which  he  aids  by  means  of  a  suture, 
may  be  more  perfect. 

6.  Process  of  M.  iMrrey. — Le  Febure,  who  wrote  to  Louis,  in  1760,  tj 
announce  to  him  the  result  of  his  researches,  had  conceived  the  idea  of  tying 
the  femoral  artery  in  the  groin.  M.  Larry  has  given  this  as  a  precept,  which 
permits  the  surgeon,  he  says,  to  act  with  more  security,  and  causes  the  patient 
to  run  much  less  risk.  The  artery  being  tied,  the  operator,  placed  on  the  out- 
side of  the  member,  passes  the  point  of  a  long  knife  at  two  or  three  fingers' 
breath  below,  and  inside  of  the  anterior-superior  spine  of  tlie  ileum,  so  as  to 
fall  upon  the  anterior  face  of  the  bone ;  inclines  it  a  little  inwards,  and 
slides  it  upon  the  internal  face  of  the  neck  of  the  femur,  and  thus  conducts  it 
backwards,  until  it  again  passes  through  the  skin  in  the  sub-ischiatic  groove ; 
cuts  aninternal  flap  about  four  inches  long,  in  the  same  manner  as  M.  Delpech ; 
causes  this  flap  to  be  elevated  ;  divides  the  capsule  for  half  its  circumference 
at  least  very  near  the  cotyloid  cavity,  as  if  hewould  cut  through  the  middle 
of  the  head  of  the  femur,  without  attempting  to  enter  the  articulation ; 
abducts  the  member  ;  divides  the  internal  ligament  ;  passes  the  knife 
about  the  external  side  of  the  sphere  of  articulation ;  finishes  the  section 
of  the  capsule ;  arrives  at  the  tendons  of  the  glutei  beliind  the  great  tro- 
chanter ;  inclines  the  knife  flatwise,  by  directing  its  edge  downwards ; 
grazes  the  extenial  face  of  the  body  of  the  bone,  and  forms  a  second 
flap  as  much  as  possible  like  the  first.  All  the  arteries  being  tied,  the  two 
flaps  are  Ui'ought  together,  taking  care  to  leave  the  ligatures  in  the  posterior 
angle  of  the  wound  to  serve  as  a  conduit  to  the  matter  formed. 

7.  Process  of  M.  Blandin, — It  appears  tliat  the  double  flap  method  had 
been  a  long  time  in  use  when  Larrey  made  his  publication,  in  180S.  That  of 
M.  Blandin,  a  method  that  this  operator  had  used  as  early  as  1795,  consists 


OPERATIVE   SURGERY.  251 

in  first  tying  the  artery,  and  tlien  making  the  first  flap  like  Mr.  Larrey;  but  in- 
stead of  continuing  from  within  outward,  like  the  latter,  M.  Blandin  makes  his 
external  flap  before  touching  the  capsule  and  proceeding  to  the  disarticulation. 

8.  Process  of  M.  Lisfranc. — M.  Lisfranc  makes  use  of  a  narrow  two-edged 
knife ;  plunges  it  from  before  backwards  on  the  outside  of  the  neck  of  the 
femur,  turns  about  the  great  trochanter,  and  thus  begins  by  forming  a  flap 
three  or  four  inches  long ;  placing  his  instrument  again  at  the  superior  angle 
of  this  incision,  he  inclines  the  point  a  little  inwards,  to  glide  over  the  nock  of 
th^  bone  ;  immediately  elevates  the  handle ;  draws  the  ilesh  inwards,  so  that 
the  knife  may  pass  out  under  the  ischium  without  again  touching  the  integu- 
ments ;  divides  all  the  tissues  (without  leaving  the  os-femoris),  as  far  as  the 
lesser  trochanter ;  turns  this  osseous  process ;  directs  an  assistant  to  embrace 
the  origin  of  this  second  flap,  by  thrusting  his  thumb  into  the  wound  and  thus 
-compressing  the  artery,  and  terminates  the  section  of  the  internal  soft  parts, 
vas  M.  Larrey  does ;  ties  all  the  vessels,  and  then  disarticulates  the  limb. 

9.  Process  of  M.  Dupuytren. — The  surgeon  places  himself  on  the  inside  of 
the  limb,  and  uses,  if  ambidexter,  the  right  hand  for  the  right,  and  the  left 
hand  for  the  left  side;  has  the  integuments  drawn  towards  the  pelvis;  sup- 
ports the  thigh  himself,  inclining  it  more  or  less  towards  flexion,  extension,  or 
abduction;  makes  on  the  inside  a  semilunar  incision  with  downward  con- 
vexity, commencing  near  the  anterior  superior  spine  of  the  ileum  and  ending 
near  the  tuber  of  the  ischium;  divides  at  first  only  the  skin,  which  an  assist- 
ant then  retracts ;  immediately  divides  the  muscles  in  the  same  way,  thus 
forming  an  internal  flap  four  or  five  inches  long;  causes  this  to  be  elevated ; 
attacks  the  capsule,  like  M.  Larrey ;  passes  through  the  articulation,  and 
finishes  v/ith  an  external  flap. 

10.  Process  of  Beclard. — Placed  on  the  outside  of  the  hip,  Beclard  began 
by  cutting  an  external  and  posterior  flap,  by  thrusting  his  knife  obliquely 
inward  and  backward,  from  near  the  iliac  tubercle  to  the  internal  extremity 
of  the  sub-ischiatic  notch,  and  touching  the  posterior  sides  of  the  neck  of  the 
femur.  A  second  flap  must  be  formed  in  the  same  manner  before,  in  order  to 
finish  by  the  section  of  the  capsule  and  disarticulation.  Dupuytren  and 
Beclard  content  themselves  with  the  compression  of  the  artery  on  the  hori- 
'zontal  branch  of  the  pubis. 

11.  Process  of  Mr.  Guthrie. — Two  semilunar  incisions,  one  antero -internal, 
the  other  postero -external,  extending  from  near  the  iliac  spine  to  near  the 
tuberosity  of  the  ischium,  where  they  meet,  characterize  Mr.  Guthrie's  method. 
This  surgeon  first  divides  the  integuments ;  raises  them;  carries  the  instru- 
ment to  the  edge  of  the  retracted  skin,  and  divides  the  muscles  obliquely 
upwards ;  reaches  thus  the  articulation  after  making  two  flaps,  and  terminates, 
like  MM.  A.  Blandin,  Abernethy,,  Lisfranc,  and  Beclard.  It  is  evident  that 
the  English  surgeon's  method  differs  from  that  of  Beclard  only  in  dividing 
-the  tissues  from  the  skin  towards,  instead  of  the  reverse;  but  it  is  in  this  very 
difference  that  we  find  its  real  advantages. 

C.  Oval  Operation. — The  oval  operation  has  not  yet  been  applied  on  living 
man,  for  the  amputation  of  the  thigh  at  the  articulation.  The  two  varieties 
that  it  presents,  were  tried  upon  the  dead  subject,  by  MM.  Cornuau  and 
Scoutetten  first,  and  afterwards  by  all  the  young  surgeons  who  practised  the 
manual  of  operations  in  the  amphitheatres. 


252  NEW    ELEMENTS   OF 

1.  Process  of  M,  Cornuau.—The  patient  is  laid  upon  the  healthy  side.  The 
surgeon,  placed  behind  the  hip,  makes  the  firSt  oblique  incision,  which  com- 
mences above  the  great  trochanter,  and  must  be  carried  from  behind  outward, 
and  downward  to  below  the  ischium;  makes  another  similar  incision  before 
and  inward;  then  a  second  cut  for  each  incision,  to  divide  the  muscles  as 
deeply  as  possible ;  he  then  attacks  the  articulation  at  its  external  face  at  the 
same  time  that  the  member  is  abducted  by  an  assistant :  passes  through  the 
articulation  inwardly  as  soon  as  the  head  of  the  femur  is  dislocated.  In  fine, 
whilst  a  second  assistant  raises  the  two  flaps,  he  divides  the  interosseous  liga- 
ment, the  inner  part  of  the  capsule,  and  all  the  soft  parts  tbiit  separate  the 
inner  extremities  of  the  two  first  incisions,  or  form  the  base  of  the  V. 

2.  Process  of  M.  Scoutetten. — The  operator  first  sinks  the  point  of  the  knife 
above  the  great  trochanter  ;  then  depresses  the  handle  gradually,  to  divide 
all  the  tissues  as  before  ;  commences  again  at  the  posterior  extremity  of  the 
first  incision,  and  passes  over  the  other  side  of  the  member,  to  unite  it  with 
the  summit  of  the  first.  If  there  remain  any  soft  parts  between  the  internal 
posterior  part  of  the  neck  of  the  femur  and  the  integuments,  the  operator 
divides  them,  and  finishes  by  disarticulation. 

§  2.  Relative  Value  of  the  Various  Methods. 

Of  these  numerous  methods,  I  can  only  repeat  what  I  have  said  of  the  ampu- 
tation of  the  shoulder.  Almost  all  are  applicabl  e  in  practice.  No  one  should  be 
exclusively  adopted.  Yet  as  many  of  them  are  mere  modifications  of  others, 
they  may  be  rejected  without  inconvenience.  In  the  circular  method,  for 
instance,  which  is  certainly  the  least  advantageous,  and  which  should  be  se- 
lected only  in  case  the  disorganization  of  the  integuments  extends  over  every 
part  of  the  circumference  of  the  member  to  very  near  the  hip,  Abernethy's 
method,  and  that  of  Graefe,  differ  only  in  this,  that  that  of  the  German  surgeon 
admits  of  a  more  easy  reunion  of  the  lips  of  the  wound  than  the  other.  The 
modification  of  Mr.  Weitch  has  no  other  value  than  as  it  permits  the  operator 
to  remove  the  fractured  member  first,  and  then  to  proceed  with  the  disarticu- 
lation of  the  superior  fragment  by  another  incision.  A  precaution  that  I 
would  not  fail  to  take  would  be,  to  dissect  and  evert  carefully  all  the  healthy 
skin,  in  order  to  divide  the  muscles  very  high,  and  to  remove  as  much  of  them 
as  possible. 

The  oval  operation  is  appropriate  wherever  that  of  the  double  flap  seems 
applicable.  It  makes  a  wound  almost  as  regular  as  the  circular,  presents  no 
obstacle  to  immediate  reunion,  and  exactly  tills  the  cotyloid  cavity.  Of  the 
two  aspects  that  it  has  been  made  to  present,  one  has  scarcely  any  advantage 
over  the  other.  I  would  only  recommend  that  the  cutaneous  envelope  should 
be  divided  lower,  and  the  muscles  higher  than  has  been  prescribed.  The 
bringing  together  of  the  lips  of  the  wound  will  be  thus  rendered  more  easy, 
whilst  the  inflammation,  reaction,  and  suppuration,  will  manifest  themselves 
with  less  intensity. 

Among  the  flap  operations,  the  double  ones  are  somewhat  indispensable, 
when  it  is  possible  to  give  them  the  same  length,  and  when  the  soft  parts  are 
equally  altered  in  all  directions.  Then  Dupuytren  and  Guthrie-s  are  superior 
to  the  others,  because  they  permit  us  to  save  more  skin  than  muscle ;  and  also 
because  the  flap,  being  placed  obliquely  and  not  on  each  side,  as  in  Blandin's, 


OPERATIVE    STTRGERY.  QS$ 

Larrey's  and  Lisfranc's,  more  easily  fill  up  the  cavity  formerly  filled  by 
the  head  and  neck  of  the  femur  with  the  great  trochanter. 

When  an  external  flap  is  formed  after  the  manner  of  Larrey,  it  is  rare  that 
it  does  not  present  a  slope  on  its  inferior  edge,  or  that  it  corresponds  in  thick- 
ness with  the  internal  one. 

The  single  flap  operation  should  be  preferred,  if  the  soft  parts  of  one  side 
be  diseased  when  those  of  the  other  side  are  not.  In  such  case  the  nature  of 
the  disease  indicates  in  what  direction  to  preserve  the  flap,  which  should  not 
be  outside  nor  behind  if  it  can  be  avoided.  Inwards  and  anteriorly  I  prefer 
Lalouette's  to  Delpech's  method,  and  still  more  one  of  the  modifications  re- 
cently proposed.  As  M.  Lenoir  performs  it,  Lalouette's  method  gives  a  flap 
much  more  regular  than  that  of  the  professor  of  Montpeliers ;  but  this  flap  is 
too  thick,  and  not  sufficiently  large.  By  cutting  from  the  exterior  inwardly, 
as  Mr.  Ashmead  does,  the  operator  is  more  sure  of  what  he  does ;  the  ligature 
of  the  artery  may  be  neglected,  and  he  saves  more  of  the  integuments  than 
of  the  muscles.  It  was  thus  that  I  operated  on  the  patient  of  whom  I  have 
spoken.  After  raising  the  skin  for  three  inches  before  and  within,  and  making 
a  semicircular  incision  outwards  above  the  great  trochanter,  I  went  on  to  the 
division  of  the  flesh  and  the  disarticulation  from  the  front,  without  stopping 
for  the  artery,  which  an  assistant  compressed  upon  the  crest  of  the  pubis :  the 
(^eration  occupied  but  half  a  minute.  The  previous  tying  of  the  femoral 
artery,  recommended  by  Lefebure,  Moublet,  M.  A.  Blandin,  and  M.  Brula- 
tor,  adopted  by  MM.  Larrey,  Delpech,  Orthon,  and  Roux,  and  rejected 
by  Abernethy,  Baffos,  Guthrie,  &c.,  is,  as  has  been  said,  one  operation  more 
added  to  the  primary  one ;  yet  if  in  the  flap  operation,  compression  over  the 
pubis  or  with  the  fingers  in  the  flap,  as  it  may  be  effected,  in  executing  the 
method  of  Lalouette,  Lisfranc,  or  Delpech,  and  even  the  oval  method,  should 
not  give  all  the  security  desirable,  it  is  so  easy  to  discover  the  femoral  artery 
under  Poupart's  ligament,  that  it  is  best  to  do  so,  unless  it  be  thought  prefer- 
able to  adopt  the  proposition  of  Mr.  Ashmead. 

Unless  the  patient  be  very  weak,  or  the  operation  occupy  considerable  time, 
I  cannot  see  the  necessity,  or  even  the  utility  of  tying  the  arteries  before  dis- 
articulation. The  fingers  of  a  skillful  assistant  appliecf  upon  these  as  they  are 
divided,  permit  us,  as  I  have  satisfied  myself,  to  wait  until  after  the  removal 
of  the  limb.  These  arteries  are,  the  obturator  within,  the  ischiatic  without  and 
behind,  then  before  and  without,  some  branches  of  the  gluteal  or  of  the 
internal  pudic :  it  is  also  necessary,  even  if  the  ligature  should  have  been 
applied  before  the  operation,  to  again  tie  the  femoral  artery  at  the  bleeding 
surface,  as  well  as  the  deep-seated  muscular,  in  order  to  produce  immediate 
union  of  the  little  wound  which  had  been  first  made. 

The  necessity  of  bringing  in  contact  as  much  as  possible  the  two  sides  of 
the  enormous  wound  which  is  left  by  the  disarticulation  of  the  thigh,  is  not 
contested  by  any  person.  The  suppuration  of  so  large  a  surface  would  soon 
destroy  the  patient,  from  exhaustion,  and  would  never  fail  of  being  attended 
with  the  most  violent  general  reaction.  The  suture,  which  M.  Delpech  much 
applauds,  has  been  often  applied,  and  it  must  be  confessed  that  it  is  one  of  the 
cases  in  which  its  employment  seems  most  justifiable.  It  is  not  to  be  applied 
without  pain,  it  is  true ;  but  if  it  be  useful,  should  a  little  more  or  less  suffering 
be  allowed  to  rob  us  of  its  advantages  ?     I  would  remark,  however,  that  it  is 


m 


NEW   ELEMENTS   OF 


not  the  integuments,  but  the  deeper  tissues  that  it  is  so  especially  important 
to  bring  together;  and  that  by  using  the  suture,  it  is  to  be  feared  that  the 
matter  formed,  if  it  accumulate  at  the  bottom  of  the  wound,  may  produce 
serious  injury  before  it  can  escape.  The  adhesive  plasters,  which  have  the 
advantage  of  not  impeding  the  discharge,  also  permit  us  after  some  days  to 
approximate  the  edges  of  the  wound  more  exactly  than  at  first,  if  the  base  of 
the  flaps  appear  to  unite  properly.  Without  absolutely  rejecting  the  suture, 
which  seems  to  be  jrainino-  favor  at  this  time  in  the  south  of  France,  I  believe 
that  we  may,  and  that  we  should  dispense  with  it  in  this  operation  except  in 
some  particular  cases,  which  the  intelligent  surgeon  will  always  be  able  to 
distinguish. 


TITLE  III.— EXCISION  OF  THE  BONES. 

Practised  from  the  time  of  Galen  for  certain  bones  of  the  trunk,  and  to  all 
appearance  for  some  of  the  articular  heads,  excision  of  the  bone  has  only  been 
used,  according  to  fixed  rules,  for  about  half  a  century.  It  is  performed  in  the 
continuity,  or  at  the  extremity  of  the  bone,  and  is  always  used  to  avoid  ampu- 
tation of  the  limb. 


CHAPTER  I. 

In  the  Continuity. 

In  the  continuity  of  the  bone  excision  is  rendered  necessary,  either  by 
recent  complicated  fractures,  old  fractures  not  consolidated,  caries,  necrosis, 
osteo-sarcoma,  spina-ventosa,  or  by  any  other  incurable  organic  disease. 

1st.  Recent  Fractures, — When  in  a  fracture  the  extremity  of  one  of  the 
fragments  escapes  and  projects  through  the  torn  integuments,  if  suitable 
extension  of  the  opening  and  well-directed  efforts  fail  to  replace  the  parts,  the 
excision  of  the  projecting  portion  of  the  bone  has  been  always  recommended 
and  practised.  The  operation  is  very  simple.  Two  assistants  lay  hold, 
one  of  the  upper,  the  other  of  the  lower  portion  of  the  limb,  to  increase  its 
curvature,  and  make  the  osseous  points  project  still  more.  The  operator 
extends  the  wound  if  necessary,  protects  the  flesh  by  means  of  a  fold  of  linen 
or  a  piece  of  pasteboard,  aiid  divides  the  denuded  bone,  either  with  an  ordi- 
nary saw,  or  some  instrument  appropriate  to  the  form  and  position  of  the  part. 
It  is  to  the  tibia,  fibula,  the  bones  of  the  fore-arm,  and  some  of  the  phalanges 


OPERATIVE  SURGERY.  Q55 

that  this  kind  of  excision  has  been  most  frequently  applied ;  the  principles  of 
which  it  is  almost  impossible  to  lay  down. 

2(1.  Wounds  from  Fire-arms. — In  the  sequence  of  wounds  by  fire-arms, 
when  the  principal  bone  or  bones  of  the  member  have  been  fractured  and 
reduced  to  splinters,  whilst  the  soft  parts  adjoining  have  not  been  too  much 
injured,  instead  of  amputating,  it  was  early  thought  an  advisable  course  to 
extract  the  detached  bony  pieces,  and  then  to  project  the  angular  fragments 
of  the  two  ends  of  the  bone  for  excision.  In  this  case  the  surgeon  is  almost 
always  forced  to  augment  the  original  wound,  or  even  to  make  a  new  one. 
The  tissues  are  commonly  divided  in  the  direction  of  th.e  axis  of  the  limb,  at 
some  point  distant  from  the  vessels  and  nerves.  By  this  incision  the  two 
ends  of  the  bone  are  made  successively  to  escape.  After  having  isolated 
them  properly,  the  surgeon  dissects  away  the  points  and  all  the  parts  that  may 
affect  the  cure ;  and  conducts  himself  otherwise  as  in  the  preceding  case. 

3.  Old  Non- consolidated  Fractures. — After  certain  fractures  consolidation 
does  not  take  place.  The  two  ends  become  rounded ,  and  form  in  the  continuity 
of  the  member  an  abnormal  fracture,  that  injures  or  almost  entirely  destroys 
its  functions.  To  remedy  this  accident,  some  authors  have  proposed  the  injunc- 
tion of  perfect  rest,  and  the  employment  of  certain  machines  for  a  long  time. 
Others  have  thought  it  better  to  pass  a  seton  through  this  species  of  morbid 
articulation.  Some  content  themselves  with  rubbing  the  osseous  fragments 
against  each  other  to  produce  inflammation.  M.  Somme  has  recently  passed  a 
silver  wire  around  the  intermediary  substance,  to  produce  an  insensible  divi- 
sion of  it.  M.  Harsthrom  has  not  been  less  successful  in  destroying  it,  by  apply- 
ing caustic  potass  upon  the  two  extremities  of  the  fragments.  But  in  such 
cases  rescission  is  a  means  that  offers  evidently  more  chances  of  success. 
White,  of  Manchester,  who  attempted  it  once  in  1760,  for  a  non-consolidated 
fracture  of  the  humerus,  the  two  extremities  of  which  he  sawed  after  having 
brought  them  out,  and  at  another  time  on  the  tibia,  cutting  off  only  the  supe- 
rior fragment,  completely  cured  both  subjects.  M.  Viguerie  and  Langenbeck 
imitated  him  with  the  same  happy  results,  for  fractures  of  the  fore-arm.  M 
Dupuytren,  who  from  choice  only  excises  the  upper  portion,  contents  himself 
with  rasping  the  other.  M.  Rowlans,  M.  Pezerat,  &c.,  have  also  performed 
this  resection  with  success,  for  non-consolidated  fractures  of  the  thigh.  Messrs 
Larrey,  Boyer,  Richerand,  Physic,  &c.  cite  some  cases,  which  were  followed 
by  serious  accidents,  and  even  death.  So  that  it  should  not  be  decided 
upon  until  after  mature  reflection,  and  after  its  necessity  is  well  esta- 
blished ;  the  more  so  as  the  disease  sometimes  becomes  a  supportable  infirmity. 
An  example  is  found  in  a  thesis  of  M.  Carron  of  a  man  labouring  under  one 
of  these  fractures  of  the  thigh,  and  who  walked  very  well  without  crutches.  In 
a  case  of  M.  Kulnholtz  there  was  a  complete  false  articulation,  which  scarcely 
affected  the  functions  of  the  limb.  M.  Cloquet  speaks  of  a  patient  in  whom 
the  superior  fourth  of  the  humerus  had  been  for  a  long  time  destroyed,  without 
preventing  the  movements  of  the  arm.  M.  Yvan-says  the  same  of  the  femur. 
The  double  gutter  of  tin,  contrived  by  the  artist  Baillif,  enabled  the  three 
individuals  mentioned  by  Trochel  to  walk  with  ease.  I  have  myself  seen  at 
the  central  bureau,  a  woman  who  had  one  of  these  fractures  of  the  right 
thigh,  and  who  travelled  \dthout  crutches  by  the  aidof  a  very  coarse  machine. 

The  Method  of  Operating  is,  as  to  the  rest,  nearly  the  same  as  for  fractures 


256  NEW   ELEMENTS   OF 

with  external  laceration ;  presenting  only  this  diiFerence,  that  the  division  of 
the  tissues  must  always  be  made  at  the  point  most  favorable  to  the  eversion 
of  the  end  of  the  bone,  and  where  it  will  cause  the  least  danger,  whilst  in 
the  other  case  it  is  frequently  sufficient  to  prolong  more  or  less  the  existing 
opening  in  this  or  that  direction,  and  in  a  way  which  it  is  here  unnecessary  to 
indicate.  The  two  fragments  are  made  to  present,  one  after  the  other,  at  the 
incision ;  when,  after  detaching  the  adhesions  and  protecting  the  flesh  and  skin, 
division  is  made  of  the  non-consolidated  ends  of  the  bone. 

Whether  the  excision  has  been  performed  for  a  recent  fracture,  with  or 
without  displacement,  or  for  an  ancient  fracture,  the  subsequent  treatment 
and  dressings  are  in  both  cases  nearly  the  same.  In  every  case  the  limb  must 
be  restored  to  its  natural  shape,  the  bone  sunk  into  its  place  again,  and  retained 
there  after  the  reduction.  The  incision  should  be  filled  with  charpie  or  lint, 
and  if  necessary  covered  with  a  perforated  bandage.  If  it  appear  possible  to 
escape  suppuration,  immediate  union  should  be  attempted  by  the  assistance  of 
some  pieces  of  agaric  and  graduated  compresses,  or  by  the  suture  and  appro- 
priate dressings.  The  whole  is  to  be  maintained  by  Scultet's  bandage, 
cushions  filled  with  straw,  or  even  splints,  when  it  is  not  possible  to  prevent 
movement  of  the  limb  without  them. 

Organic  Lesions. — Excision  for  caries,  necrosis,  &c.  although  less  frequently 
practised  than  that  of  which  we  have  just  spoken,  is  nevertheless  very  often 
indicated.  Except  the  observations  of  Tenon,  who  did  not  hesitate  to  remove 
the  great  trochanter;  those  of  Moreau,  who,  in  1793,  excised  a  considerable 
portion  of  the  tibia;  of  Percy  and  Laurent,  who  are  said  to  have  removed 
eight  or  ten  inches  of  this  bone  with  the  saw  and  trepan,  and  to  have  removed 
the  whole  of  the  fibula  for  a  caries,  or  rather,  no  doubt,  for  necrosis  of  the  leg ; 
of  Beclard,  who  in  conformity  to  the  advice  of  Desault,  dared  also  to  excise 
the  superior  third  of  the  fibula  for  a  spina-ventosa ;  of  Hey,  who  in  his  work 
reports  many  cases  of  the  excision  of  the  bones  of  the  leg  and  arm ;  of  M. 
Couty  de  la  Pommeraie,  who  has  lately  published  a  case  of  abscission  of 
almost  the  whole  extent  of  the  humerus,  surgeons  scarcely  mention  this  kind 
of  operation,  which,  however,  has  been  very  recently  practised  at  the  Hopitaly 
SeaujoUy  with  entire  success  for  a  very  extended  necrosis  of  the  tibia.  The 
surgeon  being  obliged  to  conform  to  circumstances,  to  vary  the  operation  in 
accordance  with  the  preservation  or  loss  of  the  natural  form  of  the  member, 
with  the  extent  or  seat  of  the  disease,  lays  the  bone  bare  by  means  of  simple 
longitudinal  incisions,  or  when  absolutely  necessary,  by  making  at  the  ex- 
pense of  the  soft  parts  one  or  more  flaps  of  suitable  size  and  form.  When 
the  disease  is  exposed,  the  saw  or  the  trepan  is  to  be  applied,  or  in  other  cases 
the  gouge  and  mallet :  the  saw,  when  the  bone  is  cylindrical  or  not  voluminous ; 
the  trepan,  when  the  bone  is  large  and  difficult  to  isolate,  when  very  thick,  or, 
in  fine,  when  the  neighbouring  parts  will  not  permit  the  use  of  the  saw ;  the 
chisel,  when  only  some  laminae,  a  part  of  the  thickness  of  the  affected  bone, 
are  to  be  removed.  Incisive  nippers  may  also  be  used,  or  indeed  any  other 
instrument  tliat  an  intelligent  operator  may  contrive.  M.  Seutin,  of  Bruxelles, 
who  with  remarkable  success  extracted  almost  the  entire  fibula,  used  a  tre- 
pan to  separate  the  superior  extremity,  and  divided  the  lower  with  a  curbed 
saw.     It  is  here  that  the  flexible  or  chain  saw,  are  particularly  indicated. 

Not  only  can  the  abscission  of  the  central  portion  of  the  limbs  be  thus 


OPERATIVE  SURGERY.  S57 

eflfected,  but  it  may  also  be  practised  upon  the  trunk,  the  cranium,  the 
sternum,  the  ribs,  the  clavicle,  the  vertebrae,  &c. 

ArLl,— 'The  Ribs, 

Among  the  excisions  of  the  bones  of  the  trunk,  there  is  one  that  has  more 
especially  fixed  the  attention  of  the  moderns:  I  speak  of  the  abscission  of  the 
ribs,  which  is  said  to  have  been  performed  by  Galen,  Aymard,  Sedillier,  Lecat, 
Ferrand,  &c.,  and  which  the  Indians  are  said  to  have  often  used,  and  to  which 
they  gave  a  particular  name.  The  old  Journal  JEncyclopedique,  contains  an 
example,  the  knowledge  of  which  I  owe  to  M.  Dezemesis.  Suif  excised  two 
ribs  from  a  man  named  Botaque,  so  that  he  could  pass  his  fist  into  the  chest. 
An  affected  portion  of  the  lungs  was  removed ,  and  the  patient  cured.  Yet  it 
was  scarcely  thought  of,  when,  in  1818,  M.  Richerand  performed  it  upon  a 
person  affected  with  cancer  of  the  thorax.  Since  then  it  is  known  that  Dr. 
Celadini  has  performed  it  twice  successfully  in  Italy.  Percy  and  Laurent 
are  said  to  have  tried  it  with  like  success,  and  recently  the  journals  inform 
us  of  its  having  been  attempted  at  the  Hopitcd  Beaujon,  at  La  Charite,  and 
in  America,  by  Dr.  Mott.  M.  Richerand's  case  is,  without  doubt,  the  most 
remarkable  of  all.  It  was  necessary  to  remove  the  central  portion  of  four  ribs 
for  several  inches  in  extent.  The  pleura,  being  much  thickened,  and  having 
passed  into  the  lardaceous  state,  had  to  be  also  destroyed ;  so  that  the  pulsa- 
tions of  the  heart  were  plainly  seen,  that  organ  being  enveloped  in  the 
pericardium.  The  result  of  this  beautiful  operation  was  at  first  most 
satisfactory ;  but  after  some  months,  and  before  the  complete  cicatrization 
of  the  wound,  the  cancer  again  appeared,  and  terminated  the  existence  of  the 
patient. 

Operation. — After  exposing  the  rib  or  ribs  to  be  excised,  after  having 
extended  the  incisions  as  far  as  the  disease  in  each  direction,  either  a  saw  in 
the  form  of  a  cock's  comb,  or  the  chisel  and  mallet,  or  simply  that  kind  of 
shears  employed  in  the  amphitheatres,  known  by  the  name  of  secateur,  may  be 
used,  commencing  at  one  or  the  other  end,  and  finishing  at  the  opposite 
extremity  of  the  rib.  It  is  necessary  to  preserv^e  as  much  as  possible  of  the 
pleura,  which  all  operators  have  remarked  is  then  sensibly  thickened.  If, 
however,  it  be  too  deeply  affected,  and  especially  if  it  be  the  seat  of  a  cancerous 
degeneration,  it  should  be  destroyed  without  hesitation. 

,Srt,  2. — Sternum, 

Galen  had  the  boldness  to  lay  bare  the  greater  part  of  the  sternum,  and 
isolate  it  by  means  of  a  trepan  and  gouge,  and  remove  the  whole  diseased 
portion,  so  as,  like  Richerand,  to  expose  the  heart  to  the  eyes  of  the  assistants. 
The  same  course  must  be  pursued  at  the  present  time,  when  it  has  been 
decided  upon  to  follow  the  precepts  of  the  physician  of  Pergamos ;  a  course 
that  has  been  followed  in  the  last  century  by  Sedillier  de  Laval. 

The  excision  of  the  crest  of  the  ileum*  attempted  by  Leaulte;  that  of  the 

OS  calcis,  two  cases  of  which  are  reported  by  Hey  and  Roux,  and  which  I  have 

myself  performed ;  of  the  spinous  processes  of  the  vertebrae,  which  M.  Jules 

Cloquet  recommends,  and  which  Dr.  A.  G.  Smith  used  with  success  on  a 

33 


258  NEW  ELEMENTS  OP 

patient  laboring  under  paraplegia  for  two  years ;  of  every  bone,  in  fine,  that 
naturally  projects  beneath  the  skin,  cannot  be  a  very  difficult  nor  even 
delicate  operation ;  but  as  the  form  of  the  disease  and  its  extent  always  pro- 
duces great  modifications  in  the  operation,  I  cannot  enter  into  more  lengthened 
details  upon  the  subject. 

Art,  3. — Lower  Inferior  Jaw, 

History  and  Value. — Wounds  from  fire-arms,  accompanied  by  comminuted 
fracture,  have  long  proved  that  considerable  portions  of  the  lower  jaw  may 
be  destroyed  without  producing  death.  Caries  and  necrosis  have  also  often 
caused  the  destruction  of  this  bone ;  and  yet  those  thus  affected  have  com- 
monly recovered,  even  without  any  very  great  deformity.  Hippocrates  gives 
an  example.  One  of  the  most  remarkable  was  that  observed  by  Guernery;  the 
jaw  entirely  exfoliated,  but  was  so  far  reproduced  as  to  permit  mastication  ! 
V.  Wy  speaks  of  a  patient  who  lost  the  whole,  either  spontaneously  or  by 
the  aid  of  art.  Two  such  cases  are  met  with  in  Desault's  journal.  Chopart 
and  Louis  have  also  extracted  it  successfully.  Walker  says  he  was  obliged 
to  remove  the  two  branches  and  a  part  of  the  body  in  a  negro,  who  afterwards 
recovered  the  power  of  masticating.  A  woman,  observed  at  Bourges  by  Rug- 
g;er,  had  lost  the  right  half.  Boyer  reports,  in  the  Bibliotheque  de  Flanque^ 
the  case  of  a  patient  who  had  it  earned  away  by  a  mill-wheel,  and  recovered. 
Wepfer  cites  a  case  in  which  the  amputation  of  the  side  of  the  jaw  had  been  suc- 
cessfully made  in  his  time.  In  fine,  M.  Larrey  speaks  of  a  soldier  who  liad  had 
the  jaw  almost  entirely  destroyed  by  a  gun-shot,  but  who  still  lives.  In  fact, 
many  subjects  may  be  seen  at  the  Invalides  with  traces  of  similar  mutilations. 

Yet  observations  of  this  kind  remained  without  application,  when  in  1812, 
M.  Dupuytren  resolved  to  amputate  almost  the  whole  body  of  a  cancerous  lower 
jaw  by  a  new  method,  to  which  the  title  of  a  surgical  triumph  has  been  given. 
Since  then  the  same  operation  has  been  repeated  a  great  number  of  times  by 
the  same  professor;  and  also  in  Germany,  England,  America,  and  France,  by 
Mott,Richerand,LaUemand,  Delpech,Roux,Casack,  Martin,  Gerdy,  Magen- 
die,  Cloquet,  Wardrop,  Lisfranc,  Warren,  Gensoul,  Grsefe,  Walther,  Wagner, 
Randolph,  and  myself.  It  is  not  only  to  necrosis  that  it  may  be  applied, 
but  also,  and  especially  to  cancers  and  all  organic  affections  that  will  not 
yield  to  any  thing  else  than  the  removal  of  the  parts  that  are  their  seat.  If 
it  should  appear  to  make  success  doubtful  to  go  beyond  the  first  molar  teeth, 
because  the  attachments  of  the  genio-glossus  and  geneo-hyoideus,  of  the  mylo- 
hyoideus  and  digastricus  muscles  being  destroyed,  the  tongue,  acted  upon  by 
the  glosso-pharyngeus,  must  be  apparently  drawn  back  and  fill  the  pharynx, 
and  thereby  endanger  suffocation,  it  should  be  known  that  experience  has 
confirmed  these  fears  only  in  part.  M.  Dupuytren  has  gone  beyond  the  first 
molar  teeth.  In  M.  Richerand's  patient,  the  whole  body  of  the  bone  was  re- 
moved. I  have  twice  performed  this  operation,  and  each  time  went  to  the  canine 
teeth.  After  the  dressing  no  precaution  was  taken  to  fix  the  tongue  anteriorly, 
and  yet  there  resulted  no  unpleasant  symptom.  M.  Walther  and  M.  Graefe, 
according  to  Dr.Pattison,  then  Dr.  M'Clellan,  have  removed  almost  the  whole 
bone,  and  cured  their  patients.  If  the  disease  be  situated  more  on  one  side 
than  on  the  other,  then  it  is  possible  to  leave  untouched  the  opposite  half  of 


OPERATIVE    SURGERY.  259 

the  organ,  removing  only  that  which  is  altered.  It  was  thus  that  Mott,  J.  Clo- 
quet,  Lisfranc,  Blanchet,  Roux,  &c.,  did ;  in  this  case  the  inconvenience  in 
question  is  not  at  all  to  be  apprehended. 

It  is  certain,  on  the  contrary,  that  in  other  cases  the  tongue  is  carried  with 
great  force  backwards  and  upwards,  as  soon  as  its  an^terior  attachments  are 
divided.  M.  Dupuytren  always  warned  his  auditors  of  this,  and  M.  Delpech, 
who  made  it  the  subject  of  some  interesting  remarks,  even  thought  of  remedy- 
ing it,  by  passing  a  golden  wire  through  the  organ  near  the  frasnum,  for  the 
purpose  of  fixing  it  to  the  teeth  nearest  to  the  extremity  of  the  remaining  frag- 
ments of  the  bone. 

Operation, 

A.  Body  of  the  Jaw. — When  the  disease  is  confined  to  the  chin,  the 
operation  is  generally  very  easy  and  simple.  In  this  case  there  are  two 
methods  of  operating.  If  all  the  soft  parts  are  healthy,  they  are  divided  upon 
the  median  line  from  above  downward,  from  the  free  edge  of  the  lip  to  the 
thyroid  cartilage,  and  the  two  flaps,  thus  formed,  dissected  and  everted.  In  the 
other  case,  two  incisions  uniting  over  the  larynx,  should  form  a  V,  or  triangle, 
comprising  within  its  limits  the  whole  disease. 

The  apparatus  consists  in  needles,  ligatures  as  for  hare-lip,  a  chafing-dish 
of  fire,  cauteries,  and  all  other  things  necessary  in  amputation  and  dissections 
of  the  most  delicate  nature.     Three  assistants  at  least  are  necessary. 

First  Stej). — The  patient  maybe  seated  on  a  chair  or  a  bed,  moderately 
elevated.    An  assistant  placed  behind,  turns  back  the  head  with  one  hand, 
and  lays  hold  of  the  angle  or  right  side  of  the  lip  with  the  other,  at  the  moment 
the  surgeon  commences  the  incision.     The  latter,  with  the  first  two  fingers  of 
the  left  hand,  takes  hold  of  the  edge  of  the  lip  on  the  other  side,  whilst  with 
the  right  hand  armed  with  a  bistoury,  he  makes  the  incision ;  and  then  suc- 
cessively dissects  away  the  two  sides  of  the  wound  as  far  as  may  be  necessary 
around  the  disease,  taking  care  to  commence  with  the  right  side.     Having 
done  this,  he  separates  the  muscles  and  other  soft  parts  that  adhere  to  the 
edges  and  internal  face  of  the  bone,  carefully  avoiding  the  insertion  of  the 
genio-glossal  muscles.     The  operator  may,  as  some  person  recommends, 
reserve  this  part  of  the  operation  for  the  end,  and  saw  the  bone  before  dis- 
secting it  away.     An  ordinary  saw  will  serve  the  purpose.     A  tooth  on  each 
side  of  the  confines  of  the  disease  should  be  removed,  if  they  have  not  already 
fallen  out,  and  if  they  seem  likely  to  interfere  with  the  action  of  the  instru- 
ment.    The  operator,  holding  with  one  hand  the  anterior  portion  of  the 
affected  mass,  applies  the  thumb  a  little  behind  it  upon  the  healthy  portion  of 
the  bone  (which  should  also  be  fixed  behind  at  the  angle  by  an  assistant),  in 
order  to  direct  the  action  of  the  saw,  which  should  pass  as  nearly  as  possible 
between  two  alveoli  and  from  above  downward,  or  vice  versa,  as  it  may  be 
most  convenient.     This  first  division  having  been  accomplished,  the  assistant 
takes  hold  of  the  diseased  tissues,  whilst  the  surgeon  passes  his  hand  behind 
them.     A  second  passage  of  the  saw  terminates  the  section  of  the  bone,  which 
in  order  to  be  removed  must  be  depressed;  whilst  the  other  assistants, 
separate,  retract,  and  protect  carefully  the  soft  parts  of  the  neck  and  face. 
It  then  rem.ains  only  to  detach  the  deceased  fragment  from  the  tissues  within 
the  mouth,  by  carrying  a  bistoury  flatwise,  and  vertically  upon  the  posterior  face 


260  NEW  ELEMENTS  OF 

of  the  chin.  At  the  same  instant,  an  assistant  having  the  hand  covered  with 
a  piece  of  linen,  seizes  the  tongue  by  its  point  and  draws  it  outward,  thus 
preventing  the  symptoms  of  suffocation,  and  permitting  the  surgeon  to  pass  a 
cautery,  heated  to  whiteness,  over  the  whole  extent  of  the  wound,  or  at  least 
wherever  any  arterial  branch  is  likely  to  be  found. 

With  two  or  three  points  of  twisted  suture  the  two  lips  of  the  wound  may 
be  united,  the  inferior  angle  of  which,  however,  should  remain  open,  and  even 
filled  with  a  tent,  to  allow  free  passage  to  the  results  of  suppuration.  Some 
strips  of  diachylon,  some  pledgets  and  compresses,  and  a  bandage,  complete 
the  dressing.  Some  persons  place  several  small  pledgets  of  coarse  charpie 
behind  the  tissues  of  the  face,  in  order  to  fill  up  the  vacuum  between  the  two 
bony  fragments. 

Remarks. — When  the  loss  of  substance  is  not  considerable,  it  is  well  to 
bring  the  fragments  in  contact,  and  fix  them  so  by  means  of  a  wire  passed  around 
the  anterior  teeth,  as  M.  Delpech  has  done.  In  the  contrary  case,  this  pre- 
caution will  be  at  least  useless.  The  ligature  through  the  inferior  face  of  the 
tongue,  recommended  by  the  professor  of  Montpelier,  will  only  be  necessary  if 
this  organ  continues  to  be  violently  retracted  towards  the  throat.  Some  persons 
find  the  bandage  superfluous,  and  content  themselves  with  the  suture  and 
compresses;  the  latter  method  gives  the  parts  more  freedom,  and  permits 
the  surgeon  constantly  to  watch  the  progress  of  the  pathological  phenomena. 
But  this  must  all  be  left  to  the  taste  of  the  surgeon. 

The  sub-mental,  sub -lingual,  very  rarely  the  ranine,  the  terminating  branch 
of  the  inferior  maxillary,  and  the  coronary  arteries  of  the  lip,  are  almost  the 
only  vessels  that  the  instrument  encounters,  and  that  require  attention. 
Some  of  them,  hid  in  the  soft  parts,  are  too  difiicult  to  find  to  admit  of 
the  ligature.  It  might  be  possible  with  cold  water,  or  sponges  soaked  in 
vinegar,  to  arrest  their  bleeding,  and  thereby  dispense  with  the  heated  iron. 
Yet,  as  M.  Dupuytren  uses  the  latter  means  constantly  with  success,  prudence 
at  least,  if  not  necessity,  justifies  its  application.  The  three  last  named 
arteries  cease  to  bleed  spontaneously,  and  scarcely  ever  require  particular 
attention.  In  one  case  M.  Graefe  had  a  hemorrhage  from  the  central  artery 
of  the  bone.  In  this  case  a  plug  of  wood  or  wax,  like  that  which  M.  Magendie 
used,  or  a  compress  of  any  kind,  at  the  point  from  which  the  blood  escapes, 
should  be  employed,  if  the  operator  do  not  prefer  to  have  recourse  to  the 
cautery.  Lastly,  instead  of  a  simple  incision,  or  two  incisions  united  at  their 
inferior  extremities,  it  may  be  necessary,  if  the  disease  be  extensive,  to  divide 
each  lip  of  the  incision  transversly  below  the  lower  edge  of  the  jaw. 

B.  One  of  the  Branches  of  the  Jaw, — When  the  amputation  need  com- 
prehend only  one  of  the  sides  of  the  inferior  maxillary  bone,  the  operation  is 
not  altogether  the  same  as  that  just  described. 

1.  M.  J.  Cloquet  began  with  the  vertical  incision  above  described;  then 
made  a  second,  extending  from  the  commissure  of  the  lips  to  a  point  above 
and  behind  the  angle  of  the  jaw;  then  dissected  and  turned  outward  and 
downward  the  very  large  flap  of  the  soft  parts  thus  described ;  detached  the 
tongue  from  the  internal  edge  of  the  alveolar  process,  and  ended  with  the 
section  of  the  bone ;  cutting  first  anteriorly  and  then  posteriorly  at  the  origin 
of  its  ascending  plate. 

2.  Dr.  Mott  operated  in  a  manner  a  little  different.    He  began  by  tying 


OPERATIVE  SURGERY.  261 

the  carotid  artery  of  the  diseased  side,  and  then  proceeded  to  the  amputation 
of  the  bone.  The  first  incision  began  at  the  ear  on  a  line  with  the  condyle, 
and  extended  in  a  semilunar  form  with  its  convexity  backwards  to  near  the  chin, 
and  below  the  labial  commissure.  The  teguments,  the  inferior  part  of  the 
masseter  muscle,  and  the  parotid  gland,  were  then  dissected  away.  A  second 
incision,  from  the  superior  extremity  of  the  first  toward  the  anterior  edge  of  the 
sterno-mastoideus  muscle,  passing  below  the  ear,  enabled  the  surgeon  to  expose 
the  whole  diseased  part.  With  the  aid  of  a  small  saw  the  jaw  could  be  divided 
anteriorly  on  a  line  with  one  of  the  lateral  incisor  teeth.  With  another  saw, 
smaller  than  the  first,  and  made  expressly  for  the  case.  Dr.  Mott  made  a  section 
of  the  ramus  of  the  jaw  immediately  below  its  two  upper  apophyses,  and  was 
not  able  to  remove  the  whole  morbid  mass,  until  after  having  carefully  de- 
tached it  from  the  internal  pterygoid  and  mylo-hyoid  muscles.  In  the  latter 
part  of  the  operation  he  properly  directs  the  complete  division  of  the  inferior 
maxillary  nerve,  before  exerting  any  traction  upon  the  bone,  and  that  it  should 
not  be  forgotten  that  the  lingual  branch  of  the  fifth  pair  is  found  in  the  neigh- 
borhood. 

Remarks. — W^henever  one  of  the  sides  of  the  jaw  is  amputated  instead  of  the 
chin,  the  facial  artery  is  necessarily  divided  at  a  greater  or  less  distance  trom 
its  termination.  In  M.  J.  Cloquet's  operation  it  was  divided  at  the  time  of 
the  transverse  incision,  and  again  whilst  detaching  the  flap ;  but  the  latter 
section  may  be,  if  necessary,  avoided.  By  Dr.  Mott's  method  we  wound  it 
inevitably  whilst  passing  over  the  external  face  of  the  bone.  When  the  aflfec- 
tion  does  not  reach  beyond  the  maxillary  angle,  it  is  evident  tli at  the  method  of 
the  French  surgeon  merits  the  preference.  When,  on  tlie  contrary,  the  alteration 
reaches  very  high  up  towards  the  temporo -maxillary  articulation,  by  imitating 
the  American  professor  we  are  more  sure  of  exposing  the  whole  disease,  whilst 
at  the  same  time  we  preserve  the  parotid  gland  and  its  duct.  His  method  is 
equally  adapted  to  disarticulation,  if  it  should  be  preferable  or  necessary,  as 
with  the  patient  operated  upon  by  M.  Gensoul,  and  who  died  of  a  pleurisy 
the  fourteenth  day.  Upon  the  whole  each  case  must  have  its  peculiar 
exigencies.  It  is  for  the  surgeon  to  select  or  originate  the  most  appropriate 
method,  when  any  other  than  the  middle  part  of  the  bone  is  to  be  amputated. 
The  preparatory  tying  of  the  carotid,  performed  by  Mott,  Cusack,  Walther, 
Graefe,  and  Gensoul,  can  be  indispensable  only  in  a  small  number  of  cases, 
and  in  them  it  must  be  because  the  saw  acts  transversely,  as,  for  instance,  very 
near  the  temporo -maxillary  articulation  ;  yet  it  is  probable  that  even  then 
it  will  often  be  possible  to  dispense  with  it.  The  temporal  artery  (opened 
once  in  England),  the  internal  maxillary,  the  external  carotid,  and  the  inferior 
dental,  which  lie  along  or  turn  around  the  posterior  edge  and  neck  of  the  con- 
dyle, or  are  found  within  the  maxillary  branch,  can  be  easily  separated  by  a 
well-taught  assistant,  at  the  moment  when,  after  having  sawn  the  bone,  the 
operator  wishes  to  detach  it  behind  from  the  tissues  that  adhere  to  its  internal 
face.  A  ligature  applied  to  tliem  after  the  dissection,  would  also  be  another  re- 
source against  any  unhappy  result,  and  the  compression  of  the  primitive  ca- 
rotid is  too  easy  to  leave  room  for  any  very  great  inquietude.  When  the  tis- 
sues of  the  face  are  healthy,  perhaps  it  would  be  better  to  imitate  M.  Roux  in 
forming  a  large  flap  with  a  downward  convexity,  which  may  be  dissected  and 
everted  from  below  upwards. 


562  NEW   ELEMENTS   OP 

After  filling  the  space  that  separates  the  two  ends  of  the  bone,  with  charpie, 
a^ariq,  or  sponge,  the  lips  of  the  wound  is  to  be  united  by  the  necessary 
number  of  needles  and  hare-lip  sutures,  as  after  amputating  the  chin. 

Jifter  the  Operation, — At  the  first  annunciation  of  this  operation,  it  was 
thought  there  would  result  from  it  a  very  great  deformity,  and  an  impossibility 
of  executing  mastication.  It  was  a  mistake.  In  the  case  of  Lesier,  tlie  first 
patient  operated  upon  b}^  M.  Dupuytren,  almost  the  wliole  body  of  the  bone 
was  taken  away,  yet  the  loss  is  now  scarcely  perceptible.  Others,  since  ope- 
rated upon,  are  almost  in  the  same  situation,  without  excepting  even  M. 
Ehrmann,  of  Strasburg.  Cellular  matter  soon  shoots  up  between  the  bony 
fragments,  becoming  fibrous  or  cartilaginous,  and  ultimately  acquiring  so  much 
solidity  as  almost  to  equal  the  bone  that  it  replaces,  the  two  remaining  portions 
of  which  it  firmly  connects. 

But  it  must  be  stated  that  M.  Lallemand's  patient  was  not  so  fortunate.  In 
him  the  two  ends  of  the  bone  remained  movable,  on  which  account  he  is  obliged 
to  use  an  artificial  chin.  But  the  loss  of  substance  had  been  very  considerable ; 
wliich  explains  at  the  same  time  the  danger  caused  at  first  by  the  retreat  of 
the  tongue — a  danger  at  once  removed  by  instantly  performing  tracheotomy. 
The  wound  may  remain  fistulous  at  its  inferior  angle,  because  of  the  passage 
of  the  saliva  through  it,  and  thereby  cause  the  exhaustion  of  the  patient. 
One  of  those  I  have  operated  upon  was  in  tliis  condition,  when  erysipelas 
carried  him  off  the  twenty-second  day  after  the  operation.  I  saw,  in  a  case 
operated  upon  by  M.  Richerand,  the  tongue  so  much  drawn  back  as  not  to 
permit  the  ingestion  of  aliments.  Death  occurred  on  the  twenty-eighth 
day,  and  seemed  the  consequence  of  suffocation.  Perhaps  it  was  the  same 
with  the  woman  operated  upon  by  Magendie,  in  1830,  at  La  vSalpetriere,  who 
died  suddenly  in  the  night.  After  the  removal  of  one  of  the  lateral  portions 
of  the  jaw,  the  fixed  point  of  the  genio-glossal  muscle  being  preserved,  there 
is  less  danger  of  retraction  of  the  tongue.  In  this  case  an  obliquity  in  the 
projection  of  the  chin,  sometimes  very  decided,  is  almost  inevitable.  It  took 
place  in  the  patient  operated  upon  at  the  Hopital  de  Perfeciionnementy  in  1826, 
and  was  also  observed  in  the  cases  cited  by  Mott,  Gensoul,  Lisfranc,  &c.. 
To  conclude,  the  amputation  of  the  chin  is  a  happy  acquisition  to  modern 
surgery,  and  that  of  one  of  the  sides  of  the  bone,  even  when  it  is  necessary 
to  comprehend  the  articulation,  appears  to  be  an  equally  valuable  resource  in 
many  cases ;  but  it  is  difficult  to  comprehend  how  the  entire  removal  of  the 
whole  bone  can  be  successful  in  curing  the  disea'se,  and  yet  preserve  the 
faculty  of  deglutition.  We  know  that  as  a  consequence  of  its  exfoliation,  of 
which  Snell,  Gambini,  and  Bellemain,  have  reported  some  new  examples,  it 
may  be  otherwise.  The  dead  part  is  not  separated  until  the  system  has  more 
or  less  completely  prepared  itself  for  its  absence  by  the  creation  of  a  new 
tissue,  that  lessens  very  much  the  deformity.  It  is  also  known  that  the  forcible 
extraction  of  the  exfoliation,  performed  by  M.  Dupuytren,  in  1830,  is  nothing 
else  than  an  amputation  properly  so  called,  and  that  there  can  be  no  method 
given  for  the  performance  of  this  operation, 

Art,  A. -^-Superior  Maxillary  Bone, 

Encouraged  by  these  successful  cases,  by  some  examples  of  the  destruction 
of  the  sinus  and  some  serious  lesions  of  the  superior  jaw-bone,  spontaneously 


OPERATIVE    SURGERY.  265 

cured,  M.  Dupuytren  immediately  thought  that  the  abscission  of  this  bone 
might  also  be  attempted.  It  besides  appeared,  that  Acoluthus  had  performed 
it  in  1693,  for  a  tumor  of  the  face,  and  cured  his  patient.  Camper  speaks  of 
a  subject  who  had  lost  the  entire  bone,  and  yet  survived.  Still,  however, 
Bidloo  and  Desault,  who  had  conceived  the  possibility  of  the  operation,  had 
gone  only  so  far  as  to  recommend  it.  These  vague  and  unfixed  notions  it  is 
evident  detract  nothing  from  the  moderns  in  this  question ;  a  question  which 
in  itself  really  comprehends  two — the  excision  and  the  disarticulation  of  the 
bone.  M.  Paillard  affirms,  and  the  bulletins  of  the  faculty  prove,  that  M. 
Dupuytren  had  recourse  to  the  first  of  these  operations,  in  1819,  and  to  the 
second,  in  1824.  M.  Pillet,  who  insists  that  M.  Gensoul  is  the  only  person 
who  has  yet  performed  the  latter,  says  that  the  patient  of  M.  Dupuytren, 
having  died  at  La  Salpetriere,  it  was  found  that  a  portion  of  the  bone  had  been 
left. 

It  was  in  1 826  that  M.  Lizars,  who  also  claims  the  priority,  proposed  it ;  he 
performed  it  in  1 827,  28,  and  30,  with  success.  But  it  appears  to  me  tliat  all' 
pai'ties  think  too  highly  of  the  importance  of  this  part  of  the  question.  The 
excision  of  some  portions  of  the  superior  maxillary  bone  has  been  long  ago 
performed;  at  the  present  time  some  have  gone  a  little  further:  this  is  the 
whole  affair.  Even  when  tlie  whole  of  the  bone  has  been  removed,  a  thing 
not  easy  to  prove,  the  circumstance  does  not  merit  the  title  of  an  invention. 
This  debate  then  is  not  w^ori  h  the  pains  that  have  been  bestowed  upon  it.  M. 
Dupuytren  has  in  certain  cases  made  the  excision  of  the  alveolar  edge  by 
means  of  nippers  or  cutting  forceps,  or  the  chisel  and  mallet ;  in  other  cases 
he  has  made  incisions  on  the  face,  in  order  to  remove  the  osteo-sarcoma  more 
surely,  and  many  of  his  patients  thus  treated  have  done  very  well.  M.  Gen- 
soul's  case,  it  is  said,  has  completely  recovered ;  although,  as  M.  Pillet  says, 
the  palate  bone  itself  was  entirely  extracted.  Mr.  Lyme,  who  attempted  it  in 
the  early  part  of  1829,  for  cancerous  tumor  of  considerable  size,  made  a  cru- 
cial incision,  one  of  the  branches  of  which  extended  to  the  corresponding 
commissure  of  the  lips,  dissected  and  everted  the  flaps,  and  destroyed  the 
tumor  by  means  of  a  cock's-comb  saw,  a  chisel,  and  a  very  strong  scalpel. 
Some  months  after,  the  appearance  of  some  vegetations  awakened  apprehen- 
sions of  a  reappearance  of  the  disease.  The  three  instances  of  success,  which 
occurred  to  M.  Lizars,  having  been  obtained  with  different  diseases,  and  by 
different  processes,  cannot  serve  for  the  foundation  of  any  particular  metiiod. 
M.  Gensoul  says,  that  although  he  removed  the  maxillary,  malar,  and  palatine 
bones  four  times ;  that  although  he  has  four  times  extracted,  and  many  times 
excised  the  first  named  bone ;  and  that  altli^ough  in  one  case  he  took  away 
the  pterygoid  apophysis  itself  to  its  base,  he  has  been  always  successful,  and 
always  cured  his  patient.  But  as  he  does  no^  give  us  the  process  he  followed, 
I  am  forced  to  pass  over  his  experience  in  silence.  M.  Lisfranc  exposed  a 
facial  tumor  by  means  of  an  incision  in  form  of  a  V ;  divided  the  naso-pala- 
tine  partition  with  the  large  scissors  of  M.  (polombat,  and  finished  with  the 
chisel  and  mallet.  In  1823,  Dr.  A.  H.  Stevenjs  used,  in  a  similar  case,  a  flexible 
saw,  passed  by  puncture  through  the  bone  ;  and  Dr.  Rogers,  of  New  York, 
who,  in  1824,  removed  the  bone  on  each  sicjle  as  far  as  the  pterygoid  apophy- 
sis, had  scarcely  any  occasion  to  divide  the:  lip.  It  is  also  necessary  to  add 
to  the  other  exam.ple  that  mentioned  by  M.  Piedagnel,  as  occurring  during 


264  NEW   ELEMENTS   OF 

the  service  of  M.  Bauchine,  in  1818,  and  that  which  M.  Lafont  has  just  com- 
municated to  the  academy. 

I  have  also  had  occasion  to  practise  the  excision  of  the  upper  jaw  upon  a 
female,  aged  forty-five  years.  AH  the  molar  teeth  of  the  left  side  had  been 
destroyed  or  extracted.  An  opening  capable  of  receiving  the  end  of  the 
finger,  permitted  me  to  explore  with  ease  the  interior  of  the  sinus,  the  surface 
of  which  was  covered  with  bleeding  vegetations.  Its  edges,  equally  fungous, 
were  hard  and  lardaceous,  and  blended  with  the  surrounding  tissues.  Many 
portions  of  the  exfoliated  bone  belonging  to  its  external  and  anterior  walls, 
were  seen  in  the  midst  of  the  diseased  mass,  which  extended  backwards  to  the 
palatine  arch,  and  forward  to  the  incisor  teeth,  and  inwards  to  the  median 
line.  The  operation  was  performed  early  in  July,  1829,  at  the  hospital  Saint 
Antoine.  One  incision  commenced  at  the  commissure  of  the  lips,  and  being  car- 
ried obliquely  upward,  outward,  and  backward,  to  the  temporal  fossa,  between 
the  external  angle  of  the  eye  and  the  pavilion  of  the  ear,  enabled  me  to  avoid 
the  parotid  duct,  and  after  dissection  to  raise  up  a  triangular  flap,  comprising 
all  the  soft  parts  that  covered  the  cheek  bone  and  the  canine  fossa.  With  a  saw, 
applied  immediately  below  the  orbit,  I  divided  the  projectingpart  of  the  malar 
bone,  and  penetrated  into  the  sinus ;  with  a  very  strong  scalpel  I  then  cut  the 
maxillary  bone  in  front,  after  extracting  one  of  the  incisor  teeth,  so  as  to  unite 
the  second  section  with  the  first ;  at  a  third  stroke  I  prolonged  the  incision  of  the 
hard  parts  to  the  molar  tuberosity.  All  the  lardaceous  tissue,  a  great  part  of  the 
necrosed  bon6,  and  the  whole  facial  walls  of  the  sinus,  were  thus  cut  away. 
With  the  point  of  the  same  instrument,  I  divided,  through  the  mouth,  a  hori- 
zontal portion  of  the  palatine  arch,  parallel  to  the  median  line.  I  then  scraped 
the  floor  of  the  orbit,  and  made  use  of  the  dissecting  forceps  to  extract  many 
scales  that  had  been  left,  that  belonged  to  the  palate  bone,  the  posterior  walls 
of  the  sinus,  or  the  cavity  of  the  orbit.  It  was  necessary  to  penetrate  in  one 
direction  into  the  zygomatic  fossa,  and  in  another  into  the  orbit.  It  was  evi- 
dent that  the  bone  that  separated  these  last  two  cavities  had  been  destroyed; 
for  the  finger,  when  carried  to  the  bottom  of  the  sore,  pushed  the  eye  upward 
under  the  superior  eye-lid. 

Fearing  tbat  some  of  the  diseased  parts  might  have  escaped  me,  I  passed 
the  actual  cautery  over  the  whole  extent  of  this  large  excavation.  After  filling 
the  wound  with  charpie,  I  united  its  lips  by  means  of  the  twisted  suture,  sup- 
ported by  a  simple  bandage.  The  local  and  general  symptoms,  which  were  quite 
serious  for  two  days,  were  soon  dissipated.  The  fifth  day  the  mouth  looked 
well,  and  I  removed  the  two  last  sutures.  The  suppuration  ceased  to  be 
fetid  about  the  eighth  day.  When  I  left  the  hospital,  three  weeks  after,  the 
interior  of  the  mouth  was  of  a  lively  red,  scarcely  sensible,  and  in  a  fair  way 
to  heal.  I  understand  that  this  wgman  returned  to  her  village  before  the  comple- 
tion of  the  cure,  and  after  some  months  the  primitive  affection  reappeared. 
In  another  patient,  operated  upon  in  the  same  hospital  in  1830,  and  for 
whom  I  only  took  away  the  left  alveolar  border,  the  cure,  which  was  com- 
pleted in  twelve  days,  has  since  continued  perfect. 

It  seems  to  me,  that  for  a  disease  of  one  of  the  halves  of  the  superior  max- 
illary bone,  the  method  that  I  have  just  described  will  ordinarily  be  sufficient, 
and  that  it  is  difficult  to  imagine  one  more  simple  or  easy.  The  crucial  inci- 
sion, employed  by  Mr.  Lyme  is  more  liable  to  injure  the  duct  of  Steno,  and  does 


•  OPERATIVE  SURGERY.  265 

not  more  certainly  expose  the  parts  to  be  removed.  The  employment  of  a 
small  scoop  has  appeared  to  me  especially  useful,  and  may  be  of  great  assist- 
ance. If  the  alveolar  edges  only  be  diseased,  the  cutting,  forceps,  or  even  the 
small  scoop  that  I  use,  enables  us  to  remove  tl^  whole  affection  without  di- 
viding the  lips.  In  other  cases  we  must,  if  it  cannot  be  dispensed  with,  divide 
the  tissues  on  each  side,  following  the  oblique  line  that  I  have  above  indicated. 
It  is,  however,  one  of  those  operations,  the  manual  of  which  must  in  some 
degree  be  accommodated  to  each  particular  case,  and  in  which  we  should  be 
cautious  not  to  bind  ourselves  down  too  rigidly  to  any  set  of  rules. 

The  extraction  of  a  simple  exfoliatiori  of  the  upper  jaw,  comprehending 
even  a  great  part  of  the  bone,  such  as  occurred  to  M.  Roux,  in  1829,  like  that 
of  the  lower  jaw,  produces  not  near  so  great  a  deformity  as  amputation.  A 
new  production  almost  always  takes  the  place  of  the  original,  and  in  one  sin- 
gular case,  observed  by  M.  Krimer,  the  molar  teeth  tliemselves  were  repro- 
duced. 


CHAPTER   II. 

Excision  of  the  Articulations. 

History  and  Value. — Although  there  is  not  one  of  the  articulations  which  at 
the  present  day  has  not  undergone  excision,  yet  there  are  some  of  them  on 
which  this  operation  has  been  more  frequently  practised  than  others.  Asa 
general  rule  it  is  better  adapted  to  the  thoracic  than  the  pelvic  members,  and 
with  them  in  proportion  to  their  distance  from  the  trunk.  Although  of  appa- 
rently modern  origin,  excision  of  the  articular  heads  was  not  unknown  to  the 
ancients.  Hippocrates  speaks  of  it  in  the  articulations  of  the  foot  and  hand, 
et  in  tibia  ad  malleolos,  et  in  cubitu  ad  juncturam  manus.  It  is  evident,  in 
fact,  that  in  their  ignorance  of  hemostatic  agents,  they  would  use  every  ope- 
ration that  could  relieve  them  from  the  necessity  of  amputating  a  member. 
None  of  them,  however,  give  the  details  of  the  method  that  they  pursued,  and 
it  is  only  since  the  time  of  White  that  it  has  been  looked  upon  as  a  distinct 
operation.  Park,  who  wished  to  extend  it  to  all  the  articulations,  ultimately 
lessened  its  importance  very  much.  M.  Moreau  is  in  reality  the  first  who 
truly  demonstrated  its  value.  The  dissertation  of  Wachter,  published  in 
1809,  being  much  more  theoretical  than  practical,  would  have  remaine'd  un- 
known, like  that  of  Chaussier,  if  it  had  not  been  for  the  labors  of  Champion 
and  Roux,  Jeffrey  of  Glasgow,  Crampton  of  Dublin,  and  Lyme  of  Edinburgh, 
who  at  last  have  succeeded  in  fixing  public  attention  upon  the  subject.  In 
spite  of  the  facts  already  known,  the  excision  of  diseased  articulations  is  far 
from  being  approved  by  all  operator^.  Compared  with  amputation,  its  advan- 
tages and  inconveniences  are  so  nearly  balanced,  as  in  fact  to  justify  hesitation. 
Its  manuel  is  delicate,  painful,  and  commonly  very  long;  presenting  in  some 
cases  numerous  difficulties,  and  necessarily  involving  acute  suffering.  Although 
34 


366  NEW    ELEMENTS    OF 

the  diseased  bone  may  be  removed,  some  portion  of  altered  tissues  may  be  left- 
The  resulting  wound  is  extended  and  irregular,  and  almost  always  becomes  the 
seat  or  source  of  profuse  suppuration,  of  reabsorption,  or  dangerous  phlebitis. 
The  cure,  when  it  occurs,  is  often  deferred  for  months,  and  sometimes  even  for 
years.  The  limb  remains  more  or  less  stiff,  sometimes  fixed,  and  commonly 
drawn  by  the  muscles  in  one  direction  or  another,  and  is  so  deformed  as  to 
be  almost  unfit  for  the  performance  of  any  of  its  functions.  Amputation,  which 
is  generally  easy,  prompt,  and  consequently  less  painful,  at  once  relieves  the 
patient  from  the  bone,  and  all  the  affected  soft  parts.  When  performed  upon 
the  healthy  tissues,  it  gives  a  clean  incision,  easy  to  unite,  of  less  extent,  less 
disposed  to  suppurate,  and  less  favorable  to  the  development  of  phlebitis 
and  metastasis.  The  cure,  more  probable  and  prompt,  is  also  more  complete. 
To  these  objections  it  may  be  answered,  that  it  is  in  the  power  of  the  intel- 
ligent surgeon  to  surmount  the  difficulties  of  the  operation,  and  shorten  its 
duration ;  to  know  whether  he  can  or  cannot  remove  the  whole  disease  ;  that 
if  the  bone  be  removed,  the  neighboring  tissues,  however  altered,  most  fre- 
quently may  be  restored  to  their  natural  condition;  that  a  fungous  or  lard- 
aceous  degeneration  of  the  ligaments,  cellular  tissue,  and  skin,  is  not  always 
an  obstacle  to  cure ;  that  as  the  principal  arteries,  veins,  and  nerves,  are  left 
untouched,  the  operation  must  in  reality  have  less  influence  on  the  rest  of  the 
system  than  amputation,  properly  so  called ;  that  some  patients  are  cured 
very  promptly,  as  Mr.  Lyme  cites  some  who  used  the  limb  after  a  few  weeks ; 
that  the  new  substance  formed  in  place  of  the  excised  matter  acquires 
solidity  enough  to  replace  the  articulation  to  a  certain  extent,  and  yet  permit 
voluntary  movements ;  that  with  the  aid  of  splints  and  proper  dressing  all 
unnatural  deviation  of  the  member  may  be  prevented,  whilst  anchylosis  may 
be  obviated  by  early  and  suitable  movements  of  the  parts  \  in  fine,  that  how- 
ever deformed  it  may  become,  it  will  always  be  adapted  more  or  less  to  a 
great  many  uses,  of  which  the  patient  would  regret  to  be  deprived :  from  all 
of  which  it  follows,  as  far  as  I  am  permitted  to  judge,  that  the  mass  of  the  advan- 
tages of  excision  is  more  considerable  than  that  of  the  inconveniences,  and 
that  it  deserves  to  be  counted  among  the  efficacious  resources  of  surgery. 

The  apparatus  should  consist  in  the  first  place,  of  that  which  is  adapted  to 
amputation ;  so  that,  if  any  accidents  or  unforeseen  circumstances  presentthem- 
selves  at  the  moment  of  the  operation,  we  may  proceed  at  once  to  amputation 
instead  of  excision :  then  some  peculiar  articles,  for  example,  several  strong 
spatulas,  a  gouge,  a  leaden  hammer  and  a  chisel,  some  saws,  cock's-comb, 
circular,  or  semicircular  form,  a  chain  saw  like  that  of  Dr.  Jeffrey's,  or  a  saw 
like  that  of  M.  Machell,  or  a  flexible  one,  such  as  the  American  and  English 
surgeons  often  use ;  finally,  one  or  more  thin  flexible  plates  of  wood,  paste- 
board, lead  or  other  metal,  or  simply  a  straight  many-folded  compress,  proper 
to  place. between  the  bone  and  soft  parts.  Besides  these,  there  should  be  one 
of  Scultet's  bandages,  cushions,  splints — a  sort  of  fracture  apparatus  for  the 
dressing. 


OPERATIVE  SURGERY.  26f 

SECTION  I. 

Thoracic  Members. 

Art.l.—TJie  Hand. 

If  the  anterior  or  posterior  third  of  one  of  the  last  four  metacarpal  bones 
should  be  diseased,  that  portion  may  be  excised  without  the  amputation  of  the 
whole  finger.  Many  surgeons  had  suggested,  and  even  performed  it  at  the 
commencement  of  the  present  century;  as  is  proved  by  several  theses  on  th{. 
subject.  It  is,  however,  to  M.  Troccon,  that  we  owe  its  subjection  to  fixed 
rules.  Mr.  Wardrop,  who  performed  the  operation  on  two  of  the  metacarpal 
bones,  is  not  the  only  one  who  has  used  it  on  living  man.  The  head  of  the 
first  phalanx  of  the  thumb  was  thus  successfully  excised  at  the  commence- 
ment of  this  century,  by  M.  Bobe.  Mr.  Evans  reckons  two  similar  cures,  and 
M.  Roux  has  been  not  less  successful  upon  some  others  of  the  metacarpal  bones. 

Operation. — This  forms,  in  fact,  but  one  of  the  steps  of  extraction,  properly 
so  called,  of  the  same  piece  of  the  skeleton.  After  dividing  the  teguments, 
separating  the  extensor  tendons,  scraping  the  bone  on  each  side  to  detach  the 
interosseous  muscles,  disarticulating  the  extremity  which  is  to  be  removed, 
there  is  nothing  more  to  be  done  than  to  slip  a  strip  of  wood,  pasteboard,  or 
the  like,  beneath  its  anterior  face,  and  then  divide  it  sloping  or  perpendicularly 
with  a  small  saw,  such  as  Jeffrey's  chain  saw. 

Art.  2.-^The  Wrist. 

Others,  besides  M.  Roux,  and  M.  Hublie,  of  Provins,  have  excised  the  car- 
pal extremity  of  the  fore-arm.  According  to  MM.  Bobe,  and  Moreau,  it  was 
performed  successfully  nearly  thirty  years  ago,  by  M.  Clemot,  of  Rochefort, 
on  a  subject  whose  radius  and  ulna  were  luxated,  and  projected  considerably 
through  the  soft  parts.  M.  Hublie's  attempt,  which  was  completely  successful, 
belongs  to  the  same  class.  There  was  a  luxation  of  the  hand,  and  a  projec- 
tion of  the  bone  through  a  laceration  of  the  integuments.  The  extensor  and 
flexor  tendons  were  uninjured :  the  surgeon  resolved,  after  properly  isolating 
them,  to  remove  the  exposed  portions  of  the  radius  and  ulna,  and  then  return 
the  arm  and  hand  to  their  natural  position.  After  the  cure,  which  occurred 
without  any  serious  intervening  accident,  the  fingers  could  be  moved  with 
almost  as  much  facility  as  before  the  disaster.  There  should  be  no  hesitation, 
if  the  reduction  of  the  luxated  bone  be  impossible,  or  too  difficult ;  but  there 
is  another  sort  of  incision,  the  utility  of  which  is  not  so  well  demonstrated:  I 
speak  of  that  relating  to  some  organic  lesions  of  long  standing,  such  as 
caries  or  necrosis.  These  diseases  are  rarely  so  serious  at  the  wrist  as 
to  require  amputation,  without  being  attended  with  profound  affection  of  the 
carpus  and  surrounding  soft  parts.  But  supposing  the  thing  should  be  ne- 
cessary, there  are  two  methods  that  may  be  followed,  and  which  have  bieen 
tried. 

Operation. — 1st  Method. — An  incision  on  the  radial  side  of  the  fore-arm, 
and  another  on  the  ulnar,  extending  from  the  root  of  the  thumb  and  from  the 
last  metacarpal  bone  to  two  or  three  inches  above  the  styloid  apophyses  of 
the  radius  and  ulna,  and  a  connexion  of  these  incisions  over  the  posterior  face 


268  NEW  ELEMENTS  OF 

4)f  the  wrist  by  a  transverse  incision,  permit  us  to  dissect  and  evert  a  flap  that 
will  expose  the  whole  dorsal  face  of  the  articulation.  The  flesh  in  front 
should  then  be  detached  from  the  bone,  so  as  to  eijable  us  to  pass  between  it 
and  the  latter  a  thin  piece  of  flexible  wood,  lead,  or  pasteboard.  The  radius  and 
ulna  are  then  to  be  divided  with  a  saw,  above  the  diseased  spot.  The  pieces 
are  then  successively  separated  with  a  bistoury  from  the  carpus,  with  which 
they  are  articulated.  The  wound  is  then  to  be  closed  by  means  of  several 
stitches.  Light  pressure  will  bring  together  the  internal  faces  of  the  wound, 
and  it  is  not  impossible  for  the  extensor  tendons  to  recover  their  power  over 
the  fingers.  In  this  manner  the  operation  is  very  easily  performed  on  the 
dead  subject,  whilst  the  radial  and  ulnar  arteries  are  easily  avoided  in  detach- 
ing the  flesh  from  the  anterior  face  of  the  wrist.  But  one  of  the  advantages 
of  excision  being  the  preservation  to  the  hand  of  the  most  of  its  movements,  it 
is  important  to  have  a  method  which  will  leave  untouched  all  the  extensor 
tendons. 

2d.  M.  Dubled^s  Method. — After  having  made  an  incision  first  on  the  inside 
of  the  ulna,  M.  Dubled  detaches  the  lips  of  it  from  the  posterior  and  then  the 
anterior  face  of  that  bone ;  draws  then  away  from  it ;  divides  the  lateral  liga- 
ment ;  abducts  the  hand ;  isolates  completely  the  head  of  the  bone ;  projects 
it  as  far  as  possible  ;  detaches  it  from  the  radius ;  passes  between  the  two 
bones  a  plate  of  wood  or  lead,  and  detaches  the  part  affected  with  a  saw.  The 
same  process  is  followed  for  the  external  edge  of  the  articulation ;  and  as  the 
ulna  is  already  excised,  it  is  then  much  more  easy  to  turn  the  hand  inward, 
draw  out  the  radius,  and  perform  the  excision.  In  this  manner  all  the  ten- 
dons will  be  saved,  and  the  consequences  of  the  operation  become  evidently 
more  simple.  In  practising  it  upon  the  dead  subject,  it  appears  to  me  very 
easy  of  execution ;  but  it  is  not  certain  that  it  will  be  the  same  on  living 
man,  and  on  a  deformed  hand. 

Moreau  and  Roux^s  Method. — The  operation  adopted  by  Moreau,  Roux,  and 
Lyme,  without  being  much  more  complicated  than  that  of  M.  Dubled,  has  the 
advantage  of  rendering  the  incision  of  the  heads  of  articulation  very  much 
more  simple.  A  transverse  incision,  which  begins  at  the  carpal  extremity  of 
each  lateral  incision,  and  prolonged  from  eight  to  ten  lines  upon  the  dorsal 
face  of  the  wrist,  circumscribes  a  small  flap  in  the  form  of  an  L,  over  the  pos- 
terior region  of  the  radius  and  ulna.  Tliey  are  dissected  and  raised  up  one 
after  the  other,  commencing  with  that  over  the  ulna.  After  separating,  de- 
taching, and  isolating  the  tendons,  a  protecting  compress  should  be  passed  be- 
tween the  two  bones  by  means  of  a  spatula,  and  brought  out  between  the  palmar 
face  of  the  ulna  and  the  soft  parts.  An  assistant  immediately  takes  hold  of 
it,  and  draws  the  two  extremities  towards  the  radius,  so  as  to  press  the  soft 
parts  towards  that  bone.  Then  with  a  saw  the  surgeon  makes  the  division  of 
the  bone,  which  he  then  detaches  from  the  carpus  and  radius,  by  means  of 
a  bistoury.  He  then  dissects  the  second  flap  with  the  numerous  tendons  and 
the  radial  artery  which  present  themselves  on  this  side.  To  finish,  he  has 
but  to  do  the  same  on  the  radius  as  he  has  just  done  upon  the  ulna.  Moreau's 
patient,  thus  operated  upon,  was  cured.  But  we  cannot  give  a  just  estimate 
of  the  value  of  the  facts  in  the  case,  for  the  want  of  minuteness  in  the  details. 
5  am  ignorant  of  the  ultimate  results  of  M.  Roux's  case. 


OPERATIVE    SURGERY.  269 

^r(,  S.^The  Elbow, 

The  excision  of  the  elbow  was  first  performed  with  success  by  Wainmann, 
who  removed  only  the  trochlea,  or  pulley  of  the  humerus,  for  a  luxation  of  the 
elbow ;  proposed  by  Park,  of  Liverpool,  in  1781,  as  applicable  to  chronic  dis- 
eases ;  practised  on  the  living  subject,  in  1782,  by  Moreau ;  shortly  afterwards 
by  Percy,  Binns,  and  many  other  military  surgeons.  It  has  been  attempted 
five  times  by  M.  Roux,  once  by  Mr.  Crampton,  four  times  by  Mr.  Lyme, 
once  by  Mr.  Spence,  and  since  their  first  attempt,  MM.  Moreau,  father 
and  son,  MM.  Champion  and  Mazzoza,  have  reported  three  or  four  new  ex- 
amples of  it ;  so  that  at  the  present  time  we  can  enumerate  nearly  thirty 
cases. 

Operation. — Parleys  Method. — Park  thought  it  sufficient  to  make  an  incision 
parallel  to  the  axis  of  the  limb,  extending  two  or  three  inches  above  and  be- 
low the  olecranon.  Its  lips  being  separated,  he  endeavored  to  divide  the  late- 
ral ligaments  and  the  tendon  of  the  triceps,  so  as  to  luxate  the  extremity  of 
the  bone  backwards ;  but  finding  it  too  difficult,  he  first  excised  the  olecranon, 
and  then  accomplished  his  object  more  easily.  The  first  step  of  the  operation 
over,  Park  made  section  of  the  humerus  upon  a  plate  which  he  had  placed  be- 
tween the  anterior  face  of  the  bone  and  the  flesh,  about  two  inches  above  the  ar- 
ticulation. The  sides  of  the  division  were  brought  together,  and  kept  so  by 
means  of  small  bandages.  In  his  letter  to  Pott,  the  author  agrees  that  this 
method  will  not  probably  serve  for  a  diseased  and  swelled  articulation ;  but 
that  in  such  a  case  he  would  add  a  transverse  incision  immediately  above  tl>e 
joint ;  dissect  up  the  four  flaps,  the  whole  posterior  face  of  the  bone  thus  ex- 
posed, and  remove  with  the  saw  successively  the  lower  head  of  the  humerus 
and  the  superior  portion  of  the  bones  of  the  fore-arm.  Such  an  operatiom. 
should  not  be  performed  in  any  case,  either  in  its  simplicity  or  with  the  crucial 
incision,  although  Mr.  Lyme  may  have  used  it  once  successfully. 

2.  iW.  Moreau' s  Method. — Instead  of  cutting  on  the  median  line,  M.  Moreau 
commences  by  dividing  the  whole  thickness  of  the  soft  parts  from  bel^w 
upwards,  for  two  or  three  inches,  beginning  at  the  condyles,  and  following  the 
edge  of  the  humerus.  A  third  and  transverse  incision  unites  the  first  two 
immediately  above  the  olecranon,  forming  a  quadrilateral  flap,  which  is  to  be 
dissected  and  turned  up  on  the  posterior  face  of  the  arm.  With  a  bistoury 
laid  flat  upon  the  anterior  face  of  the  humerus,  the  flesh  is  to  be  carefully 
detached.  Then,  having  put  a  flexible  strip  of  wood  in  the  place  of  the  instru- 
ment, the  remainder  of  the  operation  is  performed  like  that  of  Park.  If  the 
extremity  of  the  radius  and  ulna  must  be  removed,  it  is  sufficient  to  prolong 
the  lateral  incision  a  little  downward,  and  thus  form  a  small  flap  belcfw,  which» 
being  dissected,  renders  the  section  of  the  bones  that  it  covered  very  easy. 

3.  M.  DupuytrerCs  Method. — The  method  of  Moreau  is  stich  that  it  is 
worthy  of  being  followed,  as  it  has  been  by  Roux  and  Lyme,  at  least  in  most 
of  their  cases.  Yet  they  found  it  necessary  to  modify  it  ip  some  respects. 
;M.  Dupuytren  has  shown  that  the  ulnar  nerve,  which  is  almost  necessarily 
^Sacrificed,  can  and  should  be  preserved.  After  forming  the  quadrilateral  flap, 
and  exposing  the  superior  extremity  of  the  ulna,  like  Park,  he  begins  by  ex- 
cising the  olecranon ;  then  carefully  incises  the  sheath  that  envelopes  the  ulnar 
nerve  behind  the  trochlea ;  pushes  this  nervous  cord  inwards  and  before  the 


SrO  NEW   ELEMENTS   Ot 

articulation,  where  an  assistant  holds  it  with  a  curved  sound,  the  handle  of  a 
scalpel,  or  even  the  finger,  until  the  extremity  of  the  humerus  is  removed. 

4.  Process  adopted  hy  the  Author, — The  patient  must  be  placed  on  his  belly, 
or  at  least  on  the  healtlij  side.  An  assistant  compresses  the  humeral  artery, 
and  supports  the  soft  parts  of  the  arm.  Another  person  holds  the  fore-arm 
extended.  The  surgeon  on  the  outside,  and  armed  with  a  straight  bistoury, 
first  makes  an  incision  two  inches  long  upon  the  external  edge  of  the  humerus, 
commencing  or  ending  over  the  epicondyles,  and  extending  upward  so  as  to 
separate  the  anterior  brachial  muscle  from  the  external  portion  of  the  triceps. 
A  second  incision  is  then  made  upon  the  internal  edge  of  the  arm,  the  inferior 
extremity  of  which  should  fall  rather  on  the  side  of  the  olecranon  than  upon 
the  epitrochle,  in  order  to  avoid  the  ulnar  nerve.  After  uniting  these  two 
longitudinally  by  means  of  a  third  and  transverse  incision,  which  should  divide 
the  tendon  of  the  triceps,  the  flap  is  easily  dissected  and  turned  up.  An 
assistant  then  seizes  this  flap,  and  if  the  extremity  of  the  fore-arm  appears 
sound,  the  surgeon  proceeds  to  the  excision  of  the  humerus.  Otherwise 
the  lateral  incisions  must  be  prolonged,  and  an  inferior  flap  formed  analogous 
to  the  other.  As  soon  as  the  ulnar  nerve  is  exposed,  it  is  isolated  from  the 
attachments  that  fix  it  between  the  trochlea  and  olecranon ;  and  whilst  the  arm 
is  extended,  it  is  carried  behind  the  internal  tuberosity  of  the  humerus  as  above 
described.  Then  the  operator  brings  forward  the  undivided  flesh,  and  slightly 
flexes  the  arm;  separates  the  fleshy  fibres  from  the  anterior  face  of  the 
bone  with  the  point  of  the  bistoury;  makes  use  of  the  saw;  takes  hold  of  the 
superior  extremity  of  the  bony  fragment;  separates  the  tissues  from  it  that  he 
may  turn  it  downward  and  backward;  divides  the  anterior,  the  internal  and 
external  lateral,  and  the  posterior  ligaments.  If  the  excision  of  the  radius 
and  ulna  must  also  be  performed,  he  detaches  the  anterior  brachial  and  biceps 
muscles  below  the  disease,  and  then  divides  those  two  bones  with  the  saw  from 
before  backwards,  or  vice  versa,  according  as  the  state  of  the  parts  may  require, 
or  render  convenient.  It  would  also  be  better  in  this  case  not  to  disarticulate 
the  humerus,  but  pass  at  once  to  the  excision  of  the  radius  and  ulna,  as  Mr. 
Lyme  advises.  If  the  bones  of  the  fore-arm  be  perfectly  sound,  we  can 
scarcely  conceive  the  utility  of  the  extirpation  of  the  olecranon.  When  they 
are  diseased,  the  operation  becomes  necessarily  longer  and  more  serious,  and 
seems  to  me  to  offer  but  little  chance  of  success,  if  it  is  necessary  to  extirpate 
below  the  bicipital  tuberosity  of  the  radius,  because  then  the  attachments  of 
the  two  principal  flexor  muscles  of  the  fore-arm  are  destroyed.  The  brachial 
artery,  separated  by  a  thick  muscle  from  the  humerus,  is  never  difficult  to 
avoid.  There  is  greater  risk  when  it  has  descended  to  the  fore-arm  on  a  level 
with  its  bifurcation.  It  is  of  great  importance  to  divide  the  radius  and  ulna 
above  the  insertion  of  the  anterior  brachial,  and  especially  of  the  biceps 
muscle.  Yet  Mr.  Lyme  seems  to  have  extended  the  excision  to  below  the 
tendon  of  these  muscles  in  some  cases,  in  which,  nevertheless,  the  use  of  the 
hand  was  retained. 

After  you  have  removed  the  bone,  tied  the  vessels  if  there  be  any  that 
require  it,  cleansed  the  wound,  and  satisfied  yourself  that  there  remains 
nothing  of  the  disease  behind,  the  elbow  is  again  extended,  the  flaps  brought 
together,  united  by  two  or  three  stitches,  and  in  the  same  manner  attached 


OPERATIVE    SURGERY.  271 

to  the  anterior  soft  parts.  Pledgets  of  lint,  graduated  compresses,  a  Scultet 
bandage,  pads,  and  two  thin  splints,  keep  the  parts  in  contact,  and  the 
whole  limb  in  the  most  perfect  rest.  The  excision  of  the  elbow  is  a 
minute,  long,  and  extremely  painful  operation.  It  is  rarely  followed  by  im- 
mediate reunion.  It  is  very  frequently  followed  by  profuse  suppuration. 
One  of  M.  Roux's  cases  continued  nearly  a  year  before  complete  recovery. 
It  can  only  be  used  where  the  skin  and  a  part  of  the  muscles  remain  sound,  as 
in  simple  caries  or  necrosis,  or  in  a  comminuted  fracture  of  the  articulation. 
These  circumstances  have  alarmed  operators,  and  tended  to  render  this  ope- 
ration more  rare  than  would  at  first  be  imagined.  Yet  it  has  always  been 
successful  with  the  surgeons  of  Bar.  M.  Roux  also  cured  three  cases. 
His  first  patient,  operated  upon  in  1819,  was  well  of  the  operation,  when  he 
died  of  phthisis.  The  second  has  established  himself  as  scissors -grinder  on 
one  of  the  bridges  of  Paris.  The  third,  on  whom  I  saw  the  operation  per- 
formed, has  re-assumed  her  trade  of  mantua-maker.  A  hemorrhage  rendered 
the  immediate  amputation  of  the  arm  necessary  in  a  fourth,  who  died  three 
days  after.  M.  Mazzoza's  case  was  successful.  The  patient  of  Mr.  Crampton, 
operated  upon  on  the  2d  of  January,  1823,  signed  his  own  discharge  the 
29th  of  November  following.  Of  the  four  operated  upon,  from  the  first  of 
October,  1828,  to  the  first  of  October,  1830,  by  Mr.  Lyme,  two  are  dead.  A 
third  had  to  submit  to  a  subsequent  amputation  of  the  arm.  Eleven  have  been 
perfectly  cured ;  some  by  immediate  reunion,  others  after  a  longer  or  shorter 
time,  and  all  preserved  most  of  the  movements  of  the  limb.  The  patient  of 
Mr.  Spence,  treated,  in  1830,  was  equally  successful ;  so  that  it  is  impos- 
sible not  now  to  admit  excision  of  the  elbow  as  one  of  the  valuable  re- 
sources of  surgery,  notwithstanding  the  opinion  of  M.  Larrey,  and  my 
former  preceptor,  M.  Gouraud,  who  will  only  adopt  it  in  cases  of  com- 
minuted fracture  or  luxation,  with  division  of  the  integuments  and  projection; 
of  the  bone.  It  is  true  that  the  removed  parts  cannot  apparently  be  repro4 
duced,  as  some  persons  at  first  believed,  and  that  the  articulation  of  the  elbow 
is  ever  after  wanting.  But  in  their  places  there  sometimes  forms  a  substance 
sufficiently  solid  to  serve  as  a  fulcrum,  upon  which  the  muscles  can  flex  and 
extend  the  fore -arm.  The  patients  once  cured,  can  always  use  their  hand, 
and  are  certainly  very  happy  to  escape  amputation — the  only  resource  left  if 
excision  must  not  or  cannot  be  attempted. 

If  one  of  the  condyles  or  the  olecranon  only  be  diseased,  the  operation  musi; 
be  performed,  as  M.  Moreau  has  once  performed  it  successfully;  namely, 
make  one  of  the  lateral  incisions  above-mentioned;  make  a  second  for  the  ex- 
tremity of  the  first  across  to  the  middle  of  the  breadth  of  the  arm  and  belov 
the  olecranon ;  dissect  and  evert  the  triangular  flap  thus  made,  upw^ard  and 
towards  the  median  line  of  the  arm ;  then,  by  means  of  a  chisel  or  gouge,  re- 
move the  part  of  the  bone  affected,  and  return  the  flap  to  its  proper  place 
for  immediate  reunion. 


^rt.  A.— The  Radius. 

A  necrosis,  with  fungous  degeneration  of  the  periosteum  extending  almost 
throughout  the  whole  extent  of  the  fore -arm,  gave  me  the  idea,  in  1826,  of  ex- 
cising or  removing  the  radius  (this  being  the  only  part  affected),  instead  of 


271^  NEW   ELEMENTS    OF 

amputating  the  arm ;  but  the  patients  preferred  submitting  to  the  latter  ope- 
ration. Upon  the  dead  subject,  it  maj  be  done  without  difficulty,  and  with- 
out destroying  any  tendon  or  muscle.  The  fore-arm  is  to  be  placed  in  a  flexed 
position.  An  incision,  parallel  to  its  axis,  exposes  first  the  external  and  an- 
terior edge  of  the  radius.  The  two  lips  of  the  wound  are  then  separated  from 
its  posterior  and  anterior  faces,  by  means  of  a  bistoury,  to  a  point  a  little  below 
its  middle  portion,  where  it  lies  almost  naked  beneath  the  teguments.  At 
that  point,  the  operator  should  endeavor  to  pass  a  grooved  sound  between  its 
ulnar  edge  and  the  flesh,  to  serve  as  a  conductor  to  a  flexible  saw.  He  then 
divides  the  bone  from  within  outward  by  means  of  this  latter  instrument,  and 
then  extracts  the  two  fragments,  one  after  the  other,  by  dissecting  them  care- 
fully from  their  free  extremities  towards  their  articulations.  If  the  integu- 
ments, being  difficult  to  depress,  oppose  the  introduction  of  the  saw,  there 
is  no  objection  to  dividing  them  on  each  side  of  the  lips  for  some  lines.  It  is 
now  an  operation  which  has  received  the  sanction  of  experience.  Dr.  R.  Butt, 
of  Virginia,  having  performed  it  upon  a  man,  in  1825,  with  complete  success. 

Art.  5.--The  Shoulder. 

In  the  year  1740,  a  surgeon  at  Pezenas,  named  Thomas,  made  known  a 
case  in  which  the  head  of  the  humerus,  being  in  the  state  of  necrosis,  was 
successfully  extracted.  A  little  later,  Boucher,  in  his  memoir  upon  gun-shot 
wounds,  demonstrated  that  the  head  of  the  humerus,  reduced  to  splinters, 
could  be  removed  without  much  difficulty,  and  without  a  sacrifice  of  the 
whole  member.  The  same  doctrine  has  since  been  supported  by  Percy,  M. 
Lai;rey,  and  almost  all  military  surgeons.  The  theses  of  MM.  Triad  and 
Legrand  may  be  consulted  on  this  subject.  As  to  excision  in  the  case  in 
which  the  head  of  the  bone  has  been  the  seat  of  an  organic  lesion,  requiring 
its  removal,  it  has  been  performed,  first  by  White,  David,  Vigouroux ;  then 
by  Moreau  the  father.  Bent,  Orred,  Percy,  Moreau  the  son,  and  also,  it  is  said, 
by  Larre}^  Grosbois,  Porret,  C.  Petit,  Brulatour,  Roux,  Willaume,  Bottin,  &c. 
It  is  known,  from  the  testimony  of  Sabatier,  that  in  1789,  a  child  presented 
with  its  right  hand  to  the  academy  of  surgery  the  scapular  extremity  of  the 
Humerus  of  that  side  that  had  been  taken  from  him  by  the  surgeon-major  of 
the  regiment  de  Berry.  The  method  of  operating  must  necessarily  vary 
according  to  the  morbid  state. 

Operation. — 1st.  TVhite^s  Method. — When  most  of  the  surrounding  tissues 
are  healthy,  or  when  tlie  bone  is  reduced  to  fragments,  the  operator  may, 
according  to  M.  Larrey  and  M.  Porret,  be  content  with  an  incision  parallel  to 
the  fibres  of  the  deltoid  muscle,  extending  from  the  summit  of  the  acromion 
four  or  five  inches  down,  and  penetrating  to  the  articulation,  as  in  Pojet's 
method  for  the  removal  of  the  shoulder,  published  in  1759.  Then,  seizing 
the  elbow.  White  used  it  to  sway  the  humerus,  and  thus  produce  a  luxation  of 
its  head  upwards  through  the  soft  parts.  M.  Larrey  separates  the  lips  of  this 
first  incision,  opens  the  capsule,  and  then  divides,  by  means  of  a  button- 
headed  bistoury  conducted  by  the  nnger,  the  tendons  of  the  supra  and  infra 
splnatus,  subscapulars,  and  teres-minor  muscles,  so  as  to  remove  all  difficulty 
of  turning  out  the  head  of  the  bone.  In  both  cases  when  the  operation  has 
reached  this  point,  a  thick  c6mpress,  or  some  protecting  plate,  is  to  be 


OPERATIVE    SURGERY.  S75 

placed  between  the  neck  of  the  bone  and  the  teguments,  so  as  to  saw  without 
inconvenience. 

2d.  M.  Moreav^s  Method. — M.  Moreau  remarks,  justly,  that  the  simple 
incision,  recommended  by  White,  and  even  when  modified,  as  by  M.  Larrey, 
must  be  insufficient  in  most  cases.  According  to  him,  two  incisions  of  four 
inches  in  length  parallel  to  the  fibres  of  the  deltoid,  one  on  its  anterior  the 
other  its  posterior  border,  and  united  below  the  summit  of  the  acromion  by  a 
transverse  incision,  would  be  infinitely  superior ;  thereby  forming  a  trapezoid 
flap,  which  should  be  dissected  and  turned  down  towards  the  insertion  of  the 
deltoid.  Then  all  the  anterior  portion  of  the  joint  will  be  exposed.  Nothing 
will  be  more  easy  than  to  divide  the  capsule,  turn  out  the  head  as  well  as 
the  superior  portion  of  the  bone,  and  perform  the  excision.  The  flap,  then 
turned  up  in  its  place,  should  be  secured  above  and  at  its  sides,  by  a  few 
stitches. 

^d.  Manners  Method. — M.  Moreau's  plan  evidently  renders  the  excision  of 
the  humerus  much  more  easy  than  White's ;  but  his  large  flap,  which  diff*ers 
from  the  deltoid  flap  of  la  Faye  only  in  being  detached  and  turned  downwards 
instead  of  the  reverse,  renders  immediate  reunion  difficult,  and  exposes 
to  fistulae,  which  should  be  avoided.  This  plan,  therefore,  should  not  be 
wholly  adopted.  It  would  be  better,  if  the  surgeon  desired  to  have  a  trape- 
zoid flap,  to  follow  the  advice  of  Manne,  i.  e.  make  two  lateral  incisions,  like 
Moreau,  unite  them  by  their  inferior  extremity,  dissect  and  raise  the  flap 
from  point  to  base,  exactly  as  la  Faye  recommends  for  amputation  of  the  arm 
at  this  joint. 

4.  Sabatier^s  Method. — Instead  of  taking  so  much  care  of  the  soft  parts, 
Sabatier  formally  advises  us  to  circumscribe  a  portion,  in  form  of  a  V,  in  the 
midst  of  the  deltoid  muscles,  and  then  to  excise  this  triangle  to  expose  the 
naked  capsule  of  the  joint.  It  is  difficult  to  imagine  what  prompted  Sabatier 
in  the  description  of  this  method,  and  why  he  directs  the  removal  of  the 
flap  rather  than  its  preservation.  *  By  dissecting  it  up,  as  M.  Gouraud  did,  in 
1801,  and  as  it  has  recently  been  done  by  Dr.  Smith,  in  America,  the  operator 
can  easily  extract  and.  excise  the  bone. 

5.  Bent^s  Method. — After  in  vain  trying  White's  method.  Bent,  who  was 
one  of  the  first  to  remove  the  humerus,  thought  it  was  necessary  to  detach  it 
outwardly  from  the  acromion,  inwardly  from  the  clavicle,  and  then  to  divide 
the  deltoid  muscles  transversely,  so  as  to  form  a  T  incision,  which  would  per- 
mit him  to  dissect  the  two  triangular  flaps,  one  external  and  the  other  internal, 
and  afterwards  act  freely  upon  the  joint. 

6.  M.  MorePs  Method. — M.  Morel  was  dissatisfied  with  all  these  methods, 
and  made  a  semilunar  flap,  with  the  convexity  downwards,  upon  the  anterior 
face  of  the  shoulder.    The  operation  was  long,  but  the  patient  was  cured. 

7.  Mr.  Lyme^  who  has  twice  removed  the  head  of  this  bone  with  success, 
makes  a  flap  upon  the  external  half  of  the  deltoid,  giving  it  a  triangular  form, 
the  anterior  leg  of  which  is  represented  by  White's  incision,  whilst  the  other, 
much  shorter,  is  carried  obliquely  upward  and  backward  towards  the  poste- 
rior edge  of  the  arm-pit.  The  flap  being  raised,  the  surgeon  carries  the  elbow 
in  front  of  the  thorax;  divides  the  capsule,  luxates  the  head  of  the  hu- 
merus ;  excises  it ;  brings  down  the  flap,  and  proceeds  to  the  dressing. 

Remarks, — The  diseases  which  call  for  excision  of  the  humerus,  are  t|id 
35  " 


j^4  NEW   ELEMENTS   OF 

same  as  those  which  otherwise  would  require  disarticulation  of  the  arm ;  con- 
sequently the  various  methods  of  operating  proposed  for  the  latter  will  also 
apply  to  the  former.  Thus  instead  of  making  a  flap  by  means  of  three  inci- 
sions, as  La  Faye  did,  it  would  be  much  more  simple  to  imitate  M.  Morel,  or 
to  make  a  single  cut  as  MM.  Dupuytren  and  Lisfranc  do,  or  even  to  follow 
the  method  of  Mr.  Cline  or  Onsenort.  It  is  also  evident  that  excision  differs 
from  amputation  at  the  joint,  only  in  the  latter  steps  of  the  operation. 

We  may  therefore  adopt  any  method  that  may  appear  most  easily  to  isolate 
the  head  of  the  bone,  either  by  penetrating  from  above  downwards,  from 
without  inwards,  or  in  any  other  manner,  and  just  as  teguments  and 
muscles  may  be  more  or  less  altered  in  this  or  that  direction.  Whatever 
method  we  select,  Mr.  Guthrie  recommends  us  to  remove  as  much  of  the 
articular  capsule  as  possible  ;  because,  says  he,  the  more  there  is  left  of  this 
fibrous  purse,  the  less  will  be  the  chances  of  an  immediate  reunion.  This 
practice,  although  good  in  amputations,  is  not  to  be  followed  in  excision ; 
because,  in  proportion  to  the  preservation  of  the  fibrous  tissues  will  be  the 
future  strength  and  stability  of  the  limb.  When  the  extremity  of  the  hu- 
meus  is  removed,  the  operator  can  assure  himself  of  the  state  of  the  acromion, 
of  the  corocoid  apophysis,  and  the  glenoid  extremity  of  the  scapula.  If 
these  parts  be  not  altered,  he  then  proceeds  to  the  dressing ;  otherwise,  he 
must  remove  them  with  the  cutting  Ibrceps,  the  gouge  or  chisel,  or  even  with 
the  sawj  proceeding  as  we  have  described  in  the  removal  of  the  shoulder ; 
that  is  to  say,  if  the  alteration  of  the  bone  extends  beyond  a  certain  distance,  it 
will  be  necessary  to  extend  the  ineisions  which  circumscribe  the  base  of  the 
flap,  under  the  spine  of  the  scapula,  and  above  the  internal  edge  of  the  cora- 
coid  process,  in  order  to  expose  the  whole  extent  of  the  diseased  parts.  It  is 
well  known  that  M.  Larrey  does  not  hesitate  to  remove  these  three  apophyses, 
aftd  even  the  acromial  extremity  of  the  clavicle.  Mr.  H.  Hunt  proceeded  in 
the  same  manner  in  a  case  in  which  Mr.  Brown,  in  1818,  had  removed  the  head 
of  the  humerus.  This  daring  effort  was  crowned  with  complete  success. 
Moreau  had  this  excision  in  view  when  he  recommended  turning  the  del- 
toid downwards.  Then,  in  fact,  nothino;  prevents  us  from  forming  another  flap 
in  the  opposite  direction,  which  would  render  the  removal  of  the  scapular 
apophyses  quite  easy.  But  as  it  is  always  possible  to  retain  sufficient  sub- 
stance at  the  root  of  the  flaps  of  La  Faye,  Dupuytren,  or  Lisfranc,  to  prevent 
mortification,  the  motive  that  influenced  Moreau  will  not  sufiice  to  make  us 
pursue  his  method,  after  seeing  that  of  the  other  operators.  The  operation 
being  finished,  the  extremity  of  the  body  of  the  humerus  is  returned  to  its 
natural  place  by  giving  the  arm  its  natural  direction.  Whatever  may  be  the 
fonn  of  the  flap,  its  lips  must  be  exactly  brought  together,  at  least  towards 
the  lower  angles  of  the  solution  of  continuity.  To  retain  the  bleeding 
surfaces  in  contact,  the  origin  of  the  limb  should  be  covered  with  plates  of 
agaric,  pledgets  of  charpie,  or  graduated  compresses.  A  many-tailed  band- 
age, cushions  and  splints,  should  fix  the  whole  in  such  a  manner  as  to  per- 
mit the  dressing  of  the  disease  as  often  as  it  may  be  judged  advisable. 

Some  have  thought  that  the  portion  of  the  bone  removed  would  be  repro- 
duced. This  is  an  error.  From  the  case  given  by  Chaussier,  it  is  seen 
that  a  conical  osseus  mass  fills  up  the  glenoid  cavity,  ending,  it  is  true,  by  com- 
ing in  contact  with  the  superior  extremity  of  the  body  of  the  humerus^^and 


OPERATIVE    SURGERY.  275^ 

being  slightly  excavated,  really  produces  a  new  articulation  that  allows  the 
arm  almost  all  its  original  movements.  In  one  of  tlie  cases  reported  by  Mo- 
reau,  the  superior  part  of  the  bone  of  the  arm  was  drawn  and  fixed  upon  the 
breast,  when  a  sort  of  artificial  articulation  was  ultimately  formed.  But 
nothing  in  these  cases  indicated  a  reproduction  of  the  bone,  and  most  fre- 
quently the  superior  extremity  of  the  humerus  remains  movable  in  the  midst  of 
the  soft  parts.  Nevertheless,  the  patient  preserved  the  motion  of  the  fingers, 
the  hand,  and  the  fore-arm,  and  even  most  frequently  could  move  the  mem- 
ber to  a  certain  distance  in  every  direction ;  only  he  is  unable  to  raise  it  at  a' 
right  angle  with  the  trunk,  or  to  hold  it  far  from  the  breast.  After  such 
an  operation,  it  is  infirm;  but  it  is  better  to  have  a  limb  deformed,  and  some- 
what reduced  in  its  functions,  than  none  at  all,  and  the  last  cases  reported  by 
Mr.  Lyme  demonstrate  that  the  use  of  the  arm  may  be  almost  entirely  re- 
stored. 

Art.  6.— The  Clavicle, 

The  clavicle  is  situated  very  superficially,  it  is  true ;  but  as  it  covers  some 
organs,  the  wounding  of  which  would  be  very  dangerous,  surgeons  have  not' 
dared  to  attempt  its  excision,  except  in  cases  which  have  just  been  stated. 
Yet  there  are  circumstances  sufficiently  numerous,  which  require  this  opera- 
tion, if  we  wish  not  to  abandon  the  sufferers  to  certain  death.  Sometimes 
necrosis  or  caries  may  affect  its  scapula,  sometimes  its  sternal  extremity ; 
sometimes  its  middle,  or  even  throughout  its  whole  extent.  The  mode  of 
making  the  excision  or  extirpation,  is  difficult  to  lay  down,  because  the  disease 
that  requires  it  may  produce. numerous  changes  in  the  anatomical  disposition 
of  the  neighboring  parts. 

1st.  Acromial  Extremity. — In  a  woman  affected  for  a  long  time  with  necrosis 
of  the  external  third  of  the  clavicle,  I  first  made  a  crucial  incision,  the 
branches  of  which  were  each  about  four  inches  long.  After  dissecting  and 
separating  the  two  flaps,  and  dividing  the  acromio-clavicular  ligaments, 
together  with  some  fasiculae,  from  the  origin  of  the  deltoid  and  trapezius 
muscles,  I  was  able,  with  the  assistance  of  a  plate  of  wood  sunk  into  tlie  arti- 
culation as  a  lever,  to  raise  up  the  diseased  bone,  an<i  thus  detach  it  from  thie 
healthy  parts.  If  it  had  offered  too  much  resistance,  a  common  saw,  or, 
better  still,  a  cock's-comb  saw  would  have  enabled  me  to  make  the  section 
downwards  or  backwards.  Supposing  it  had  been  too  much  buried,  I  would 
have  carefully  isolated  it  from  the  soft  parts  before  and  behind,  passed  one  of 
Jeffrey's  chain-saws  under  its  inferior  face,  and  cut  it  from  behind  forward, 
and  then  disarticulated  and  removed  it.  If  the  skin  be  not  ulcerated,  nor 
positively  diseased,  we  would  succeed  as  well,  and,  I  think,  even  better,  by 
making  a  triangular  flap,  by  means  of  a  transverse  incision  parallel  to  the 
internal  edge  and  some  lines  below  the  clavicle,  to  be  prolonged  to  the  summit 
of  the  acromion ;  then  another,  much  shorter,  meeting  the  internal  extremity 
of  the  first  at  a  right  angle.  This  flap,  turned  back,  completely  exposes  the 
diseased  bone,  and  will  permit  the  application  of  the  saw  upon  the  sternal  side 
of  the  diseased  part,  which,  after  the  division,  may  with  a  bistoury  and  forceps, 
or  an  elevator,  be  removed  as  far  as  the  acromion.  This  method  would 
be  more  easily  applicable  to  the  sternal  moiety  of  the  clavicle  ;  but  in 
either  case,  on  account  of  the  axillary  vessels,  the  operation  becomes  the  more 


276  NEW  ELEMENTS  OP 

delicate  and  dangerous,  in  proportion  as  the  saw  is  applied  nearer  the  middle 
of  the  bone. 

B.  Extirpation. — From  the  dead  subject  the  clavicle  is  not  difficult  to 
remove.  An  incision,  parallel  to  its  cutaneous  edge,  reaching  a  little  beyond 
its  extremities,  is  commonly  sufficient.  Or  two  vertical  incisions,  about  one  or 
two  inches  long,  may  be  added  one  to  each  extremity  of  the  first,  and  then  by 
dissecting  up  the  flap,  the  bone  may  be  completely  uncovered.  Then  the 
operator  may  disarticulate  it  at  either  extremity,  and  seizing  it  M'ith  his  left 
hand,  detach  it  from  its  internal  adhesions  by  the  right,  armed  with  a  bistoury. 
The  bone  may  also  be  sawed  near  its  centre,  and  the  two  moieties  separately 
removed.  In  a  diseased  state  of  the  parts,  this  operation  must  be  one  of  the 
most  difficult  in  surgery.  It  was,  however,  once  performed  with  complete 
success,  by  Dr.  Mott,  on  the  17th  of  June,  1827,  in  New  York,  on  a  young 
man  aged  nineteen  years,  affected  with  osteo-sarcoma. 

The  tumor  was  as  large  as  two  fists,  extending  from  near  the  angle  of  the 
jaw  and  the  os  hyoides  in  one  direction  to  the  point  of  the  shoulder,  and  the 
sterno-clavicular  articulation  in  the  other.  The  operation  was  very  laborious. 
It  was  necessary  to  apply  more  than  forty  ligatures  before  it  was  completed. 

Dr.  Mott  commenced  by  making  a  semilunar  incision  with  its  convexity 
downwards,  and  reaching  from  one  extremity  of  the  clavicle  to  the  other,  as  if 
to  detach  the  tumor  from  below  upwards ;  he  then  made  a  second,  extending 
from  the  acromion  to  the  outer  edge  of  tlie  external  jugular  vein  ;  divided  the 
platysma  myoides,  and  a  portion  of  the  trapezius ;  passed  first  a  grooved 
director,  and  then,  by  means  of  an  eyed  probe,  a  small  chain-saw  under  the 
clavicle,  which  he  divided  a  little  nearer  the  acromion  than  the  coracoid 
apophysis.  Being  yet  unable  to  turn  out  the  morbid  mass,  the  operator  con- 
nected the  two  other  incisions  by  a  third,  at  their  sternal  extremities ;  tied  the 
external  jugular  at  two  points,  dividing  it  in  the  interval ;  divided  the  ex- 
ternal portion  of  the  sterno -mastoid  muscle  two  inches  above  its  origin,  and 
turned  it  down  upon  the  sternum;  separated  and  pushed  the  omo-hyoideus 
muscle,  upwards  and  backwards;  was  also  obliged  to  tie  and  divide  the 
internal  jugular,  and  to  separate  with  some  difficulty,  by  means  of  the  bistoury 
or  the  handle  of  a  scalpel^  the  subclavian  vein,  and  even  the  thoracic  duct  from 
the  degenerated  tissues ;  numerous  branches,  coming,  no  doubt,  from  the 
inferior  thyroid,  transverse,  cervical,  subscapular,  &c.,  arteries,  were  tied  as 
soon  as  divided  A  last  incision,  the  utility  of  which  I  cannot  comprehend, 
was  made  over  the  line  of  the  fourth  rib,  beginning  at  the  first,  and  dividing 
the  fibres  of  the  great  pectoral  muscle.  After  dividing  the  costo-clavicular 
ligament  and  subclavian  muscle.  Dr.  Mott  was  at  last  enabled  to  raise  the 
tumor,  and  concluded  by  disarticulating  the  bone  at  its  sternal  extremity. 

The  wound  was  filled  with  charpie,  and  long  adhesive  strips  used  to 
hold  its  lips  as  near  together  as  possible.  No  serious  accident  followed.  The 
cure  was  nearly  completed  by  the  last  of  July,  and  by  means  of  an  appropri- 
ate machine,  wliich  to  a  certain  extent  supplied  the  place  of  the  clavicle,  the 
patient  retained  almost  the  entire  use  of  the  arm. 

As  such  an  operation  should  not  be  attempted  but  by  the  most  skillful  sur- 
geon, it  is  useless,  I  think,  to  enter  into  any  details,  to  show  in  what  manner 
Dr.  Mott's  method  could  be  advantageously  modified.  All  such  persons  will 
easily  conceive  them,  by  recollecting  the  anatomy  pf  the  aifected  region,  and 


<M»ERA^TIYE  SURGERY.  273^ 

of  course  will  have  to  conduct  themselves  according  to  trie  peculiar  characters 
of  the  disease.  Thus  it  was  with  M.Beauchene,who,  being  obliged  more  than 
ten  years  ago  to  remove  a  great  part  of  this  bone,  and  the  rest  of  the  shoulder, 
at  Saint  Antoine,  made  use  of  diiferent  incisions  from  those  of  Dr.  Mott. 
M.  Lucke  found  himself  in  the  same  situation  in  the  excision  of  the  shoulder, 
of  which  I  have  just  spoken.  Kulm,  who  extracted  the  clavicle  in  the  early 
part  of  last  century  for  a  sarcoma  of  five  pounds'  weight,  had  also  to  invent 
his  own  method.  Nor  do  I  see  why  the  ligature  of  the  mass,  so  much 
extolled  by  M.  Mayor,  might  not  be  practised,  since  the  hemorrhage  seems 
so  difficult  to  arrest.  The  excision  of  the  body  of  the  scapula  would  be 
even  more  variable  than  that  of  the  clavicle. 

M.  Jansan,  who  has  performed  it,  began  by  circumscribing  the  tumor  by 
two  semi-elliptical  incisions,  taking  care  to  preserve  as  much  of  the  skin  as 
possible;  dissected  up  and  turned  back  the  two  lips  of  the  wound ;  detached 
the  diseased  mass  in  every  direction  as  far  as  the  subscapular  fossa ;  but  whilst 
he  was  raising  it  up  it  broke  in  the  middle,  and  he  was  forced  to  separate  the 
external  half  first.  After  dividing  the  attachments  of  the  trapezius,  the 
supra  and  infra  spinatus  muscles,  the  operator  having  discovered  that  the  por- 
tion of  the  bone  above  the  spine  was  healthy,  separated  from  it  all  the  diseased 
portion  with  a  saw,  and  thus  preserved  the  articulation  of  the  arm.  By 
another  and  the  lastincision,  made  obliquely  upwards,  forwards,  and  inwards, 
he  exposed  the  whole  tumor,  dissected  it  carefully,  lifted  it  up  gently,  felt 
the  cellular  tissue  that  fixed  it  to  the  arm,  wliich  he  tore,  and  at  last  succeeded 
in  detaching  it  entirely. 

All  the  vessels  were  tied.  The  hollow  of  the  arm-pit  was  filled  with  lint, 
and  by  the  assistance  of  adhesive  strips  the  lips  of  the  wound  were  brought 
together,  although  the  incision  measured  six  inches  in  its  transverse,  and 
nine  inches  in  its  longitudinal  diameter.  The  movements  of  the  arm  upon 
the  glenoid  cavity  were  preserved.  The  tumor  weighed  eight  pounds  and  a 
half,  was  easily  torn,  and  presented  the  aspect  of  the  interior  of  a  pomegranate. 


SECTION  II. 

Abdominal  Members, 

If  it  be  difficult  to  disprove  at  the  present  day  the  advantages  of  incision 
when  applied  to  the  thoracic,  the  same  cannot  be  said  as  to  the  pelvic  mem- 
bers. Here,  an  artificial  member  may  supply  almost  all  the  functions  of 
the  natural  one.  There,  on  the  contrary  no  machine  can  be  so  adapted  as  to 
render  the  same  services  to  the  patient.  Whatever  may  be  the  deformity  left 
in  the  arm,  or  in  whatever  state  the  hand  may  be,  if  they  be  preserved,  they 
may  always  answer  some  useful  purpose.  Notwithstanding  this,  excision  has 
been  recommended  for  all  the  articulations  of  the  inferior  members,  and  even 
performed  a  certain  number  of  times.  Having  treated  of  excision  and  ex- 
traction of  the  bones  of  the  feet,  in  the  article  Jlmputation,  I  shall  not  recur 
to  it,  especially  as  they  are  governed  by  the  same  rules  as  those  of  the  bones 
of  the  hand. 


278  .  .  HEW   ELEMENTS  -OF 

*^rt.\. — Tibio-tarsal  Articulation,  pH?^ 

Gooch  long  since  excised  the  inferior  extremity  of  the  tibia  with  success. 
This  operation  has  been  repeated  by  Cooper,  De  Bungay,  Hey,  Deschamps, 
White,  and  Taylor;  and  more  recently  by  M.  Delpech,  and  the  Moreaux, 
father  and  son.  MM.  Jesse  and  Ladent,  have  been  equally  successful  in 
excising  the  tarsal  extremity  of  both  tlie  bones  of  the  leg,  although  they  had  to 
remove  two  inches  of  the  tibia  on  the  right,  and  an  inch  and  a  half  of  both 
tibia  and  fibula  on  the  left,  in  the  case  of  a  young  girl.  At  the  end  of  three 
months  the  patient  could  walk  with  a  stick,  which  she  has  since  laid  aside. 
In  almost  all  of  these  cases,  excision  was  decided  upon,  it  is  true,  but  in  con- 
sequence of  complicated  luxations  or  comminuted  fractures.  But  many 
have  also  performed  it  for  organic  lesions,  i.  e.,  while  the  parts  retained 
their  natural  positions. 

Operation. — 1st.  Moreau's  Metliod.- — M.  Moreau  recommends  two  inci- 
sions to  be  made  on  each  side  of  the  leg,  one  extending  from  the  summit  of 
the  malleolus,  three  or  four  inches  above,  the  other  commencing  at  the  same 
point,  and  carried  forwards  transversely  to  the  insertion  of  the  peroneusbrevis 
on  the  external,  or  to  the  corresponding  tibialis  for  the  inner  side.  The 
longitudinal  incisions  should  go  to  the  bone,  but  the  others  only  through  the 
skin.  He  commences,  by  dissecting  the  external  flap,  to  disengage  the  fibula 
from  the  tendons  that  surround  it,  and  then  divides  it  with  a  chisel  or  cock's- 
comb  saw  above  the  disease,  and  disarticulates  it  from  above  downwards,  by 
dividing  the  fibrous  fascia  that  connects  it  to  the  tibia,  astragalus,  and  os 
calcis.  The  same  course  is  pursued  in  isolating  the  tibia  from  the  soft  parts, 
and  in  dividing  and  disarticulating  it.  If  the  astragalus  be  diseased,  it  also 
must  be  removed  totally  or  in  part,  as  has  been  done  by  M.  Moreau,  the  younger,' 
After  the  operation  the  foot  must  be  brought  to  the  inferior  extremity  of  the 
leg,  and  kept  there  by  adhesive  plasters  and  a  suitable  bandage. 

2d.  M.  Roux^s  Method. — This  is  exactly  the  same  operation  as  for  the  carpal 
extremity  of  the  fore-arm.  Instead  of  the  chisel  and  mallet,  the  chain-saw 
of  Dr.  Jeffrey  is  better  adapted  to  the  tibio-tarsal  articulation  than  anywhere 
else.  Notwithstanding  the  narrowness  of  the  interosseous  space,  M.  Roux 
once  succeeded  in  passing  a  compress  through  it,  which  enabled  him  to  saw- 
first  the  fibula  and  then  the  tibia  without  fear,  having  first  brought  it  between 
the  bone  and  the  soft  parts. 

Fa/wc.'^This  excision,  always  difficult,  may  be  sometimes  followed  by  the 
most  serious  consequences.  M.  Roux's  patient  ultimately  succumbed.  After 
the  most  complete  cure  the  member  must  necessarily  lose  some  of  its  length, 
and  the  patient  can  walk  only  with  the  assistance  of  a  more  or  less  elevated 
shoe.  It  has  no  advantage  over  amputation.  It  seems  to  me  that  the  exci-' 
sion  of  the  tibia  only  can  never  accomplish  the  object  the  surgeon  proposes.'^ 
The  foot,  losing  its  principal  support,  will  be  in  fact  incapable  of  sustaining 
the  weight  of  the  body,  and  will  be  turned  inwards,  as  M.  Moreau,  the  younger, 
has  observed  in  one  of  his  patients.  It  would  seem  then,  that  the  fibula,  even 
when  sound,  must  be  excised  whenever  the  tibia  is  to  be  removed.  The  parts 
to  be  preserved  are,  first,  anteriorly,  the  tendons  of  the  anterior  tibial,  some 
of  the  extensors,  and  the  peroneus  brevis ;  second,  on  the  outside,  the  peroneus 
longus;  third,  on  the  inside,  the  tibialis  posticus  and  the  flexors;  fourth. 


vi#PERATlVE    SURGERY.  27*9 

behind,  the  semi -tendinous  portion  of  these  muscles ;  fifth,  and  lastly,  the  an- 
terior tibial  artery  in  front,  and  then  the  posterior  tibial  behind  the  internal 
malleolus. 


^rt.  2.— The  Knee, 

History. — The  excision  of  the  bones  forming  the  femuro-tibial  articulation, 
first  recommended  by  White,  has  been  put  in  practice  twelve  times ;  once 
by  Park,  with  sufficient  success  to  enable  the  patient  to  walk  without  the 
assistance  of  a  stick;  a  second  time,  without  success,  the  patient  dying 
after  some  months  from  exhaustion;  a  third  time,  by  Moreau,  senior;  twice 
by  Moreau,  jun.,  one  of  whose  cases  died  three  months  after  the  operation, 
the  other  was  for  a  long  time  obliged  to  use  crutches.  A  case  was  pre- 
sented by  Mulder,  in  1809.  M.  Roux  has  published  a  seventh.  His  pa- 
tient died  on  the  nineteenth  day;  the  case  was  reported  in  1815,  to  M. 
Gourard,  by  M.  Haime,  of  Tours.  Mr.  Crampton  performed  it  twice, 
first,  on  a  young  woman  aged  twenty -three,  on  the  7th  of  May,  1823,  and  the 
second,  in  1824.  The  first  recovered,  and  actually  walked  without  crutches, 
notwithstanding  the  deformity  of  the  member.  The  other  died  from  the 
effects  of  the  operation.  Mr.  Lyme  has  also  had  recourse  to  it  twice ;  one  of 
his  patients  died ;  the  other,  a  child  nine  years  old,  recovered,  and  walks  very 
well.  According  to  this  author,  it  has  also  been  once  attempted  in  Germany. 
It  certainly  is  not  because  of  its  difficulties  that  excision  of  the  knee  should 
be  proscribed,  but  because  it  is  infinitely  more  painful,  tedious,  and  dan- 
gerous, either  immediately  or  secondarily,  than  amputation  in  the  continuity 
of  the  thigh,  and  especially  because,  in  the  most  fortunate  cases,  the  preserved 
member  is  really  less  useful  to  the  patient  than  an  artificial  leg.  A  shortening 
of  from  four  to  eight  inches  is  necessarily  produced.  The  articulation  cannot 
be  re-established.  If  the  limb  retains  its  faculty  of  moving,  it  is  very  irregu- 
larly, and  is  almost  always  very  much  bent  outwards.  Experience  has  con- 
firmed all  this.  Of  the  eleven  patients,  the  history  of  whose  cases  is  known , 
five  at  least  have  succumbed.  Some,  like  the  patients  of  M.  Roux,  very  sud- 
denly; others,  after  long  continued  suffering.  Almost  all  who  have  been 
cured,  owe  their  recovery  to  the  most  extraordinary  care,  whilst  they  have 
run  the  greatest  risk  of  losing  their  lives.  Yet  it  is  certain,  whatever  Mr. 
Lyme  may  say,  that  none  can  use  the  preserved,  with  the  same  advantage 
that  they  could  use  an  artificial  limb.  The  following  methods  should  be 
adopted,  when  the  operation  is  undertaken. 

Operation. — 1st.  Mr.  Parle's  Method. — A  crucial  incision,  the  transverse 
branch  of  which  placed  above  the  patella  should  comprehend  one  half  of  the  cir- 
cumference of  the  member,  is  the  characteristic  feature  of  Mr.  Park's  method. 
After  having  divided*  the  tendon  of  the  extensor  muscles,  everted  the  four 
flaps,  raised,  up  the  patella,  divided  the  lateral  ligaments,  pierced  the 
articulation  from  before  backwards,  he  pushed  a  large  knife  under  the  pos- 
terior face  of  the  femur,  to  separate  it  from  the  soft  parts,  taking  care  of  the 
popliteal  vessels,  and  sawed  the  bone  above  the  condyles. 

2d.  M.  Moreau^ s  Method. — The  articulation  of  the  knee  being  very  simir 
lar  to  that  of  the  elbow,  M. Moreau  thought  that  the  excision  of  one  should  be 


280  \EW   ELEMENTS    O/** " 

performed  like  that  of  the  other.  Accordingly  he  commenced  by  making  two 
lateral  incisions  a  little  behind  tlie  borders  of  the  ham;  which  were  terminated 
at  the  bottom  by  a  transverse  incision,  uniting  them ;  and  divided  the  skin  and 
the  end  of  the  triceps  femoris  below  the  patella,  so  as  to  reach  the  articulation ; 
then  denuded  the  posterior  face  of  the  bone  from  the  surrounding  flesh;  the 
quadrilateral  flap,  made  by  the  three  incisions,  was  then  dissected  and  raised 
up  ;  and  the  section  of  the  femur  made  with  the  same  caution,  as  by  Park.  If 
the  bone  of  the  leg  be  at  the  same  time  affected,  the  external  incision  should  be 
prolonged  to  the  head  of  the  fibula.  Another  should  be  made  over  the  crest  of  the 
tibia,  thereby  forming  two  lower  flaps,  one  internal  the  other  external,  which 
are  to  be  dissected  and  depressed.  The  posterior  face  of  the  tibia  is^  to  be 
isolated  from  the  vessels  and  nerves,  as  well  as  the  head  of  the  gastrocnemii 
muscles,  so  as  to  be  able  to  remove  the  whole  of  the  diseased  bone  with  the 
saw. 

3.  MM.  Sanson  and  Begin'^s  Method. — Instead  of  making  first  a  large 
quadrilateral  flap,  the  new  editors  of  Sabatier  commence  by  a  transverse  in- 
cision below  the  patella,  extending  from  one  lateral  ligament  to  the  other,  and 
penetrating  at  the  first  cut  into  the  articulation.  This  done,  they  disarticulate 
the  femur  or  tibia  only,  if  there  be  but  one  of  them  diseased,  by  making  two 
lateral  incisions  from  the  extremities  of  the  first,  upwards  or  downwards,  and 
shorter  or  longer,  according  to  the  length  and  situation  of  the  aftected  portion 
of  the  bone. 

4.  Mr.  Lyme's  Method  differs  from  all  the  preceding  in  more  than  one 
respect.  This  operator  makes  two  semilunar  incisions  in  front  of  the  joint, 
one  above  and  the  other  below,  which  are  united  on  a  line  with  the  lateral  liga- 
ments, and  form  a  transverse  ellipsis  enclosing  the  patella.  He  excises  this 
ellipsis  and  the  bone  contained  in  it ;  divides  the  ligaments,  opens  the  arti- 
culation, and  removes,  one  after  the  other,  the  extremities  of  the  femur  and 
tibia. 

Remarks. — Whatever  method  may  be  followed,  the  bleeding  surfaces 
must  be  brought  together,  and  occupy  the  place  of  the  removed  bone;  a  few 
stitches  or  adhesive  strips,  some  charpie,  compresses,  cushions,  splints,  and, 
in  fine,  all  the  apparatus  for  a  complicated  fracture  of  the  leg,  are  necessary 
to  complete  the  dressing,  and  hold  the  limb  in  the  most  perfect  state  of  rest. 

These  various  methods  all  permit  the  accomplishment  of  the.object  in  view. 
The  operation  is  alike  possible,  whether  we  make  a  crucial  incision,  like  Park, 
or  a  quadrilateral  flap,  like  Moreau,  or  penetrate  the  joint  at  the  first  stroke 
like  Sanson  and  Begin,  or  remove  or  not  the  patella,  like  Mr.  Lyme.  It 
is  the  consequences,  and  not  the  operation  that  are  so  dangerous,  and  which 
should,  in  my  opinion,  cause  it  to  be  generally  proscribed.  I  would  admit 
no  exception,  but  where  the  articulating  surfaces  alone  are  diseased,  so  as 
to  permit  the  removal  of  the  whole  disease  without  excising  more  than  one  or 
two  inches  of  each  bone.  i* 

If  the  rotula  be  carious,  or  affected  with  necrosis,  it  should  be  removed 
without  hesitation,  even  if  the  joint  should  be  opened.  One  such  case 
only  is  known  in  medicine,  and  in  that  the  disease  was  cured.  I  have  seen 
two  persons  in  whom  it  was  fractured,  and  although  the  fragments  were  sepa- 
rated more  than  six  inches,  they  preserved  the  use  of  the  leg. 


OPERATIVE    SURGEHY.  £81 


JlrU  3. — Head  of  the  Femur » 

Toward  the  middle  of  last  century,  White  ventured  to  propose  the  disar- 
ticulation of  the  femur,  and  the  excision  of  its  superior  extremity.  A  simple 
incision  was  to  enable  him  to  expose  the  articulation,  open  the  capsule,  luxate 
the  bone,  and  turn  it  out  for  excision.  Vermandois  and  Petit-Radel  revived 
tliis  idea  without  any  modification.  But  Rossi  soon  saw  that  the  incision 
proposed  by  White  was  insufficient,  and  that  it  would  be  more  easy  to  reach 
the  joint  by  making  externally  a  triangular  flap.  Chaussier,  nearly  thirty  years 
ago,  made  a  number. of  experiments  upon  this  subject,  and  excisions  in 
general.  According  to  him,  excision  of  the  head  of  the  femur  in  dogs  is  not  much 
more  dangerous  than  that  of  the  humerus.  There  forms  in  place  of  the  ex- 
cised bone,  a  matter  first  fibro-cellular,  then  cartilaginous,  and  finally,  so 
solid  as  almost  to  equal  the  hardness  of  the  bone  itself.  Wachter  expresses 
himself  nearly  in  the  same  terms  in  his  dissertation.  Still  there  is  at  present 
but  one  case  given  of  the  e^^cision  of  the  head  of  the  femur,  and  the  results 
attending  it,  as  given  in  the  American  journals,  are  so  strange,  that  it  is  diffi- 
cult to  give  tliem  entire  credence. 

If  the  head  of  the  femur  should  escape  through  the  torn  soft  parts  and 
could  not  be  reduced,  it  might,  without  doubt,  indeed  it  should  be  removed 
with  the  saw,  and  especially  if  it  be  fractured ;  but  what  is  the  disease  so 
serious  as  to  require  removal  of  the  head  of  the  femur,  that  would  attack 
it  without  also  implicating  the  cotyloid  cavity  ?  and  when  the  bones  of  the 
pelvis  are  diseased,  of  what  use  would  it  be  to  excise  the  femur  ?  However, 
if  some  one  should  desire  to  attempt  it,  the  most  simple  method  would  be, 
provided  there  already  existed  no  external  wound,  to  make  a  simple  semilunar 
incision,  extending  from  the  antero- superior  spinous  process  of  the  ileum  to  the 
tuberosity  of  the  ischium,  forming  thereby  a  large  flap  with  its  convexity 
below,  behind  the  articulation,  and  at  the  expense  of  the  soft  parts  at  the 
origin  of  the  limb.  After  having  raised  this  flap  up  and  divided  the  posterior 
half  of  the  capsule,  abduct  and  flex  the  thigh  at  the  same  moment  to  divide 
the  inter-articular  ligament;  pass  the  knife  between  the  head  of  the  bone  and 
the  cotyloid  cavity,  inward  and  forward  to  the  groove  at  the  neck  of  the  femur 
to  detach  the  rest  of  the  capsular  ligament,  and  turn  out  the  portion  of  the 
bone  to  be  removed.  After  its  removal,  there  will  be  little  else  to  do  than 
return  the  thigh  to  its  natural  position,  bring  down  the  flap,  and  secure  it  with 
stitches  or  adhesive  strips,  and  for  the  rest  pursue  the  course  usual  in  com-, 
plicated  fractures  of  the  superior  part  of  the  bone. 

Artificial  Articulation. — Some  operators  have  made  use  of  another  kind  of 
operation  on  the  femur.  When  the  hip  is  anchylosed,  they  have  proposed  a 
kind  of  new  joint  by  sawing  the  bone  near  the  body  or  at  the  neck,  and 
even  by  excising  a  portion  if  judged  prudent.  Twice  already  has  this 
daring  operation  been  attempted  in  America.  The  first  time,  in  Novem- 
ber, 1826,  with  entire  success,  by  Dr.  J.  R.  Barton;  and  the  second,  by 
Dr.  Rogers,  at  tlie  hospi^l  of  Philadelphia.  I  understand  from  Dr.  Buck, 
that  in  the  last  case,  the  patient,  who  for  some  time  gave  strong  hopes  of  a 
second  instance  of  success,  ultimately  died.  Without  wishing  to  become  its 
36  , 


€Sf  NEW  ELEMENTS  OF^ 

defender,  I  would  however  remark,  that  with  the  aid  of  an  incision  over  the 
external  and  superior  part  of  the  member,  or  of  a  crucial  incision,  and  one  of 
Jeffrey's  chain-saws,  or  an  elastic,  or  even  a  small  hand  saw.  Barton's  ope- 
ration is  much  less  difficult  than  one  would  at  first  imagine.  And  I  would 
add,  as  to  the  probability  of  its  effects,  that  in  a  case,  published  by  M.  Pailloux, 
of  false  articulation  of  this  joint  following  the  fracture  of  the  neck  of  the 
femur,  the  patient  walked  very  well  before  his  death ;  and  that  M.  Martin 
has  found  another  case  of  false  articulation  of  the  same  species,  between  the 
great  trochanter  and  body  of  the  bone,  the  head  of  it  being  destroyed;  and, 
in  fine,  that  the  number  of  non-consolidated  fractures  of  the  part,  justify  to  a 
certain  extent,  this  apparently  dangerous  operation. 


'tm 


TITLE  IV.— TREPANNING. 


Trepanning  appears  to  have  been  practised  from  the  highest  antiquity. 
Its  origin  is  lost  in  the  obscurity  of  time.  It  is  used  on  almost  all  the  bones 
«f  the  body,  but  especially  on  those  of  the  head. 


CHAPTER  I. 

THE  CRANIUM. 

Notwithstanding  the  improvements  it  received  from  the  physicians  of  an- 
cient Greece,  and  the  abuse  it  suffered  in  the  middle  ages  from  those 
charlatans  that  Sylvaticus  called  circulatores,  trepanning  is  one  of  the  opera- 
tions that  has  most  strongly  attracted  the  attention  of  surgeons,  since  the 
time  of  G.  de  Chauliac.  For  a  long  time  it  was  thought  the  principle  and 
almost  only  remedy  for  the  traumatic  lesions  of  the  head,  produced  by  blows, 
falls,  &c.  At  the  present  it  is  but  rarely  resorted  to.  No  person  would 
think  now  of  imitating  Panaroli,  in  trepanning  for  a  simple  chronic  cephalalgia, 
even  if  it  were  most  violent,  or  of  venereal  origin ;  nor  for  epilepsy,  although 
Marchetti  lias  used  it  once  successfully,  and  M.  A.  Severin  has  formally 
recommended  it  for  that  disease ;  nor  for  fractures  of  the  inner  table  of  the 
bone,  for  which  Garengeot  speaks  of  using  it ;  nor  for  remedying  an  attrition 
or  simple  contusion  of  the  diploe,  as  Acrel,  Richter,  and  Fritz  recommend. 
Mr.  Ramsden,  as  stated  by  "Mr.  S.  Cooper,  has  seen  a  patient,  on  whom  the  os 
frontis  had  been  perforated  for  a  simple  sub-orbitary  pain,  die  of  meningitis 
the  fourth  day  after  the  operation. 


OnSRATIVE   SURGERY.  28$ 

Indications. — Its  object  being  to  give  exit  to  foreign  fluids  extravasated  in 
the  cranial  cavitj,  to  permit  the  elevation  or  removal  of  any  fragments  of 
bone  or  other  bodies  that  may  have  been  forced  in  upon  the  brain,  and  whose 
presence  may  impede  the  functions  of  that  organ,  there  arise  indications  very 
difficult  to  appreciate.  Nothing  is  more  vague,  than  tlie  signs  by  the  aid 
of  which  authors  pretend  to  recognize  the  various  lesions  for  which  they 
use  it.  The  sound  of  a  broken  kettle,  perceived  at  the  moment  of  the  acci- 
dent, and  the  sound  given  by  percussion  on  the  bone  with  a  small  stick,  recom-^ 
mended  by  Lanfranc,  are  altogether  insignificant.  The  same  may  be  said  of 
the  tendency  of  some  patients  to  carry  their  hands  mechanically  to  some  cer- 
tain point  of  the  head ;  of  a  shock  felt  by  others  the  moment  that  a  piece  of 
thread  or  string,  held  between  the  teeth,  is  snatched  from  the  mouth ;  of  the 
painful  sensation  produced  by  a  deep  inspiration,  and  upon  which  Roger,  of 
Parma,  so  much  insisted.  All  these  signs  may  be  wanting  although  there  is  a 
fracture,  or  on  the  contrary  exist  as  accompaniments  of  much  less  important 
lesions.  Besides  it  is  not  the  fraction,  properly  speaking,  but  the  compression 
produced  by  it,  that  justifies  the  use  of  the  trepan.  Whether  the  effusion  be 
sanguineous  or  purulent  is  also  as  difficult  to  determine,  whilst  it  is  extremely 
difficult  frequently  to  designate  its  exact  seat.  Sometimes,  in  fact,  it  is 
immediately  under  the  point  struck  that  this  extravasation  is  found,  some- 
times at  a  point  directly  opposite,  and  frequently  at  some  point  less  distant. 
The  paralysis,  which  indicates  the  seat  of  the  affection  to  be  on  the  opposite 
side  of  the  head,  may  be  met  with  on  the  corresponding  side.  If  the  integu- 
ments of  the  head  be  in  nowise  diseased,  if  there  be  no  contusion  nor  solu- 
tion of  continuity  to  be  observed,  it  is  almost  impossible  to  guess  within  half 
an  inch,  often  indeed  within  several  inches,  of  the  exact  seat  of  the  collection. 
The  application  of  a  cataplasm  over  all  the  head,  recommended  by  some  of 
the  ancients,  in  order  to  discover  the  spot  where  the  application  is  most  rapidly 
dried — a  spot  corresponding  to  the  disease — is  a  puerile  resource  long  since 
appreciated  at  its  just  value. 

On  the  other  hand,  as  these  aflTections,  even  when  considerable,  have  been 
seen  to  disappear  without  trepanning,  and  as  even  fractures  with  depressions 
of  near  an  inch,  of  which  Physick,  Horner,  Paillard,  Gragfe,  &c.  each  report 
a  case,  have  also  alloNved  of  the  recovery  of  the  sufferers,  without  an  opera- 
tion, Desault  and  his  followers,  combating  the  doctrine  of  the  ancients,  of 
Garengeot,  J.  L.  Petit,  de  Quesnay,  Pott,  and  all  the  academy  of  surgery, 
and  returning  to  the  ideas  of  Van  Wyck,  Aitkin,  and  Metzger,  have  esta- 
blished as  a  general  position  that  the  operation  of  trepanning  is  most  frequently 
injurious,  and  tliat  it  should  consequently  be  dispensed  with  in  almost  all 
the  cases  in  which  the  surgeons  of  the  last  century  recommended  it.  This 
doctrine,  supported  by  the  researches  of  M.  Jftriot,  sustained  by  Professor 
Graefe,  at  Berlin,  and  which  the  English  surgeons  have  adopted,  prevails  very 
generally  in  France,  and  has  just  found  an  ardent  defender  in  M.  Gama.  Still 
some  able  surgeons,  such  as  M.  Larrey,  M.  Roux,  M.  Dupuytren,  and  M. 
Delpech,  among  others,  have  used  the  trepan  successfully  at  the  hospitals 
of  the  Garde  JRoyale,  La  Charitie,  and  Hotel-Dieu,  I  know  also  of  a 
surgeon  of  Chauteau-du-Loir,  who  performed  it  some  years  ago  with  entire 
success  for  a  purulent  collection,  the  existence  of  which  was  only  known  by 
pains  and  symptoms  of  paralysis.    In  1823,  Beclard  and  M.  P.  Dubois  were 


^d4  NEW  ELEMENTS  OF 

not  less4iappy  Avith  a  subject  affected  with  fracture  without  displacement,  al- 
though they  were  obliged  to  take  out  three  circles  of  bone  in  the  temporal 
fossa,  and  to  extract  nearly  eight  ounces  of  blood  furnished  by  the  arteria  me- 
ningea.  And  in  1825,  M.  Touissaint  reported  an  instance  of  success  of 
the  same  kind,  which  he  obtained  by  the  application  of  the  crown  of  the  trepan 
six  times. 

Thus  then,  without  being  as  prodigal  of  trepanningas  surgeons  were  before 
the  time  of  Desault,  or  without  admitting,  with  MM.  Foville  and  Florens,  that 
it  may  be  useful  in  relieving  the  organ  from  compression  in  inflammatory  or 
other  defluxions  of  the  brain,  it  would  seem  that  it  should  be  at  least  more 
frequently  used  than  is  now  customary.  If  it  be  true  that  we  are  often  em- 
barrassed in  ascertaining  the  seat  and  nature  of  the  disease  that  indicates  its 
use,  it  is  equally  true  that  in  some  cases  the  thing  is  not  beyond  the  reach  of 
an  intelligent  surgeon.  Besides,  when  it  is  decided  to  attempt  it,  the  patients 
are  in  such  an  alarming  state,  that  a  simple  perforation  of  the  cranium  cannot 
add  much  to  the  dangers  that  menace  them.  If  then  we  learn  in  any  manner 
to  a  certainty,  that  a  foreign  body,  such  as  a  splinter  or  angle  of  bone  be  the 
cause  of  the  alarming  symptoms,  we  should  trepan  ;  it  is  even  necessary  for 
long  standing  or  consecutive  effusions,  indicated  by  necrosis  of  the  bone 
separation  of  the  pericranium,  black  color  of  the  neighboring  tissues,  pale 
aspect  of  the  lips  of  the  wound,  crepitation  of  the  cranial  integuments,  &c. 

Parts  of  the  Cranium  that  admit  of  its  Application. — The  operation  having 
been  determined  upon,  another  question  presents  itself — upon  what  point 
shall  it  be  made  ?  It  was  formerly  a  rule  that  the  trepan  should  not  be  applied 
above  a  horizontal  line,  which  would  separate  the  base  from  the  arch  of  the 
cranium,  passing  through  the  nasal  projection,  and  over  the  external  occipital 
protuberance ;  nor  over  the  sutures;  nor  over  the  course  of  sinuses  of  the  dura- 
mater,  the  frontal  sinuses,  the  temporal  fossa,  the  anteror-inferior  angle  of 
the  parietal  bones,  &c.  But  Beranger  de  Carpj,  Cortesius,  Hoffman, 
Bromfield,  and  Pallas,  trepanned  over  the  sutures  with  complete  success. 
Acrel,  Wurm,  and  many  others,  have  perforated  the  frontal  sinuses  with 
advantage.  Warner,  Marchetti,  Garengeot,  Sharp,  Potts,  Callisen,  Mosque, 
and  Lassus,  have  opened  various  sinuses  of  the  dura-mater,  without  any 
unhappy  result ;  and  the  new  experiments  of  M.  Flourens  upon  animals,  tend 
to  prove  that  this  may  be  done  almost  without  any  inconveniences  resulting. 
Carcano  and  Job  a  Meckren,  had  the  boldness  to  trepan  over  the  temporal 
fossa,  without  meeting  with  any  impediments  from  the  fibres  of  the  temporal 
muscle ;  and  Bilguer,  Copland,  Gooch,  Abernethy,  and  Hutchison  have  ex- 
posed the  brain  in  perforating  through  the  occipital  bone.  When  the  trepan 
is  applied  over  the  sutures,  and  the  body  to  be  extracted  is  found  immediately 
below,  then  the  adhesions  must  necessarily  have  been  destroyed ;  but  if  that 
be  not  the  seat  of  the  disease,  the  operation  must  be  performed  upon  another 
point.  Over  the  frontal  sinus,  MM.  Larrey,  Boyer,  S.  Cooper,  and  C.  Bell, 
remark,  that  to  avoid  a  lesion  of  the  membranes  it  is  sufficient  to  commence 
the  operation  with  a  crown  larger  than  the  one  with  which  you  terminate. 
Besides,  what  danger  is  there  here  of  wounding  the  dura-mater  ?  When  the 
venous  sinuses  are  opened,  the  hemorrhage,  so  much  dreaded  by  the  ancients, 
.^tops  of  itself,  or  is  easily  stopped  with'simple  dressing.  Over  the  protube- 
riisces  of  the  cerebellum  there  are  no  arterial  branches  of  importance,  except 


OPERATIVE  SURGERY.  285 

the  occipital,  and  the  lesion  of  the  trapezius  or  complexus  muscles  is  not  of 
much  consequence.  In  the  temporal  fossa,  the  division  of  the  muscle,  in 
whatever  manner  the  operation  may  be  performed,  will  not  prevent  the  re- 
establishment  of  its  functions..  As  to  the  opening  of  the  arteria  meningea,  it 
will  be  easy  to  remedy,  either  by  means  of  some  lint  fastened  by  a  thread  to 
the  interior  of  the  cranium,  as  Dr.  Physick  has  done,;  or  by  cauterization  with 
a  stylet  heated  white,  like  M.  Larrey ;  with  a  piece  of  cork,  a  morsel  of  wax, 
or  a  strip  of  lead,  curved  in  such  a  manner  as  to  compress  both  faces  of  the 
bone  and  the  groove  that  encloses  the  artery,  as  successfully  performed  by 
Dr.  Dorsey,  of  Maryland.  Sabatier,  renewing  the  precept  of  Lan franc,  advises 
the  crowns  of  the  trepan  to  be  placed  at  the  lowest  point  of  the  effusion.  Aa 
it  is  almost  always  possible,  by  varying  the  position  of  the  patient,  to  turn  the 
opening  of  the  cranium  below ;  as  it  is  more  frequently  for  the  extraction  of 
a  solid  foreign  body  than  to  give  vent  to  liquid  matters ;  and  as  it  is  rare  that 
the  extent  of  the  seat  of  the  injuring  cause  is  considerable,  this  precept  is  less 
important  in  practice  than  it  would  at  first  appear  to  be. 

Apparatus. — Hippocrates  mentions  a  scraper,  known  by  the  name  of  xistre, 
with  which  he  scraped  the  bones  to  thin  them,  or  to  discover  the  sutures. 
His  trepan  was  a  sort  of  drill,  operating  like  a  gimlet.  He  speaks,  however, 
of  another,  which  must  have  had  some  analogy  to  the  crown  more  recently 
described.  Cetsus  gives  this  crown  the  name  of  modiolus ;  without  doubt, 
says  Guy  de  Chauliac,  because  it  resembles  a  small  hogshead  {muid).  He 
compares  the  trepan,  properly  so  called,  to  a  carpenter's  auger.  Galen  is  the 
first  who  speaks  of  ahaptist  trepans,  that  is,  with  crowns  or  perforators, 
surrounded  by  a  collar  or  sheath,  which  prevented  it  from  penetrating  too 
deep.  These  abaptistes,  which  are  also  spoken  of  in  the  works  of  Lanfranc, 
and  a  great  many  other  surgeons,  have  been  for  a  long  time  rejected  from 
practice.  A  double  convex  knife,  the  gouge  and  chisel,  as  well  as  the  meningo- 
phylax,  a  sort  of  blade  terminated  by  a  flat  knob  or  button,  intended  to  push 
the  compress  between  the  dura-mater  and  the  bone  during  the  dressing,  was 
employed  from  the  time  of  Heliodorus  and  Galen.  We  find  still  further,  in 
the  work  of  Andre  de  Lacroix,  the  cutting  forceps,  the  punch,  and  the  elevator, 
as  well  as  the  idea  of  the  famous  triploide,  recommended  by  Scultetus,  and  of 
which  J.  L.  Petit  has  taken  pains  to  show  the  inconveniences.  The  agents 
at  present  used,  and  which  are  commonly  placed  together  in  a  box,  are  a 
trepan,  properly  so  called,  with  its  shaft  and  its  crowns,  a  punch,  a  pyramid 
and  its  key,  elevators,  a  lenticular  knife,  a  chisel,  a  cutting  forceps,  a  cock's- 
comb  saw,  a  small  brush,  and  a  leaden  mallet. 

Operation. — The  patient,  lying  on  a  bed,  having  his  head  supported  upon  a 
pillow,  below  which  a  plank  or  metallic  plate  should  be  placed,  is  held  in  this 
position  by  the  assistants. 

First  Step. — The  operator,  armed  with  a  straight,  thick,  and  sharp  bistoury, 
enlarges  more  or  less  in  various  directions  the  solutions  of  continuity,  if  there 
be  any.  If  none'' exist,  the  operator  makes  on  the  integuments  previously 
shaven  an  incision,  the  form  of  which  varies  with  different  surgeons. 
Lanfranc,  G.  de  Chauliac,  and  Lassus  recommend  that  it  should  resemble  a 
7  inverted.  Van  Swieten,  an  X ;  and  that  the  flaps  should  be  excised.  At 
present  it  has  generally  the  form  of  a  T,  or  a  cross.  When  operating  over 
the  temporal  region,  cotemporary  authors,  as  Sabatier  and  Richerand,  recom- 


286  NEW   ELEMENTS   oF 

mend  that  it  Imve  the  form  of  a  V,  with  the  base  above,  which,  according  to 
them,  will  divide  but  few  of  the  fleshy  fibres.  If  the  summit  of  the  V  com- 
prehends a  transverse  extent  of  the  temporal  muscle  less  than  that  of  the  base, 
the  operator  must  still  divide  all  the  fibres  ccmprehended  between  the  two 
extremities  of  the  latter.  It  is  a  long  time  since  circular  and  triangular  incisions, 
and  all  those  by  which  the  flaps  were  removed,  have  ceased  to  be  recommended 
by  any  surgeon.  Whatever  Pott  may  have  said  of  it,  the  crucial  incision  is 
the  one  that  merits  the  preference.  When  there  is  no  fear  of  sinking  into 
fissures,  the  bistoury  may  be  carried  to  the  bone  at  the  first  cut.  TItc  flaps 
being  turned  up,  covered  with  fine  linen,  and  held  back  by  the  assistant's 
fingers,  the  operator  has  been  directed  to  destroy  the  pericranium  with  the 
scraper.  This  is  a  useless  and  even  injurious  precaution.  The  pericranium 
does  not  oppose  the  action  of  the  trepan.  The  wounding  of  it  with  the  saw  is 
riot  more  dangerous  than  that  produced  by  tearing  it  with  the  scraper.  By 
making  immediate  use  of  the  trepan,  no  more  than  the  necessary  circle  is  torn ; 
whilst  with  a  scraper,  it  is  disruptured  always  to  a  certain  distance  beyond, 
which  necessarily  becomes  exposed  to  necrosis.  The  vascular  lines,  which 
even  Hippocrates  notices  as  being  liable  to  be  mistaken  for  fissures,  will  not 
he  effaced  by  the  scraper,  especially  if  they  coincide  with  an  abnormal  depres- 
sion of  one  of  the  frontal  protuberances,  and  are  somewhat  deep,  as  I  have 
recently  seen  them  at  La  Fitie.  It  will  evidently  be  of  no  assistance  in 
distinguishing  a  true  fissure  from  the  lateral  suture,  sometimes  observed  on  the 
parietal ;  from  the  deviations  of  the  sagittal  suture,  mentioned  by  Van  Swieten 
and  Quaisnay ;  or  the  accidental  disposition  of  the  wormian  bones,  which 
failed  to  deceive  Saucerotte.  Still,  if  the  operator  desire  to  use  this  instru- 
ment, he  takes  it  in  the  right  hand  by  the  handle,  with  the  plate  between  the 
tliumb  and  index  finger,  handling  it  in  such  a  manner  that  it  shall  neither 
leave  any  part  untouched,  nor  denude  more  than  is  desired. 

Second  Step. — When  the  trephine,  which  the  English  almost  exclusively 
adopt,  is  used,  and  of  which  M.  Withusen  has  recently  become  the  advo- 
cate in  Germany,  the  surgeon,  holding  it  in  his  hand  by  the  handle,  makes  it 
act  like  a  gimlet  or  cork-screw.  If,  on  the  contrary,  the  trepan  be  preferred, 
the  crown  is  placed  on  it,  and  then,  taking  hold  of  the  stock  with  the  right 
hand  as  if  holding  a  pen,  the  operator  places  the  point  of  the  pyramid  upon 
the  centre  of  the  piece  of  bone  to  be  removed ;  presses  upon  the  crown  to 
mark  this  point,  whilst  the  other  hand  supports  the  rest  of  the  instrument; 
then  removes  the  crown,  and  puts  in  its  place  the  perforator,  the  summit  of 
•which  he  puts  in  the  point  marked  by  the  pyramid ;  embraces  the  ebony 
plate  that  terminates  the  handle  of  the  trepan  circularly  between  the  thumb 
and  index-finger  of  the  left  hand ;  presses  upon  this  plate  with  the  chin  or 
forehead ;  takes  hold  of  the  shaft  of  the  trepan  with  the  right  hand ;  gives  it 
two  or  three  turns  from  right  to  left ;  puts  the  crown  in  place  of  the  perforator; 
takes  hold  of  the  instrument  as  when  first  using  it ;  fixes  the  pyramid  in  the 
hole  just  made,  and  turns  it  again  as  just  stated,  taking  care  to  press  equally 
on  all  the  teeth  of  the  saw,  in  order  to  form  the  circular  groove  as  regular  as 
possible.  When  this  groove  has  been  made  deep  enough  to  prevent  the  crown 
from  escaping  from  it,  the  pyramid  should  be  removed.  Otherwise  it  would 
render  the  operation  longer  and  more  ^ngerous;  reaching  below  the  level 
of  the  crown,  it  would  necessarily  reach  the  membranes  before  the  completion 


OPERATIVE    SURGERY.  2^7 

of  the  section  of  the  bone.  The  trepan  having  been  again  placed  in  its  groove, 
the  surgeon  should  use  it  rapidly,  inasmuch  as  it  is  still  at  some  distance  from 
the  dura-mater,  withdrawing  it  from  time  to  time  to  see  if  the  section  be 
regular,  to  clear  the  teeth  with  the  brush,  and  also,  as  Hippocrates  remarked,, 
to  prevent  its  becoming  too  much  heated  ;  when  it  has  passed  the  diploe^  use 
it  gradually  more  slowly ;  from  time  to  time  attempt  with  the  elevator  or 
other  suitable  piece  of  metal  to  move  the  osseous  disk  formed  by  the  crown, 
and  cease  entirely  from  using  the  trepan  as  Soon  as  a  certain  cracking  noise 
is  heard,  which  it  will  be  impossible  to  confound  with  any  other  sound  when 
once  heard,  and  which  indicates  that  the  operator  has  reached  the  membranes. 
When  the  osseous  plate  is  completely  divided,  it  sometimes  comes  away  with 
the-  crown  of  the  instrument.  In  other  cases  it  is  removed  by  an  elevator  of 
any  kind,  used  as  a  lever  of  the  first  class. 

Third  Step.^—li  the  section  be  regular,  it  is  useless  to  apply  any  other  in- 
strument ;  but  if  there  be  left  in  its  deeper  parts  any  points  or  sharp  scales, 
it  will  be  proper  to  apply  the  lenticular  knife,  placing  the  button  between  the 
dura-mater  and  the  bone,  passing  it,  edge  foremost,  entirely  around  the  cir- 
cumference of  the  orifice  in  the  bone.  If  it  be  the  seat  of  the  disease,  the 
matter  begins  immediately  to  be  discharged.  If  there  be  a  foreign  solid  body, 
it  is  to  be  seized  and  removed  with  the  forceps,  or  any  other  appropriate  in- 
strument. Sometimes  we  meet  w^itli  an  effusion  extending  some  distance 
from  the  point  on  which  we  have  operated,  and  if  it  consist  of  coagulated  blood, 
or  other  plasiic  matter,  a  single  perforation  is  insufficient  for  its  escape.  Then 
there  should  be  no  hesitation  in  applying  the  trepan  a  second,  or  even  a  third. 
The  destruction  of  a  considerable  portion  of  the  arch  of  the  cranium  should 
not  excite  alarm  when  it  is  necessary.  Solingen  says  that  the  Prince  of 
Orange  bore  seven  applications  of  the  trepan  without  inconvenience.  Spigel 
reports  a  similar  case.  V.  D.  Wiell  speaks  of  one  on  whom  it  had  been  applied 
twenty-seven  times;  and,  as  before  stated,  M.  Toussaint  communicated 
a  case  to  the  academy,  in  which  he  used  it  six  times.  Besides,  every  one 
knows  the  facts  cited  by  Blegny,  Saviard,  and  de  la  Vauguyon,  in  which, 
almost  all  the  arch  of  the  cranium  had  been  removed  without  destroying 
'the  patients.  Many  of  the  Strasbourg  theses  contain  not  less  remarkable 
cases. 

i?emarA;s.'--When  several  circles  of  bone  are  removed  for  the  simple  pur- 
pose of  obtaining  a  large  opening,  it  is  not  now  customary  to  leave  between 
them  bony  bridges,  which  it  is  subsequently  necessary  to  remove  with  the 
chisel,  as  Hippocrates,  Helidorus,  Celsus,  and  many  of  the  surgeons  of  the 
middle  age  did.  The  operator  should  remove  them  in  such  a  manner  that  the 
circumference  of  one  should  reach  as  nearly  as  possible  to  that  of  the  other; 
so  that  if  there  remain  between  any  more  or  less  projecting  angles,  they  may 
be  easily  removed  with  the  cutting  forceps.  If  a  new  perforation  is  to  be^ 
made  because  the  first  did  not  fall  upon  the  effusion  or  foreign  body,  it  is  a* 
second  operation  in  which  the  operator  must  conduct  himself  as  above  directed. 
When  the  seat  of  the  disease  is  found  immediately  below  the  circle,  there  is 
no  need  of  dividing  the  dura-mater ;  but  when  the  extravasated  fluids  are 
more  profound,  since  the  time  of  Glandorp,  we  do  not  fear  to  incise  that 
membrane.  It  should,  however,  be  done  only  where  we  have  good  reason  to 
tlnnk  that  we  shall  strike  the  seat  of  the  disease ;  that  is,  when  we  observe  a 


286.  NEW   ELEMENTS    OF, 

blackish,  livid,  or  yellow  tinge,  and  a  greater  or  less  projection  of  the  external 
meninges.  This  division  is  to  be  made  by  a  bistoury  held  perpendicularly, 
commencing  at  one  extremity  of  one  of  the  principal  diameters  of  the  opening, 
and  carried  to  the  other  extremity  without  going  any  deeper.  It  has  also 
been  recommended,  that  when  there  exist  no  fluids  between  the  membranes, 
to  incise  the  substance  of  the  brain.  Authors  cite  on  this  subject  a  certain 
number  of  facts ;  among  others,  a  case  observed  in  the  practice  of  M.  Dupuytren, 
in  which  he  did  not  hesitate  to  sink  the  bistoury  more  than  an  inch  deep  into 
the  brain  ;  such  conduct  must  be  but  rarely  imitated.  When  the  effusion  has 
its  seat  in  the  cerebral  substance,  how  shall  we  know  where  to  find  it  ?  Is  it 
not  then  almost  always  the  effect  of  an  internal  cause  ?  By  what  sign  are  we 
to  recognize  its  presence,  even  when  it  corresponds  with  the  opening  of  the 
bone  ?  Without  doubt,  a  simple  puncture  of  the  brain,  even  very  deep,  may 
possibly  not  produce  death,  or  even  any  other  than  the  slightest  consequences ; 
but,  on  the  contrary,  as  it  is  equally  possible  that  it  may,  it  will  always  be  witb 
trembling  that  a  circumspect  surgeon  will  decide  to  injure  thus  the  substance 
of  the  encephalic  organ.  In  some  cases  the  effusion  is  separated  into  different 
portions,  by  bridles,  adhesions,  or  partitions.  If  this  condition  be  suspected, 
the  operator  must  not  be  content  with  one  circle,  but  remove  two,  one  on 
each  side,  as  has  been  recommended  v/hen  operating  in  the  neighborhood  of 
sutures,  or  in  the  course  of  the  sinuses.  Wlien  trepanning  for  the  extraction 
or  elevation  of  a  fracture  or  splinter,  the  operation  requires  some  peculiar 
modifications.  First,  the  point  of  the  pyramid  must  be  applied  upon  the  edge 
of  the  bone  that  offers  the  most  solidity,  and  the  crown  made  to  cover  both 
sides  of  the  fracture  at  the  same  time.  Then,  when  the  effusion  is  removed, 
the  attention  must  be  turned  to  the  splinters  or  depressed  fragments  of  the 
bone.  All  that  is  proper  to  be  removed  should  be  detached  with  the  pincers, 
cutting  forceps,  or,  if  necessary,  with  the  chisel,  or  gouge  and  mallet.  To 
elevate  parts  which  are  simply  depressed,  recourse  may  be  had  to  levers  of 
different  forms.  Neither  the  tripod  of  the  ancients,  the  triploide  elevator  of 
Scultetus,  nor  the  instrument  similar  to  a  cooper's  piercer,  is  any  longer  in 
use.  The  elevator,  with  a  bridge  proposed  by  J.  L.  Petit,  and  the  same  instru- 
ment modified  by  Louis,  are  also  rejected.  All  operating  surgeons  use 
the  simple  elevator,  with  a  steel  stock  about  six  inches  long,  curved  ia 
the  form  of  an  italic  ^S*,  with  a  rasp-like  roughness  on  the  concave  face  of 
its  two  extremities,  which  extremities  are  flattened  like  a  chisel.  It  would 
even  be  possible  to  substitute  an  ordinary  spatula  for  this  instrument. 
Often,  when  there  is  a  fracture,  we  may,  by  introducing  a  chisel  or  some  other 
instrument  into  the  fissure,  produce  a  separation  of  tlie  bones  sufficient  to 
allow  the  escape  of  the  fluids,  and  thereby  render  the  application  of  the  trepan, 
properly  speaking,  useless.  In  fractures  with  considerable  separation  of  the 
edges,  and  in  simple  fractures  of  the  sutures,  of  which  M.  Robert  and  M. 
Goubert  have  each  published  a  remarkable  example,  observed  in  the  adult, 
the  cranium  should  not  be  perforated  unless  the  fluids  are  extravasated  under 
some  other  point. 

Tlie  Dressing  is  much  more  simple  now  than  formerly;  there  is  no  further 
demand  in  practice  for  the  oils,  tinctures,  balsams  and  ointments,  of  which  the 
ancients  were  so  prodigal.  The  sieve-like  plate  of  gold  of  Auck,  and  the  plate  of 
lead,  recommended  by  Belloste,  are  also  obsolete.  The  operators  of  the  preseat 


OPERATIVE    SURGERY.  289 

day  content  themselves  with  a  disk  of  fine  linen,  pierced  through  the  centre 
th  a  thread,  which  is  to  keep  it  out,  and  which  is  carefully  placed  be- 
tween the  dura-mater  and  the  bone,  by  means  of  the  meningophylax,  of  a 
spatula,  or  of  a  simple  probe-pointed  stylet;  nay,  even  this  may  be  replaced 
by  a  small  fine  compress,  covered  with  cerate  and  pierced  with  holes.  The 
middle  part  should  be  sunk  into  the  opening  in  the  bone,  and  the  rest  made  to 
cover  the  internal  everted  face  of  the  fiap  and  all  the  wound.  The  excava- 
tion or  purse  resulting,  is  to  be  filled  with  rough  charpie  or  lint,  which  should 
be  covered  by  one  or  more  pledgets.  Some  compresses  are  then  placed  over 
these,  and  the  whole  supported  by  a  bandage,  which  the  surgeon  sometimes 
applies  in  one  way,  sometimes  in  another;  or  by  a  simple  triangular  kerchief, 
the  couvre-chef  of  Galen ;  or,  still  better,  an  ordinary  cotton  cap ;  or,  as 
Heliodorus  has  recommended,  a  netting  of  hair,  which  the  Spaniards  employ- 
under  the  name  of  reddizella,  and  which  is  used  among  us  to  cover  the  heads 
of  young  girls. 

Mynors  and  M.  Maunoir  direct  that  no  part  of  the  dressing  shall  be  intro- 
duced into  the  opening  of  the  skull,  and  that  the  integuments  be  brought  to- 
gether and  held  in  contact  by  adhesive  strips.  Blount  and  Herlich,  who  give 
the  same  advice,  are  said  to  have  put  it  in  practice  successfully.  Others  have 
gone  still  further.  Job  a  Meckren  speaks  of  a  person,  in  whom  the  morsel  of 
bone  had  been  replaced  by  a  similar  piece  taken  from  the  head  of  a  dog.  M. 
Maunoir  thinks  that  we  might  thus  close  the  opening  from  the  trepan.  It  even 
appears,  according  to  Richter  and  Walther,  that  this  strange  transplanting 
operation  has  been  attempted  in  Germany,  not  without  some  success.  For 
my  part,  it  appears  evident  to  me  that  the  approximation  of  the  edges  of  the 
wound  will  not  prevent  the  effusion  of  a  certain  quantity  of  fluids  between 
the  dura-mater  and  hairy  integuments;  besides,  we  must  most  frequently 
desire  to  preserve  the  solution  of  continuity  open,  to  give  vent  to  the  extrava- 
sated  fluids,  and  room  for  the  detersion  of  the  diseased  parts.  As  to  M.  Mau- 
noir's  idea,  it  belongs  much  more  properly  to  the  history  of  animal  engrafting 
than  to  trepanning. 

The  sequel  of  trepanning  requires  no  attention  which  it  will  be  very  diffi- 
cult for  the  patient  to  obtain.  The  dressings  should  be  renewed  every  day 
once  or  oftener,  if  the  abundance  of  the  discharge  appear  to  require  it. 
When  the  suppuration  has  dried  up,  the  cerebral  affection  has  disappeared, 
and,  in  fine,  when  there  remains  nothing  more  than  the  wound  from  the  opera- 
tion, the  surgeon  then  occupies  himself  with  its  cicatrization,  which  he  should 
do  by  endeavouring  to  bring  together  the  edges,  and  treating  it  as  any  other 
simple  wound.  This  cicatrization  presents  some  peculiar  phenomena.  Some- 
times the  circumference  of  the  opening  of  the  bone  becomes  thinner,  and  seems 
to  approach  the  centre,  to  confound  itself  at  last  with  the  dura-mater  and 
integuments  of  the  skull.  At  other  times,  especially  when  the  opening  is 
very  large,  the  edges  become  blunted  or  rounded ;  some  cellular  sprouts, 
shooting  up  from  the  fibrous  membrane  of  the  brain,  gradually  fill  the  open- 
ing, become  more  and  more  solid,  and  ultimately  unite  wdth  the  exterior 
soft  parts ;  forming  in  reality  a  stopper  or  plug,  of  which  Duvemey  pre- 
served a  very  pretty  example.  After  the  cure  there  generally  remains  a 
depression  over  the  cicatrix,  of  which  M.  Serre  has  reported  three  examples, 
the  tliinness  of  which  sometimes  permits  the  movements  of  the  brain  to  be  seen 
37" 


290  NEW    ELEMENTS   OF 

externally.  It  has  also  been  recommended,  in  order  to  prevent  cerebral  her- 
nia, to  keep  a  convex  disk,  or  plate  of  lead  or  other  metal,  over  the  depression 
just  spoken  of.  To  enforce  the  necessity  of  this  sort  of  plate,  Monro  reports 
the  case  of  a  young  girl,  who  thought  she  might  dispense  with  one  she  had  worn 
for  a  long  time,  and  who  was  soon  after  taken  with  a  cerebral  affection,  of  which 
she  died  at  the  expiration  of  five  days.  As  the  metals  become  easily  charged 
with  a  great  quantity  of  caloric,  it  has  been  feared,  and  especially  with  those 
forced  by  their  social  condition  to  remain  exposed  to  the  rays  of  the  sun,  that 
they  might  occasion  some  serious  consequences.  Now  their  place  is  supplied 
by  pieces  of  leather  or  the  like,  which  are  placed  like  the  pads  of  a  truss. 

If  a  necrosed  speculum,  or  part  of  the  bone  remain  fastened  in  the  healthy 
parts,  so  as  to  resist  the  action  of  the  forceps,  as  has  sometimes  been  observed, 
it  should,  at  the  instance  of  J.  L.  Petit,  be  entirely  uncovered,  isolated  by 
some  strokes  of  the  chisel,  raised  up,  and  extracted  with  an  elevator  or  some 
other  instrument.  In  young  children,  the  cranium  is  so  thin  that  it  may  be 
perforated  by  scraping  it  with  a  piece  of  glass ;  or  better,  with  a  scraper,  as 
many  authors  recommend.  The  cock's-comb  saw,  one  of  Hey's  little  saws, 
should  take  the  place  of  the  crown,  if  it  be  only  required  to  remove  some  pro- 
jecting angle  of  the  edge  of  the  fracture.  If  the  necrosis  should  not  compre- 
hend all  the  thickness  of  the  bone,  or  if  the  seat  of  the  disease  be  between  the 
two  tables  of  the  skull,  the  scraper  and  the  perforator  will,  without  doubt,  be 
sufficient,  and  the  surgeon  will  take  care  not  to  penetrate  to  the  dura-mater. 
But  whenever  the  disease  extends  to  the  membranes,  it  will  be  dangerous  to 
follow  the  advice  of  Hippocrates ;  namely,  to  leave  at  the  bottom  of  the  open- 
ing an  osseous  lamina  as  thin  as  possible,  and  depend  on  its  exfoliation  for 
the  opening  of  the  passage  for  the  escape  of  the  effused  fluids.  I  would 
finally  add,  that  in  some  cases  detergent  injections,  or  any  other  kind  suited 
to  the  indications,  will  serve  to  hasten  the  modification  of  the  pathological 
cavity,  as  well  as  the  rest  of  the  wound,  and  that  there  may  be  some  incon- 
venience from  neglecting  to  employ  them. 


CHAPTER    II. 

7%c  Thorax.)  Pelvis^  and  Extremities. 

Next  to  the  cranium,  the  thorax  is  the  part  of  the  body  on  which  the 
trepan  has  been  most  frequently  applied.  The  father  of  medicine  used 
it,  by  applying  it  «ver  a  rib  to  open  an  abscess.  It  was  with  the  trepan 
that  Galen  removed  the  carious  sternum  of  a  young  man  that  had  been  in- 
jured in  wrestling,  and  in  which  case  he  was  obliged  to  penetrate  to  the  peri- 
cardium, which  was  itself  injured  on  its  anterior  face.  Avenzour,  Friend 
*ays,  recommended  trepanning  the  sternum,  not  only  for  abscess  of  the  medi- 
astinum, but  also  for  that  of  the  pericardium.    V.  D.  Wiell  performed  thi» 


OPERATIVE    SURGERY.  29t 

operation  successfully  for  a  large  purulent  collection.  Colombo,  Salius, 
Uiversus,  and  Junker,  formally  recommend  it.  Pauli  and  Solingen  say  that 
Purman  found  it  very  useful  in  two  different  cases ;  J.  L.  Petit  followed  their 
advice.  According  to  Sprengel,  Boettchen  recommended  its  application  to 
fractures  of  the  sternum,  in  order  to  open  a  way  to  the  elevation  of  the  pieces 
of  sunken  bone.  To  impress  the  advantages  of  it  in  this  case,  de  la  Mar- 
tinier e  reports  that  a  soldier,  wounded  at  the  siege  of  Philipsburg,  in  1734,  was 
perfectly  cured,  after  having  had  four  large  bony  plates,  comprehending  the 
whole  thickness  of  the  sternum,  removed.  Mesniere,  of  Angouleme,  was 
equally  successful  with  a  young  patient,  who  had  had  this  bone  broken  across. 
Almost  all  the  carious  portion  was  removed  with  a  large  crown,  and  the  aspcr 
rities  of  the  opening  were  removed  with  the  lenticular  knife.  Alny  followed 
the  example  of  Wiell,  on  a  coachman  to  the  king,  who  had  been  a  long  time 
affected  with  an  internal  abscess,  that  had  opened  at  the  neck.  Sedillier 
treated  a  young  woman,  aged  twenty -two  years,  in  the  same  way,  who,  as  a 
sequel  of  an  abscess  produced  by  a  blow  upon  the  thorax,  was  afflicted  with 
fistulous  ulcer,  through  which  he  could  penetrate  without  difficulty  into  the 
mediastinum.  The  carious  sternum  was  found  to  have  concealed  a  purulent 
collection,  and  the  patient  was  cured  in  two  months.  A  male  adult,  in  whom 
an  internal  abscess  had  made  its  way  to  the  exterior,  between  the  two  first 
pieces  of  the  sternum,  was  admitted  into  the  hospital  of  Rouen,  in  1754; 
Lecat  enlarged  the  opening  in  the  integuments,  scraped  the  face  of  the  bone 
which  had  been  altered  by  caries,  and  a  few  days  after  applied  the  crown  of 
a  trepan,  which  enabled  him  to  convey  into  the  abscess  such  medicines  as 
were  necessary  to  the  detersion  of  its  walls.  Ferrand,  of  Narbonne,  did  not 
fear  in  a  similar  case,  although  much  more  complicated,  to  remove  a  great 
part  of  the  same  bone  with  the  trepan,  and  many  of  the  cartilages  of  the  ribs 
with  a  small  saw :  his  patient  recovered.  In  fine,  it  was  with  the  same  success 
that  Auran  treated  a  simple  caries  of  the  sternum.  It  is  very  true  that  in 
this  last  case  the  actual  cautery  has  more  than  once  advantageously  replaced 
the  trepan.  The  fact  related  by  Aymar,  of  Grenoble,  is  a  conclusive  proof 
of  it ;  but  Marchetti  remarks,  that  according  to  his  own  experience  caute- 
rizing the  neighbouring  parts  may  be  very  dangerous,  and  that  it  frequently 
fails  of  producing  a  separation  of  the  dead  bone.  In  support  of  his  assertion 
I  could,  if  necessary,  appeal  to  a  late  case  in  one  of  the  hospitals  of  Paris. 
The  cautery  was  applied,  the  necrosis  did  not  exfoliate,  and  the  subject  died 
from  the  progress  of  the  disease.  We  may  then,  with  De  la  Martiniere,  assert 
that  the  trepan  is  a  valuable  resource  in  necrosis  of  the  sternum,  whether  this 
necrosis  may  or  may  not  be  caused  by  some  external  lesion,  or  whether  it  do 
or  do  not  cover  a  purulent  collection. 

The  Method  of  Operating  is  governed  by  the  same  rules  as  those  applicable 
to  the  perforation  of  the  skull,  whether  using  the  crown,  the  perforator, 
Hey's  saw,  the  scraper,  or  any  other  part  of  the  apparatus ;  only  the  density 
of  the  bone  being  less,  it  is  infinitely  easier  to  penetrate  into  the  thorax  than 
into  the  cavity  of  the  skull.  The  internal  mammary  artery  cannot  be 
touched,  unless  the  disease  makes  it  necessary  to  apply  the  instrument  with- 
out the  edges  of  the  sternum.  In  his  first  patient,  de  la  Martiniere  saw  it  so 
completely  isolated,  that  he  thought  it  right  to  keep  it  enveloped  in  charpie 
for  some  weeks.    In  another  case,  the  hemorrhage  to  which  it  gave  rise  was 


^2  NEW  ELEMENTS   OF 

arrested  with  simple  styptics.  I  shall  say  nothing  of  trepanning,  proposed  by 
some  persons  for  the  purpose  of  getting  at  the  envelope  of  the  heart  in  peri- 
carditis ;  nor  of  that  which  has  been  proposed,  to  enable  us  to  reach  the  trunk 
of  the  innominata  for  the  application  ot  a  ligature,  because  I  have  said  else- 
where what  I  think  of  them. 

The  Scapula. — There  are  some  other  large  bones  that  may  be  easily  tre- 
panned. A  soldier  received  the  thrust  of  a  foil  through  the  shoulder.  The 
wound  remained  fistulous.  An  ulcer  formed  in  the  subscapular  fossa,  and  the 
pus  could  only  partially  escape  by  an  opening  in  the  scapula.  Marechal  de- 
cided to  apply  the  crown  of  a  trepan  over  this  bone,  and  by  it  the  patient 
was  promptly  cured.  Else,  of  London,  proceeded  in  the  same  manner  for  a 
simple  necrosis  of  this  bone,  and  was  equally  fortunate.  Boucher  also  pro- 
fesses to  have  trepanned  the  ischium,  for  the  purpose  of  evacuating  an  abscess 
of  the  pelvis;  and,  according  to  Sprengel,Bilgueris  believed  to  have  done  the 
same  to  the  os  coccygis. 

Hie  Spine. — Even  the  vertebral  column  has  not  escaped  the  application  of 
the  trepan.  Mr.  CUne  first,  and  then  Mr.  Tyrell,  have  each  tried  it  upon 
the  rachidian  groove,  for  the  purpose  of  extracting  either  splinters  or  blood, 
compressing  the  cord,  but  the  patients  died  a  short  time  after;  and  I  can 
scarcely  believe  that  a  surgeon  can  meet  with  indications  sufficiently  precise 
to  justify  the  repetition  of  these  attempts  with  any  expectation  of  success. 

The  Long  Bones. — I  have  already  said  that  the  trepan  and  gouge  are  fre- 
quently used  for  removing  some  parts  of  the  long  bones.  Boyer  many  times 
made  use  of  it,  towards  the  last  of  the  seventeenth  century,  to  arrest  a  caries 
of  the  tibia.  It  is  principally  in  encased  necrosis  that  it  is  of  much  assistance. 
"When  an  exfoliation  of  a  certain  extent  forms  and  becomes  loose  in  the  body 
of  the  tibia,  femur,  humerus,  &c.,  some  fistulas  may  open  from  it  outwardly, 
but,  if  left  to  its  own  exertions,  the  system  can  rarely  accomplish  its  expul- 
sion. With  the  assistance  of  one  or  more  crowns  of  the  trepan,  placed  op- 
posite to  each  other  over  certain  points  of  the  new  osseous  sheath  that 
envelopes  it,  and  a  few  strokes  of  the  chisel  to  break  up  the  bridges  left  ba 
tween  the  crowns,  the  operator  may  expose  the  exfoliation  near  one  of  its  ex- 
tremities in  such  a  manner,  that  with  a  pair  of  strong  forceps  he  may  extract 
it  entire.  It  is  an  operation  that  M.  Dupuytren  has  often  successfully  per- 
formed at  the  Hotel  Dieu,  and  which  many  other  surgeons  have  also  extolled. 
But  more  ample  details  on  this  subject  belong  to  the  chapter  on  Excisions  ; 
and  all  the  other  cases  of  trepanning  not  found  here,  will  be  spoken  of  under 
the  head  of  the  special  operations  of  which  they  form  a  part. 


OPERATIVE  SURGERY.  293 


SPECL\L  OPERATIONS. 

PART  I.— OPERATIONS  ON  THE  HEAD. 

CHAPTER  I. 

CRANIUM. 

1.  Fungous  Tumors, — The  ligature,  cauterization,  or  excision  of  fungous  or 
sarcomatous  tumors  of  the  du.ra-mater,  would  evidently  only  hasten  the  death 
of  the  suflferer.  Extirpation,  the  only  rational  remedy,  appears  itself  to 
be  but  rarely  followed  with  success.  In  fact,  the  external  tumor  is  often 
but  the  least  part  of  the  disease.  After  removing  it,  the  operator  soon 
sees  it  reproduced,  perhaps  under  a  new  form.  In  a  word,  they  have 
the  common  nature  of  cancerous  tumors  of  all  other  parts  of  the  body ; 
but  not  being  able  to  present  themselves  in  any  other  way  than  through 
an  osseous  opening,  it  is  not  possible,  as  in  the  latter  case,  to  define,  as  they 
advance,  their  exact  limits.  Nevertheless,  I  cannot  see  why  we  should  not 
attempt  to  extract  them,  when  every  thing  indicates  them  to  be  circumscribed, 
and  the  disease  itself  strictly  local.  In  a  woman,  cured  of  a  cancer  of 
the  breast,  who  died  of  a  pleurisy  at  the  Hopital  de  VEcole,  in  1824,  a  scir- 
rhus  tumor  of  the  size  of  a  pullet's  egg,  growing  from  the  dura-mater,  had 
crossed  the  right  inferior  occipital  fossa,  made  a  slight  projection  under  the 
splenius  muscle,  and  was  so  regularly  circumscribed,  that  it  certainly  would 
have  been  possible  to  have  removed  it  entire,  if  there  had  been  any  suspicion 
of  its  existence  during  life.  The  operation  might  be  attempted  at  least  for  the 
fungous  tumors  of  new-born  infants,  to  which  Mr.  Neagle  was  one  of  the  first 
to  call  the  attention  of  operators,  as  well  as  those  which  Mr.  Abernethy  makes 
to  proceed  from  sanguineous  concretions  or  diseased  lymphatics. 

Method  of  Operating, — The  operation  in  itself  has  nothing  remarkable. 
After  shaving  the  head,  the  surgeon  makes  a  crucial  incision  of  the  scalp, 
dissects  and  turns  back  the  four  flaps,  so  as  to  expose  the  tumor  to  a  certain 
distance  from  its  base ;  makes  use  of  the  lenticular  knife  to  enlarge  the 
osseous  opening,  if  he  finds  its  edges  thin — should  he,  however,  make  use  of 
the  trepan,  he  will  apply  it  successively  at  several  points  around  the  disease, 
so  that  he  may  reach  even  beyond  its  limits — returning  to  the  lenticular 
knife,  or  using  the^  gouge  and  mallet,  he  destroys  the  angles  left  by  the 
trepan ;  then,  with  the  point  of  a  bistoury,  he  makes  a  circle  on  the  non-affected 
portion  of  meninges ;  extirpates  and  removes  the  whole  morbid  mass ;  and 
then  follows  in  the  dressing  the  rules  laid  down  for  the  same  stage  in  simple 
trepanning. 


a94  NEW    ELEMENTS    OF 

2.  Oiseous  Tumors, — Exostosis  of  the  external  table  of  the  skull  bone 
rarely  produces  consequences  serious  enough  to  induce  the  sufferers  to  apply 
for  its  removal.  But  it  is  not  so  if  they  comprehend  the  whole  thickness  of 
the  bone,  especially  when  they  jut  inward  and  compress  the  brain.  In  the 
first  case,  after  having  uncovered  the  tumor,  a  small  saw,  the  chisel,  or  the 
gouge  and  mallet,  and  then  the  scraper,  will  suffice  to  remove  it;  in  the 
second,  the  trepan  will  be  indispensable  to  isolate  it  at  its  circumference  and 
permit  total  extirpation. 

3.  Encephcdocele. — There  is  no  other  remedy  for  a  hernia  of  the  cerebrum, 
or  cerebellum,  than  a  bandage  supporting  an  elastic  cushion  or  ball,  properly 
applied.  All  kinds  of  bloody  operations  are  dangerous,  and  might  probably 
produce  death,  as  in  the  case  published  by  M.  Lallement,  of  the  Sal- 
petriere. 

4.  Lupia. — Many  persons  all  their  lives  carry  steatomatous  or  melicerique 
tumors  under  the  hairy  scalp,  without  being  sensibly  incommoded  by  them, 
or  desiring  any  attempt  to  remove  them.  Otliers  suffer  more  or  less  from  them, 
and  for  one  reason  or  another  wish  at  all  hazards  to  be  rid  of  them.  The 
nature  and  formation  of  these  tumors  are  still  imperfectly  known,  and  seem 
to  me  to  require  new  researches.  At  the  commencement,  there  are  some 
which  present  the  appearance  of  a  small  mass,  hard,  yellow,  friable,  not 
organized,  similar  to  a  mass  of  fibrin,  or  of  blood  deprived  of  its  coloring 
matter  and  serum.  Whilst  growing  they  soften,  commencing  at  the  centre, 
and  thus  transform  themselves  into  a  cyst,  filled  with  a  substance  more  or  less 
fluid,  which  resembles  neither  pus  nor  fat.  May  we  not  attribute  their  origin  to 
some  of  the  constituents  of  the  blood  extravasated  ?  It  is  at  least  certain  that 
they  are  not  distended  cutaneous  follicles,  as  Beclard  and  S.  Cooper  assert.  If 
it  were  desirable,  the  ligature  might  cause  them  to  fall  off,  of  which  Boyer  re- 
lates an  example,  although  it  is  rare  that  they  can  be  strangulated  at  their  base. 
Bertrand  is  said  to  have  cured  them  by  passing  through  them  a  long  needle, 
■which  he  retained  like  a  seton.  Bui  a  cutting  instrument  is  infinitely  better, 
and  should  be  preferred  in  every  case. 

Operation, — When  the  tumor  is  very  voluminous,  and  the  skin  greatly 
attenuated,  an  elliptical  flap  of  the  teguments  should  be  removed  with  the  cyst. 
Two  semilunar  incisions  are  then  first  made.  A  transverse  incision  is  then 
made  outwards  from  each  lip  of  the  wound,  so  as  to  form  four  flaps,  which  being 
turned  back  with  care,  allow  of  the  removal  of  the  entire  tumor  without 
difficulty.  Most  frequently  the  last  two  incisions  mentioned  may  be  neglected. 
Whilst  with  a  hook  or  a  good  pair  of  forceps  the  surgeon  draws  the  cyst 
with  one  hand,  with  the  other  he  dissects  its  external  face  carefully  from  the 
neighboring  tissues  with  the  point  of  the  bistoury.  In  the  ordinary  method, 
and  when  it  is  not  necessary  to  sacrifice  any  part  of  the  skin,  a  simple  crucial 
incision,  or  T,  is  recommended ;  and  every  possible  caution  is  to  be  taken  not 
to  open  the  cyst  whilst  dissecting  the  flaps,  which  are  to  be  reunited  immedi- 
ately after  the  extirpation  of  the  tumor. 

Sir  A.  Cooper  pursues  another  method.  He  first  opeijs  the  lupus  freely ^ 
empties  it  by  compression  between  the  fore-finger  and  thumb ;  then  seizes 
the  cyst  with  a  crotchet  or  forceps  by  one  of  its  edges,  dissects  it,  and  takes  it 
away.  An  incision  being  made  in  such  a  manner  as  to  leave  the  posterior  wall 
of  the  meliceric  purse  untouched,  M.  J.  Cloquet  immediately  lays  hold  of  the 


•PERATIVE    SURGERY.  295 

anterior  wall  under  the  right  lip  of  the  incision  with  a  pair  of  forceps,  draws 
it  towards  him  as  he  divides  its  adhesions,  which  are  generally  slight,  and 
operating,  as  it  were,  with  a  single  cut,  removes  the  whole  cyst.  I  have 
more  than  once  been  contented  with  merely  dividing  tlie  integuments,  then 
thrusting  to  the  bottom  of  the  wound  a  strong  hook  to  lay  hold  of  the  tumor, 
after  which  it  is  easy  to  dissect  and  remove  it.  By  these  three  steps  of  the 
simple  method,  the  operation  is  rendered  much  more  prompt  and  less  difficult 
than  by  the  ordinary  method.  After  the  removal  of  the  cyst  the  edges  of  the 
incision  bring  themselves  into  contact,  and  reunion  is  generally  eifected  in  a 
few  days. 

Hy  drocephlus. — The  only  operation  that  has  been  proposed  for  l.ydrocepha- 
lus  is  puncturing  the  cranium.  Holbrook  and  Vose  pretend  to  have  practised 
it,  or  seen  it  practised,  successfully.  Bossi  took,  in  this  way,  at  several  times, 
six  pounds  of  serosity  from  the  head  of  a  child  of  eleven  or  twelve  years  of 
age,  who  was  ultimately  cured.  Mr.  Lyme  had  recourse  to  it  in  1826,  five 
times  on  one  child  in  the  space  of  some  months,  and  each  time  with  some  ap- 
pearance of  benefit,  but  the  little  sufferer  ultimately  died.  The  Lancet  states 
that  Mr.  Conquest  succeeded  with  it  twice,  and  Mr.  Geatwood  once.  Sir  A. 
Cooper  seems  to  have  been  partially  successful  with  it.  M.  Bedor,  who  has 
tried  it,  also  believes  in  its  utility.  But  the  disorder  of  the  brain  produced  by 
hydrocephalus,  is  commonly  too  important  to  be  removed  by  simple  puncture. 
Still,  if  the  operation  be  decided  upon,  nothing  is  more  easily  done,  with  either 
a  lancet,  a  bistoury,  or  a  trocar.  No  other  precaution  is  necessary  than  to 
take  care  not  to  injure  the  venous  sinuses.  If  the  operator  does  not  desire  at  once 
to  evacuate  the  whole  of  the  fluid,  I  think  it  better  to  repeat  the  operation  from 
time  to  time,  than  to  leave  a  canula  remaining  in  the  wound,  according  to  the 
proposition  of  Lecat. 


CHAPTER    II. 

The  Face, 

SECTION    II. 

The  Nose. 
Art.  1. — The  Rhinoplastic  or  Taliacotian  Operation* 

History  and  ^Appreciation. — In  Italy  and  India  it  was  once  the  practice  to  cut 
off  the  noses  of  criminals.  It  was  thus  that  Sextus  the  Fifth  treated  thieves 
and  robbers,  and  the  king  of  Ghoorka  the  inhabitants  of  Kistipoor,  even 
when  infants  at  the  breast,  in  order,  as  he  said,  to  know  them  anywhere,  and 
to  be  able  to  apply  to  their  city  the  name  of  Nasicatopoor,  In  all  countries  per- 
sons have  been  known  to  cut  it  off  themselves  to  avoid  pursuit,  or  to  tear  it  from 
others  to  gratify  the  desire  of  revenge.  Charles  II.  thought  he  could  not  in- 
flict a  more  cruel  punishment  on  the  Chevalier  de  Coventry,  who  had  dared  to 
speak  lightly  of  two  actresses  kept  by. his  king.  Frederick  II.  treated  a  cer- 
tain noble  in  the  same  manner,  that  complained  with  insolence  of  having  been 


296  NEW    ELEMENTS    OF 

enrolled  bj  fraud.  At  the  approach  of  the  Danes,  a  great  many  women  and 
young  girls  amputated  it  themselves,  for  the  purpose  of  saving  their  honor.  An 
abbess  and  her  forty  nuns  also  made  use  of  it  when  the  Saracens  presented  them- 
selves before  Marseilles.  Who  does  not  recollect  the  history  of  the  wife  of  a  no- 
tary at  Paris,  who,  out  of  revenge,  cut  off  the  nose  of  another  man's  wife,  of  whom 
she  was  jealous  ?  When  we  add  to  these  strange  mutilations,  those  which  de-. 
pend  on  unforeseen  accidents,  those  produced  by  small-pox,  syphilis,  cancer, 
scrofula,  freezing,  burning,  &c.,  it  will  be  seen  that  an  occasion  to  supply  the 
loss  of  the  nose  may  present  itself  quite  frequently.  The  hideous  aspect  of 
those  who  have  had  the  misfortune  to  lose  this  organ,  must  soon  create  a  de- 
sire to  correct  as  much  as  possible  so  repulsive  a  deformity.  Galen,  Aetius, 
and  Celsus  speak  of  the  art  of  mending  the  nose  in  their  time ;  but  it  was 
not  until  about  the  fifteenth  century  that  the  rhinoplastic  operation  took  its 
place  among  the  regular  efforts  of  surgery.  P.  Ranzano  says  that  the  Brancas, 
father  and  son,  surgeons  of  Sicily,  who  lived  in  1442,  practised  it  very  suc- 
cessfully. Boiani,  Celestius,  Benedetti,  and  Bernard  treat  of  it  as  a  customary 
remedy.  G.Tagliacozzi,  who  died  in  1599,  acquired  such  celebrity  from  thia 
operation,  that  a  statue  was  erected  to  him  in  the  anatomical  amphitheatre  at  Bo- 
logna. Mercurealis,  Fyens,  Fallopius,  Yesalius,  Read,  and  Gourmelin,  speak  of 
the  art  of  restoring  the  nose.  According  to  F.  de  Hilden,  Griffon  of  Lausanne, 
was  a  very  able  nasifex;  and  Ambrose  Pare  says  that  the  court  of  Henry  IIL 
"was  astonished  at  the  appearance  of  the  Chevalier  de  Thoan,  after  his  return- 
from  under  the  hands  of  a  nose-mender  of  Italy.  Yet,  notwithstanding 
these  testimonials,  to  which  may  be  added  that  of  Cortesius,  Molinelli,  Du- 
bois, Garengeot,  Rosenstern,  Moinichen,  Leyser,  and  of  Fioraventi,  who  re- 
plied to  the  incredulous  of  his  time,  *'  Go  visit  the  Seigneur  Andreas,  living 
at  Naples,  where  every  body  knows  his  history,  and  he  will  tell  you  that,  hap- 
pening to  be  at  the  place  at  the  time  of  his  accident,  I  picked  up  his  nose  that 
had  fallen  in  the  dirt,  washed  it  in  warm  water,  and  replaced  it  ^  well  as  I 
could.  Examine  this  nose  and  cicatrix  well ;  listen  to  what  will  be  told  you, 
and  then  see  if  you  can  doubt  any  longer  a  fact  so  well  proven."  Notwith- 
standing so  much  testimony,  I  say,  it  was  scarcely  admitted  amongst  us  as  pos- 
sible to  form  a  new  nose,  when  the  work  of  Dr.  Carpue,  published  in  181 6,  put 
the  matter  beyond  further  dispute.  A  Mahratta,  who  served  in  the  English 
army,  was  taken  prisoner  by  Tippo-Saib.  This  prince  ordered  his  nose  to  be 
cut  off.  Having  returned  to  his  comrades,  Cowajee  (the  name  of  the  sufferer) 
excited  the  pity  of  a  Hindoo,  who  refitted  a  nose  in  the  presence  of  T.  Cruso 
and  Finley,  physicians  of  Bombay.  Pennant  made  known  another  case  of  the 
same  kind,  in  1798 ;  and  Sir  C.  Makes  affirms  that  this  operation  is  common  all 
over  the  East  Indies,  where  Mr.  Lucas  says  that  he  performed  it  about  the 
time  of  Hyder-Ali.  These  facts  being  transmitted  to  London,  attracted  the 
attention  of  Messrs.  Lynn,  Carpue,  and  Hutchison,  who  immediately  set  them- 
selves to  examine  into  the  origin  of  the  Indian  operation,  and  the  advantages 
that  surgery  might  derive  from  it.  Dr.  Carpue  performed  it  twice  with  suc- 
cess. M.  Gracfe  also  paid  attention  to  it,  and  made  known  the  result  of  his 
experience,  in  1818.  Soon  after,  some  essays  of  the  same  nature  were  made 
in  France,  by  MM.  Delpech,  Dupuytren,  Moulaud,  Thomasin,  Lisfranc,  and 
Blandin.  In  fine,  Travers,  Liston,  and  Green,  in  England ;  Dieffenbach  and 
Beck,  in  Germany,  have  also  endeavored  to  diffuse  the  art  of  repairing  the  nose 


oi'erativb  surgery.  '2^ 

Upon  consulting  the  writings  of  Tagliacozzi,  Dr.  Carpue,  and  Professor 
Graefe,  we  will  be  forced  to  admit  that,  in  certain  cases  at  least,  the  new  nose 
does  not  differ  as  much  as  might  be  expected  from  the  original.  One  of  the 
patients  operated  upon  bj  M.  Delpech,  and  who  has  been  seen  in  Paris,  had 
not  much  cause  for  complaint  after  this  repair.  I  have  seen  the  subject 
whose  case  M.  Ltsfranc  published,  and  I  must  say,  that  in  him  the  new 
nose  was  far  from  presenting  all  the  regularity  desirable.  On  the  other  hand, 
it  must  not  be  forgotten  that  at  Paris  particularly  are  to  be  found  false  noses, 
made  of  plates  of  silver,  copper,  pasteboard,  and  even  wax,  which  may  be  so 
applied  to  the  face  by  means  of  springs,  or  by  securing  them  to  spectacles, 
which  is  still  better,  that  the  deformity  is  almost  entirely  removed.  M.  Boyer 
speaks  of  a  patient  in  whom,  at  first  sight,  the  deception  was  not  perceptible. 
Yet  a  metallic  nose  will  never  permit  the  wearer  to  blow  it,  take  snuff',  or 
to  use  the  olfactory  function  as  freely  as  the  mended  one. 

1.  The  Italian  Operation. — 1st.  Tagliacozzi'* s  Method, — Although  in 
Sicily  and  Calabria  there  appears  to  have  been  many  methods,  there  is  one 
particularly  superior  to  the  others,  which  appears  to  have  been  generally 
adopted :  it  is  that  of  Tagliacozzi ;  the  only  one  spoken  of  in  Europe  until  re- 
cent times.  The  surgeon  begins  by  forming  a  nose  of  pasteboard,  or  of  wax,  upon 
the  arm  of  the  patient;  applies  its  anterior  face  to  the  nares ;  applies  it  again 
to  the  arm,  with  its  point  towards  the  shoulder,  at  some  suitable  spot,  and  marks 
the  circumference  with  ink ;  then  circumscribes  a  triangular  flap  of  skin,  which 
he  dissects  from  its  point  to  its  base,  by  which  it  is  left  adhering.  A  strip  placed 
below  brings  together  the  lips  of  the  wound.  After  some  time  the  operator  pares 
oft' the  edges  of  the  deformed  nose,  as  well  as  that  of  the  tegumentary  piece  of 
the  arm.  Nothing  further  is  then  necessary  but  to  bring  the  bleeding  edges 
of  the  two  together  by  means  of  sutures,  and  to  fix  the  arm  in  front  of  the  face 
by  means  of  an  appropriate  bandage.  Some  rolls  of  linen  are  also  placed  in  the 
anterior  opening  of  the  nostrils.  When  reunion  has  taken  place,  the  sur- 
geon divides  the  base  of  the  flap  which  remains  on  the  face,  and  makes 
the  lobule  of  the  new  nose.  Others  are  content  to  make  an  incision  in  the 
fore-arm,  in  which  they  fix  the  denuded  edges  of  the  mutilated  nose  until  it 
has  contracted  intimate  adhesions  with  the  skin.  Then  they  have  only  to  cut 
and  separate  a  triangular  flap  on  each  side  from  the  arm,  unite  them  at  the 
median  line,  and  thus  leave  a  sort  of  rapha  on  the-nose. 

b,  M.  Grasfe^s  Method, — In  M.  Grsefe's  method  the  patient  begins  by 
putting  on  a  laced  jacket,  which,  covers  a  capuchin  or  cloak  and  hood,  which 
firmly  embraces  the  head.  One  of  the  sleeves  of  this  jacket  is  open  before,  and 
has,  near  the  elbow,  four  leather  straps,  and  two  others  shorter  near  the  wrist. 
The  operator  makes  raw  tlie  openings  of  the  destroyed  nose ;  measures  it, 
like  Tagliacozzi ;  marks  out  and  cuts  a  flap  in  the  same  manner ;  secures 
the  arm  thus  prepared  by  means  of  the  straps  above  mentioned,  and  to  keep 
the  denuded  edges  of  the  mutilated  nose  and  the  flap  in  contact  makes  use 
of  needles  and  the  twisted  suture.  After  from  four  to  thirty  days,  the 
union  will  have  been  completed.  The  bandages  may  be  then  removed, 
and  the  flap  detached.  After  it  has  once  been  secured  to  the  nasal  partition, 
two  openings  may  be  made  similar  to  the  natural  openings  of  the  nostrils, 
in  which  the  end  of  a  gum- elastic  sound  should  be  placed  until  the  parts  have 
8 


298  NEW    ELEMENTS    O* 

completely  cicatrized.  M.  Gnefe  is  the  only  person  who  has  followed — though 
he  has  modified  it — the  Tagliacotian  method;  by  which  he  has,  he  says,  suc^ 
ceeded  four  times  out  of  five. 

2.  Indian  Methods. — It  appears,  according  to  M.  Dutrochet  and  the 
above  mentioned  authors,  that  there  are  three  kinds  of  rhinoplastic  operations 
in  India. 

a.  By  means  of  a  Cutaneous  Flap  from  the  Rump. — In  some  countries  when 
a  mighty  personage  has  lost  his  nose,  he  procures  a  slave,  whose  rump  is  to  be 
slapped  violently  with  a  slipper  until  the  integuments  become  swelled.  A  nasi- 
fex  cuts  a  flap,  of  a  form  and  size  sufficient  to  replace  the  lost  nose,  from  this  sin- 
gularly prepared  part;  applies  and  fixes  it  firmly  to  the  nares,  which  he  keeps 
open  by  means  of  a  small  cylinder  of  wood.  There  is  every  reason  to  believe 
that  this  method  has  been  more  than  once  put  in  practice.  It  is,  in  fact,  but 
amodification  of  the  Italian  method,  using  the  skin  of  another  part  of  the  body. 
"Van  Helmont,  in  speaking  of  it,  says  that  a  nose  formed  in  this  way  mortified 
suddenly  at  the  end  of  a  year,  because  the  man  from  whom  it  had  been  takea 
died  at  the  same  moment. 

h.  By  Transplantation. — In  the  country  of  the  Parias  the  nobles  do  not  hesi- 
tate to  clip  off  the  nose  of  one  of  their  subjects,  and  put  it  in  the  place  of  their 
own,  when  lost.     They  succeed  so  well  in  this  way,  say  the  travelers,  that,  to 
prevent  criminals  whom  they  have  just  punished  from  repairing  their  de- 
formity, they  take  the  precaution  to  throw  their  nose  into  the  fire  as  soon 
as  it  is  lopped  off.     This  is  a  method  of  which  they  were  not  ignorant  ia 
Italy,  as  is  proved  by  the  above  extract  from  Fioraventi  Molinelli,  who  affirms 
that  his  father,  having  received  the  nose  of  an  Italian  in  a  warm  loaf  of  bread, 
•was  enabled  to  readjust  it  a  little  while  after  the  execution  of  the  sentence ; 
and  Leyster  says  as  much  of  a  young  man  of  a  high  family.     Dionis  tells  that 
a  robber,  having  had  his  nose  cut  off,  ran  to  a  surgeon,  who  demanded  of  him 
the  end  of  the  organ  that  he  might  reset  it.     His  comrades  went  back  and 
brought  it  warm  to  the  surgeon,  who  applied  it,  and  the  fellow  recovered.     In 
a  quarrel  a  soldier  bit  off  the  nose  of  his  adversary,  and  threw  it  in  the  mud; 
the  wounded  man  picked  it  up,  and  in  full  pursuit  of  the  one  who  had  done 
him  the  injury,  threw  the  nose  into  the  stall  of  M.  Gallien,  who  cleansed 
it  with  some  warm  wine.     The  soldier  returned,  says  Garengeot,  the  nose  was 
reapplied  and  secured,  and  cicatrization  took  plac€.     So  that  those  observ- 
ations, that  have  during  a  century  drawn  forth  injurious  sarcasms  on  their 
authors,  may  not  be  altogether  apochryphal.    In  1742,  Dubois  being  applied 
to  by  a  man,  the  end  of  whose  nose  was  held  by  only  a  thin  pedicle,  brought 
the  parts  together,  and  thus  obtained,  to  his  great  surprise,  union  by  the 
first  intention.    M.  Boyer  attended  a  young  man,  the  cartilaginous  portion 
of  whose  nose  had  been  almost  entirely  cut  off,  and  the  pedicle  supporting 
it  was  scarcely  a  line  broad.    This  surgeon  attempted  to  produce  reunion, 
and  succeeded  quickly  and  completely.    Besides  these,  there  has  been  in- 
voked in  support  of  these  transplantations  the  testimony  of  Aulaus,  who  saw 
the  flesh  of  a  living  fowl  employed  successfully  for  the  cure  of  a  hare-lip  ; 
of  T.  Bartholin,  who  says  that  a  sailor  was  promptly  cured  of  a  wound  with 
loss  of  substance,  in  the  hypochondriac  region,  by  the  application  of  mut- 
ton, which  soon  adhered  and  grew.    The  experience  of  Baronioj  of  Milan, 


OPERATIVE    SURGERY.  299 

contradicted,  it  is  true,  by  that  of  Hazard  and  Goliier,  but  strengthened  by 
that  of  Duhamel  and  Hunter,  proving  that  the  skin  from  the  sides  of  an  animal, 
transplanted  from  right  to  left,  or  applied  in  the  same  situation  upon  other  ani- 
mals, adheres  and  continues  to  live.  The  case  of  the  young  men  of  the  north  of 
Germany,  who,  as  an  evidence  of  their  intimate  friendship,  exchanged  witli 
each  other  a  flap  from  the  anterior  face  of  the  fore-arm;  and  finally,  those 
cases  of  complete  separation  of  the  fingers  from  the  hand,  reported  by  Heister, 
Pouteau,  Thompson,  Bayley,  M.  Lespagnol,  M.  Wigorn,  Balfour,  and  many 
others,  cited  by  Percy,  &c.,  go  to  establish  this  point.  If  it  be  admitted  that 
many  of  these  cases  should  be  numbered -among  the  stories  of  old  women,  it  is 
difficult  to  have  any  doubt  of  the  numerous  and  well-authenticated  cases, 
recently  related  by  Hoffaker  in  Germany,  Piedagnel,  Berard,  junior,  and 
Barthelemy,  in  France ;  cases  in  which  portions  of  the  nose,  ears,  lips,  fingers, 
&c.,  have  been  seen  completely  or  almost  separated  from  the  living  tissues,  re- 
applied to  the  wounded  surface,  contract  adhesion  and  reassume  vitality.  The 
six  examples  of  Hoffaker  epsecially,  leave  not  the  least  doubt  in  this  matter ; 
and  M.  Layraud  saw  a  man  whose  two  middle  fingers,  cut  by  a  single  stroke  so 
nearly  through  that  they  held  but  by  a  small  strip  of  skin  on  the  palmar  face, 
were  yet  perfectly  recovered  by  being  brought  into  reunion,  and  held  so  by 
small  splints. 

c.  With  the  Skin  of  the  Forehead,  or  the  Method  of  the  Koomas. — By  the  method 
generally  preferred  in  England  and  France,  the  surgeon  commences,  as  in  the 
preceding,  by  forming  a  nose  of  wax  or  pasteboard,  which  he  then  spreads 
upon  the  forehead  with  the  point  downward.  Its  circumference  is  marked 
with  some  coloring  matter.  The  operator  then  dissects  the  flap  thus  traced, 
taking  care  to  leave  at  its  base  a  small  prolongation  destined  to  replace  the 
nasal  partition;  turns  it  downward  by  detaching  it  as  low  as  the  malar  bones ; 
twists  the  pedicle  so  that  the  cuticular  surface  of  the  flap  may  be  outwards ; 
cuts  and  regulates  the  form  of  the  nares;  unites  their  bleeding  edges  with 
those  of  the  flap;  secures, them  in  contact  by  means  of  a  composition  of 
terra  japonica,  or  by  the  suture ;  brings  down  the  middle  pedicle  upon  the 
upper  lip,  and  fills  the  openings  of  the  new  nose  with  small  compresses 
rolled  into  cylinders,  pieces  of  the  barrels  of  quills,  or  gum-elastic  sounds. 

Remarks, — The  East  Indians  scarcely  ever  use  the  suture.  Dr.  Carpue 
preferred  it;  and  M.  Delpech,  who  performed  the  rhinoplastic  operation 
twelve  times,  says  that  it  should  never  be  neglected,  and  that  the  twisted 
suture  should  be  preferred.  Tagliacozzi  has  well  remarked,  that  the  skin, 
once  separated  from  the  parts  which  kept  it  extended,  contracts,  and  that  it 
is  important  to  give  the  flap  a  greater  size  than  seems  necessary  for  the  new 
organ  that  it  is  about  to  form.  The  wound  of  the  forehead,  at  first  very  large, 
contracts  rapidly,  and  leaves  a  cicatrix  much  smaller  than  would  be  expected 
immediately  after  the  operation.  Blandin  also  pursued  this  method  with 
the  two  patients  on  whom  he  recently  operated.  The  one  I  saw  has  done 
very  well.  His  nose  is  somewhat  large  and  round,  but  not  much  deformed, 
firm,  and  of  a  very  regular  continuity  with  the  forehead,  as  well  as  with 
the  cheek,  by  two  grooves,  the  right  of  which  being  deeper  than  the  left, 
gives  it  an  evident  inclination  in  that  direction.  Instead  of  dividing  and 
fexcising  the  pedicle  after  adhesion  has  taken  place,  M.  Blandin  denuded 
the  root  of  the  flap,  and  united  it  with  the  wound  of  the  nose,  which  he  pro- 


Ji^ 


500  NEW    ELEMENTS   0^ 

longed  upwards  by  loss  of  substance  for  this  purpose  expressly.  In  this 
manner  the  circulation  was  never  stopped,  and'  the  form  of  the  new  organ 
became  more  regular  between  the  two  orbits.  His  second  patient,  although 
attacked  with  erysipelas  and  delirium,  was  finally  cured,  and  has  a  nose  still 
more  regular  than  the  first.  M.  Lisfranc  contented  himself  with  adhesive 
straps  instead  of  sutures,  in  the  case  of  his  first  patient,  Eval.  In  order  to 
lessen  as  much  as  possible  the-  effect  of  the  twisting  of  the  flap,  he  extended  its 
ftpex  three  lines  lower  down  on  one  side  than  the  other;  and  also,  to  avoid 
cutting  the  pedicle  at  a  later  period,  he  united  it  by  two  lateral  incisions  made 
on  the  sides  of  the  natural  nose.  Uhion  took  place  at  first  only  on  one  side, 
and  the  suture  became  necessary  on  the  other.  In  one  case  treated  by  M. 
Lisfranc,  everything  announced  a  happy  termination,  when  another  disease^ 
foreign  to  the  operation,  put  an  end  to  the  hopes  of  the  surgeon.  "*■* 

4th.  French  Method. — M.  Dieffenbach's  operation  consists  rather  in  the 
mending  of  the  nose  than  the  formation  of  a  new  one.  He  dissects  up  and 
fashions  the  sides  from  the  mutilated  nose,  places  small  flaps  or  strips,  which 
he  gets  from  the  neighborhood,  between  them  to  fill  up  the  void,  and  then 
unites  the  whole  together  by  fine  needles  and  the  twisted  suture.  The  pas- 
sages in  Celsus,  Galen,  and  Paul  of  Egina,  apparently  relating  to  the  rhi- 
noplastic  operation,  indicate,  I  think,  this  method  of  operating.  It  was  also 
on  different  parts  of  the  face  that  they  sought  flaps  to  cover  the  denuded  parts. 
Celsus  even  says,  that  if  the  operator  takes  the  precaution  to  make  long  ver- 
tical incisions  near  the  ear,  it  then  becomes  much  easier  to  bring  the  skirt 
towards  the  median  line.  It  was  by  making  use  of  the  neighboring  tissues 
that  Franco  succeeded,  as  we  shall  see  further  on,  in  restoring  the  cheek  of 
one  of  his  patients.  We  may  add,  that  qne  rhinoplastic  operation  of  this  kind, 
performed  in  1820,  by  M.  Larrey,  was  entirely  successful;  and  that  the 
soldier  was  presented  to  the  faculty  of  medicine,  when  I  had  an  opportunity  of 
examining  him.  Among  his  cases,  M.  Dieffenbach  insists  particularly  on  that 
of  a  young  girl,  in  whom  the  vomer,  ossa  malarum  and  vertical  lamina  of  the 
ethmoid  bone  had  been  destroyed  by  scrofula ;  whose  nose,  instead  of  being 
convex,  was  so  sunken  as  to  present  a  hollow.  Many  incisions,  much  nearer 
one  another  on  the  side  towards  the  forehead  than  on  that  towards  the  upper 
lip,  permitted  him  to  bring  out  this  semblance  of  a  nose,  and  also  to  raise  up 
its  sides.  Other  transverse  or  semilunar  incisions  facilitated  the  union 
of  the  bands  made  by  the  first  incisions,  whilst  a  small  flap  was  borrowed 
from  the  lip  to  form  the  partition.  Several  needles  were  afterwards  applied 
in  various  directions,  and  by  the  assistance  of  some  small  patchings,  which 
several  accidents  rendered  necesssary,  M.  Dieffenbach  ultimately  succeeded 
in  giving  to  the  nose  of  this  patient  a  passable  form  and  regularity. 

5th.  Jlelalive  Value. — Of  every  method,  that  of  the  Koomas,  besides  being 
evidently  the  most  painful,  has  the  great  disadvantage  of  correcting  one  de- 
formity only  by  producing  another.  As  a  consequence,  the  forehead  neces 
sarily  becomes  the  seat  of  an  indelible  cicatrix,  which  is  sometimes  very  large. 
In  those  persons  whose  eyebrows  meet  over  the  median  line,  or  who  have  the 
hair  of  the  head  very  low  down,  the  base  and  another  point  of  the  flap  may 
remain  covered  with  hair  after  the  cure,  without  the  possibility  of  pre- 
vention. Few  men  would  consent,  at  this  day,  to  sell  their  noses  to  a  rich 
man,  who  would  wish  to  obtain  one  in  the  place  left  by  his  own.    Should  that 


OPERATIVE    surgery/  ^01 

which  has  been  said  of  this  species  of  aDimal  grafting  be  true,  the  Parian 
method  could  only  be  put  in  practice  in  cases  analogous  to  that  spoken  of  by 
Garengeot.  The  Mogul  method,  the  strangest  of  all,  is  subject  to  the  same 
remark.  The  distress  which  would  result  from  the  necessary  union  of  the 
two  individuals  until  the  base  of  the  borrowed  flap  could  be  divided,  will  doubt- 
less prevent  the  adoption  of  this  method.  As  to  M.  Dieffenbach's  ideas,  it 
would,  I  think,  be  as  injurious  to  adopt  them  exclusively  as  to  reject  them  en- 
tirely. Although  applicable  to  cases  of  mere  deformity,  or  where  the  loss  of  sub- 
stance is  small,  it  will  not  suffice  when  there  is  an  almost  complete  absence  of 
the  organ.  A  patient  on  whom  MM.  Lisfranc  and  Serre  performed  it,  and 
whom  I  have  seen  at  La  Pitie,  obtained  very  little  benefit  from  it.  And 
M.  Marjolin  told  me  that  he  had  seen  a  man  operated  on  in  this  manner  at 
Rouen,  who  had  not  been  more  fortunate.  Every  thing  seems  to  go  on  well 
for  some  time,  but  as  the  cicatrix  hardens  the  tissues  contract,  and  the  new 
nose  becomes  more  and  more  flat.  It  is,  then,  Tagliacozzi's  method,  or  rather 
M.  Graefe's  modification  of  it,  which  seems  most  rational.  It  is  there  that 
we  must  seek  the  general  method,  whilst  the  others  may  be  reserved  for  par- 
ticular cases.  The  method  of  the  Koomas,  however,  is  the  one  which  in  our 
day  has  been  the  most  frequently  and  completely  successful. 

When  the  bone  has  not  disappeared,  but  only  the  lobe  and  the  cartilages 
have  been  destroyed,  the  rhinoplastic  operation  may  remedy  in  a  great  mea- 
sure the  deformity.  In  other  cases  there  is  much  reason  to  fear  that  the  new 
organ  will  reduce  itself  ultimately  to  a  sort  of  stump,  and  remain  always 
flabby,  sinking  in  like  a  piece  of  linen  from  the  pressure  of  the  atmo- 
sphere. When  the  integuments  of  the  forehead  are  used  in  the  formation 
of  the  nose,  it  is  necessary  to  leave  the  twisted  pedicle  large  enough  to 
preserve  the  circulation  of  the  part.  Before  separating  it  from  the  root  of 
the  nose,  and  excising  that  portion  above  the  neighboring  surfaces,  the  opera- 
tor should  wait  until  the  new  tissues  in  front  are  firmly  united.  Instead  of  a 
roll  of  linen,  a  ball  of  charpie,  or  a  gum -elastic  canula,  to  maintain  the  open- 
ing of  the  nares,  I  prefer  a  plate  of  lead  curved  into  a  ring,  which  may,  at  the 
same  time,  also  form  a  mould  or  pattern  for  the  formation  of  the  nose.  M. 
Delpech  seems  to  me  to  have  very  well  combined  every  step  of  the  operation. 
Although  not  absolutely  necessary,  the  modification  of  M.  Lisfranc,  or  that 
of  M.  Blandin,  which  is  but  an  improvement  of  the  other,  has  its  advantages. 
In  taking  the  teguments  from  the  arm  I  do  not  know  whether  it  will  be  more 
advantageous  to  follow  the  precepts  of  the  surgeons  of  Sicily,  or  to  imitate 
the  professor  of  Berlin.  Finally,  this  operation  is  one  too  little  used  to  pre- 
vent each  one  from  pursuing  his  own  method ;  and  the  circumstances,  too, 
that  require  it,  are  too  different  not  to  demand  that  the  manuel  of  each  ope- 
ration should  be  left  to  the  particular  ingenuity  of  the  operator, 

\Art,  2. — Other  Operations  on  the  Nose. 

1st.  Excision  of  Tumors. — The  removal  of  tumors  from  the  nose  does 
not  differ  much  from  the  same  species  of  operation  on  other  parts.  I  will, 
however,  remark  that  the  lobe  of  this  organ  being  much  thinner  than  one 
would  imagine  at  first  sight,  it  is  very  easily  cut  through,  and  that  its  perfora- 


502  NEW   ELEMENTS   OF 

tion  is  almost  necessarily  followed  by  a  fistula  difficult  to  cure,  on  account  of 
the  atmospheric  air  passing  through  it. 

2d.  New  Operation. — In  describing  the  partition  of  the  nose,  Bichat  indi- 
cated the  possibility  of  an  operation  which,  until  very  lately,  remained  apiece 
of  theory,  but  which  M.  Rigal  has  just  reduced  to  practice.  Whilst  resting 
against  each  other  at  the  median  line,  the  cartilages  of  the  lobe  leave  between 
them  a  small  groove  perceptible  even  through  the  skin,  which  permits  us  to 
separate  them,  and  to  penetrate  as  far  as  the  bony  partition  of  the  nostrils 
without  opening  these  cavities.  A  cancerous  tumor,  developed  under 
the  anterior  nasal  spine,  and  which  had  gradually  extended  forwards  and 
downwards,  and  sideways  to  the  alae  of  the  nose,  had  yet  scarcely  al- 
tered its  tegumentary  covering.  Two  incisions  united  before,  turning  back- 
wards and  outwards,  so  as  to  resemble  a  Y  reversed,  having  dug  it  out 
laterally,  it  became  easy,  by  means  of  a  transverse  incision,  to  detach  it  below 
from  the  upper  lip;  then,  by  separating  the  two  lips  of  the  first  incision,  to 
reach  the  cartilage  of  the  partition,  its  anterior  edge  was  excised,  and  thus  the 
whole  morbid  mass  was  removed.  The  sides  of  the  division  were  then  brought 
together,  and  the  cure  was  not  attended  with  any  thing  unpleasant,  except  that 
the  cicatrization  drew  the  tissues  backward,  and  slightly  flattened  the  alae 
and  apex  of  the  nose. 

i  Sd.  Occlusion  of  the  Nostrils. — In  consequence  of  confluent  small-pox, 
syphilitic  or  other  kinds  of  inflammation,  the  rhinoplastic  operation  itself, 
and,  in  fine,  of  all  lesions  which  may  alter  the  form  of  the  nose,  the  anterior 
opening  of  this  organ  is  liable  to  be  closed,  or  at  least  contracted  so  far 
as  very  much  to  impede  respiration.  For  all  inconveniences  of  this  kind 
there  are  three  orders  of  remedies:  1st,  dilatation;  2d,  incision;  3d,  ex- 
cision. It  is  rare  that  simple  dilatation  will  suflice;  it  is,  besides,  only 
adapted  to  cases  of  stricture  or  contraction,  and  not  to  those  of  complete 
closure.  Incision,  in  its  turn,  almost  always  requires  the  assistance  of  dila- 
tation. Excision  becomes  useful  if  tubercles  or  morbid  projections  require 
removal.  If  the  opening  be  simply  contracted,  it  should  be  cut  in  many 
eccentric  rays,  and  more  or  less  deep  according  to  the  degree  of  the  disease. 
When  it  is  entirely  closed,  a  straight  bistoury  must  be  plunged  into  the  place 
which  the  opening  naturally  occupies.  By  this  means  the  operator  makes 
an  antero -posterior  opening,  the  sides  of  which,  I  think,  it  will  be  well  to  incise 
at  two  or  three  points.  As  it  is  necessary  at  every  hazard  that  these  sides 
should  heal  separately,  and  in  the  position  first  given  them,  it  seems  to  me  that 
we  shall  better  attain  this  end  with  a  plate  of  lead  rolled  into  a  ring,  or  of  such 
other  form  as  may  be  appropriate,  than  with  the  dilating  bodies  commonly 
employed.  This  is,  however,  a  very  simple  operation,  on  which  I  shall  not 
dwell. 

Rhinoraplua,  or  the  simple  suture  of  a  cleft  of  the  wings,  or  any  other  part 
of  the  nose,  once  successfully  performed  by  M.  Roux,  being  but  a  step  of  the 
rhinoplastic  operation,  or  governed  by  the  same  rules  as  cheiloraphy,  need  not 
be  discussed  in  this  place. 


OPERATIVE    SURGERY.  50S 


SfeCTION  II. 

The  Apparatus  of  Vision. 
Art,  1. — Lachrymal  Passages. 

§1.  Anatomical  Remarks, 

The  nasal  duct,  formed  internally  by  the  posterior  border  of  the  ascending 
apophysis,  the  anterior  third  of  the  os  unguis,  and,  quite  low  down,  by  a  little 
lamina  of  the  inferior  spongy  bone ;  without,  forward,  and  behind,  by  the 
maxillary  bone  and  its  cornet ;  then  a  little  by  the  hook  of  the  os  unguis ;  is 
from  three  to  five  lines  long ;  cylindrical  towards  its  middle ;  a  little  longer 
antero-posteriorly  than  transversely  in  its  superior  part ;  terminating  below 
in  a  funnel-shaped  orifice,  and  has  but  little  solidity,  exceptin  the  internal  and 
anterior  third  of  its  circumference :  whence  it  follows,  that  in  attempting  to 
pass  through  it  it  is  extremely  easy  to  break  its  other  wall,  and  penetrate 
either  into  the  nasal  fossa  or  into  the  maxillary  sinus.  The  lachrymal  groove 
seems,  in  prolonging  the  internal  wall  towards  the  corresponding  orbitary 
apophysis  of  the  frontal  bone,  to  become  more  and  more  superficial  as  it  goes 
upward  in  the  orbit,  but  presents,  on  the  contrary,  in  the  lower  part  of  its 
extent,  two  lips  easy  to  be  distinguished :  one,  anterior,  belonging  to  the 
ascending  apophysis;  the  other,  posterior,  formed  by  the  external  crest  of  the 
OS  unguis. 

The  fibro-mucous  membrane  which  lines  the  nasal  canal,  and  to  which  it 
fidheres  but  very  feebly,  becomes  much  stronger  and  more  complicated  in  the 
groove,  where  it  takes  the  name  of  the  lachrymal  sac.  Here  the  straight 
tendon  of  the  orbicularis  muscle  crosses  its  antgrior  face  at  a  right  angle,  so  as 
to  divide  it  into  two  equal  parts ;  one,  superior,  over  which  this  tendon  sends 
a  fibrous  expansion,  known  under  the  name  of  the  reflected  tendon  of  the 
naso -palpebral  muscle;  the  other,  inferior,  covered  outwardly  by  cellular 
tissue,  the  limits  of  which  it  is  very  important  to  know.  The  triangular  space, 
limited  above  by  the  straight  tendon,  below  by  the  rim  of  the  orbit,  and  out- 
wardly by  a  vertical  line  which  touches  the  external  edge  of  the  caruncula  la- 
chrymalis,  always  comprehends  this  last  portion.  It  is  only  covered  by  some 
fleshy  fibres,  a  little  laminated  tissue,  and  the  integuments  of  the  greater  angle 
of  the  eye.  As  it  is  badly  supported  by  the  surrounding  tis  ues,  it  yields 
easily  to  the  action  of  the  causes  which  tend  to  dilate  it,  and  thus  becomes  the 
ordinary  seat  of  the  lachrymal  tumor  and  fistula. 

Surrounded  by  a  small  circle,  dense  and  elastic,  but  not  cartilaginous,  the 
lachrymal  puncture  has  a  direction  completely  vertical,  and  forms  a  very  evi- 
dent angle  at  its  continuation  into  the  lachrymal  duct,  properly  so  called.  The 
latter,  which  traverses  only  the  anterior  fifth  of  the  free  edge  of  the  eye-lids,  oc- 
cupies more  particularly  its  posterior  part.  Consisting  only  of  the  mucous  mem- 
brane, it  is  very  thin  and  superficial  in  its  poster© -superior  half;  whilst  the  rest 
of  its  circumference,  consolidated  with  the  lid,  presents  anteriorly  and  below  a 
texture  much  more  solid.  It  is  this  anatomical  disposition  which  requires  us 
to  give  the  instrument,  first,  a  perpendicukr  direction,  .then  to  incline  much 


304  NEW   ELEMENTS  OF 

more  towards  the  nose  than  towards  the  eye,  when  we  desire  to  pass  it  through 
the  duct  itself.  At  their  entrance  into  the  sac  these  ducts  are  sometimes 
separated  by  a  small  projection,  a  kind  of  spur;  very  often,  however,  they  are 
confounded  in  the  same  opening. 

Taken  all  together,  the  lachrymal  sac  and  the  nusal  canal  present  a  double 
curve,  somewhat  resembling  that  of  an  italic  /;  that  is,  that  the  first  is  slightly 
convex  backwards  and  inwards,  and  the  second  convex  in  a  contrary  direction ; 
so  that  to  cauterize  it  from  the  upper  eye-lid,  it  is  necessary  to  take  care, 
whilst  the  stylet  traverses  the  sac,  to  incline  its  inferior  extremity  rather 
forwards  and  outwards  than  in  a  contrary  direction,  and  that  to  pass  through 
the  nasal  canal,  it  is  better,  on  the  contrary,  to  push  the  instrument  backwards 
and  inwards. 

Thus,  as  every  one  may  have  observed,  the  axis  of  the  nasal  canal,  in  its 
relation  to  the  superior  orbitary  projection,  presents  numerous  variations. 
The  depth  at  which  it  should  be  sought  in  tlie  orbit  presents  as  many  more. 
In  those  subjects  on  whom  the  root  of  the  nose  is  flat  and  broad,  it  seems  to 
be  thrown  outwards  and  sensibly  shortened;  when  the  ossa-malarum  are 
very  near  each  other  at  their  internal  face,  it  can,  on  the  contrary,  be  only 
reached  by  going  much  nearer  the  median  line;  when  the  forehead  is  very- 
prominent,  and  the  maxillary  bone  very  much  dilated,  the  lachrymal  duct  is 
at  some  distance  from  the  posterior  face  of  the  orbicularis  tendon,  whilst  it 
seems  to  pass  a  little  in  front  of  this  tendon  in  those  who  have  the  canine  fossa 
very  deep  and  the  forehead  depressed.  To  discover  it  through  the  soft  parts, 
the  operator  may,  like  M.  Lisfranc,  follow  the  inferior  edge  of  the  orbit,  be- 
ginning from  the  cheek  bone,  and  feeling  with  the  pulp  of  the  index  finger 
until  he  feels,  near  the  root  of  the  nose,  the  anterior  groove  of  the  lachrymal 
sac,  or  by  carrying  the  nail  of  the  finger  over  the  inferior  and  internal  edge 
of  the  triangular  space  described  above,  after  having  by  gentle  pressure 
dissipated  the  engorgement  of  the  soft  parts.  The  sort  of  valve  or  diaphragm 
which  contracts  the  inferior  extremity,  is  commonly  open  only  in  its  posterior 
half.  Its  orifice  is  six  or  eight  lines  deep  in  the  nose,  at  the  summit  of  an 
excavation,  limited  anteriorly  by  the  base  of  the  ascending  apophysis  of  the 
maxillary  bone,  and  inwardly  by  the  concave  face  of  the  inferior  spongy  bone. 
As  this  excavation  is  a  little  longer  from  the  lachrymal  valve  before  than 
behind,  it  happens  that  it  is  sometimes  very  difficult  to  pass  through  the  lower 
part,  if  the  surgeon  be  ignorant  of  this  arrangement.  Sandifort,  Callisen,  and 
others,  speak  of  concretions,  small  calculi  that  entirely  obliterate  the  nasal 
canal.  M.  Demours  has  met  with  abnormal  bands.  M.  Taillefer  described 
a  membranous  fold  occupying  the  superior  third,  the  free  edge  of  which,  hang- 
ing downwards,was  produced  in  many  small  filaments,which  fixed  it  to  another 
point  of  the  canal,  so  that  a  stylet  carried  from  below  upwards  was  evidently 
arrested  by  this  anomaly.  Further,  some  have  seen  the  canal  entirely  closed. 
Morgagni  relates  a  case  of  its  being  double ;  Jurine  and  Dupuytren  have  also 
met  with  this  arangement. 

§  2.  Obstruction^  Tumor. 

Stenon,  Valsalva,  Stahl,  and  a  veterinary  surgeon  quoted  by  Morgagni, 
had  already  attempted  to  explore  the  route  of  the  tears  by  means  of  probes  very 
fine  and  more  or  less  appropriate,  when  Anel  fixed  public  attention  on  this 


OPERATIVE    SURGERY.  g^5 

point  in  1716.  Accox'ding  to  his  partizans,  this  operation  is  indicated  in 
tumor,  fistula,  simple  obstruction,  obliterations  more  less  complete,  stricture 
partial  or  general,  ulcerations,  and  chronic  inflammations  of  the  canals, 
sac,  or  puncta,  as  well  as  of  the  duct.  It  may  be  used  for  the  introduction 
of  threads,  tents  of  ditterent  kinds,  injections  of  medicated  or  other  fluids, 
and  may  be  performed  either  from  the  lids  or  from  the  nose. 

1.  AneVs  Method, — Anel  had  two  methods  of  treating  affections  of  the 
lachrymal  passftges.  Sometimes  he  attempted  to  remove  the  obstructions  by 
means  of  a  very  fine  stylet,  slightly  enlarged  at  one  of  its  extremities ;  at 
other  times,  by  means  of  detersive  or  otherwise  medicated  injections. 

Injections. — For  injecting  he  invented  a  small  syringe  of  silver  or  gold, 
holding  three  or  four  drachms  of  fluid,  terminated  by  a  very  fine  tube,  to  the 
point  of  which  was  adapted  a  copper  pipe  finer  still.  The  patient  is  placed 
fronting  the  strong  light  of  a  window.  With  the  left  hand  for  the  left,  and  the 
right  for  the  right  eye,  the  surgeon  moderately  depresses  the  lid,  and  brings 
forward  its  free  edge.  With  the  other  hand  he  manages  the  syringe ;  places 
the  point  perpendicularly  in  the  punctum  ;  in  this  direction  sinks  it  in  about 
one  line,  then  turns  it  horizontally;  sinks  the  little  tube  of  copper  about  three 
or  four  more  lines ;  then  with  the  thumb  upon  the  ring  at  the  posterior  extre- 
mity, and  holding  the  body  of  the  instrument  between  the  index  and  middle 
fingers,  gently  forces  the  medicated  fluid  into  the  lachrymal  sac.  The  operator 
should  prefer  the  lower  punctum  in  this  operation,  because  by  the  upper,  it 
would  be  less  convenient  and  less  sure.  The  first  time  the  patient  finds  it 
difficult  to  bear.  It  is  followed  in  some  cases  by  considerable  irritation.  It 
IS  only  after  being  several  times  repeated  that  the  patient  becomes  accustomed 
to  it,  and  that  it  produces  only  slight  pain. 

•  Catheterism. — When  injections  will  not  succeed,  or  will  succeed  o::ly 
partially,  in  passing  into  the  nasal  fossa,  Anel  advises  recourse  to  the  probe. 
The  operator  places  himself  behind  the  patient ;  turns  the  lid  slightly  outwards 
and  upwards;  takes  hold  of  the  probe  like  a  pen;  places  the  button  perpendi- 
cularly over  the  orifice ;  then  inclines  the  base  outwards  and  upwards,  as  if  with 
an  intention  of  carrying  it  to  the  external  orbitary  apophysis ;  sinks  it  gently; 
with  the  other  hand  draws  the  nasal  portion  of  the  lid  inwards,  and  towards  the 
internal  orbitary  apophysis,  as  if  to  give  it  a  vertical  direction ;  then  pushes  on 
the  instrument  in  this  direction,  taking  care  at  the  least  obstacle  to  draw  it 
back  and  change  its  course  a  little,  either  forwards,  outwards,  backwards,  or 
inwards,  until  it  pass  into  the  corresponding  nostril ;  after  which  it  is  with- 
drawn to  give  place  to  injections. 

The  introduction  of  this  probe  is  a  delicate  operation,  and  very  fatiguing  to 
the  patient.  It  requires,  on  the  part  of  the  surgeon,  an  exact  knowledge  of*' 
the  anatomical  arrangement  of  the  parts  concerned.  The  smallest  fold,  na- 
tural or  morbid,  of  the  mucous  membrane,  suffices  to  arrest  the  instrument, 
which,  in  consequence  of  its  fineness  and  flexibility,  is  really  incapable  of  over- 
coming the  slightest  resistance  ;  yet  it  continues  to  be  described  and  used,  be- 
cause some  surgeons,  as  we  shall  see  hereafter,  have  applied  it  to  the  cure  of 
fistula  lachrymalis. 

2.  Laforest^s  Method. — Seeing  that  injections  and  catheterism,  after  the 
manner  of  AncI,  were  sometimes  very  difficult  to  be  practised,  and  at  the  same 
time  believing  in  their  utility,  Laforest  and  iVllouel,  following  Bianchi,  and 


306  NEW    ELEMENTS  OF 

the  veterinary  surgeon  cited  by  Morgagni,  and  supported  by  a  passage  from 
La  Faye,  invented  almost  at  the  same  time  a  method  of  penetrating  the 
lachrymal  passages  through  the  nostrils.  To  accomplish  this  object,  Laforest 
made  some  small  solid  probes  curved  in  an  arc  of  a  circle,  and  hollow  probes 
of  the  same  form,  conical,  open  at  their  points,  and  terminated  below  by  a 
pavilion  furnished  with  a  small  lateral  ring,  proper  to  fix  the  instrument  to 
the  side  of  the  nose  during  the  intervals  of  dressing.  The  sound,  passed  from 
below  upwards  into  the  nasal  canal,  was  intended  to  remove  the  obstructions. 
After  this  was  withdrawn,  the  hollow  sound  took  its  place,  and  served  for  the 
injection  of  suitable  fluids  by  means  of  a  small  syringe. 

Remarks. — Like  AnePs,  the  method  of  Laforest  has  been  but  rarely  used  for 
the  purpose  intended  by  its  author;  but  other  surgeons  have  attempted  to 
combine  it  with  certain  steps  of  the  operation  for  fistula  lachrymalis.  M.  Briot, 
of  Besancon,  for  example,  is  in  the  habit  of  using  it  constantly,  and,  as  M. 
Vesigne  says,  with  the  greatest  advantage.  These  injections,  either  from 
above  or  below,  are  means  worthy  to  be  kept  in  use.  It  is  evident,  in  fact, 
that  by  applying  medicated  fluids  to  the  seat  of  the  disease,  we  may  often 
render  a  more  serious  operation  unnecessary.  But  it  may  be  asked,  if  we 
may  not  accomplish  the  object  by  still  more  simple  means  ;  if  fluids  carried 
into  the  nose  by  means  of  fumigation  or  inspiration,  would  not  traverse  the 
lachrymal  passages  in  the  same  manner  ?  Moulac  and  Louis  are  said  to  have 
used  this  application  successfully.  Recently  Mr.  Mackensie  has  formally 
recommended,  as  a  result  of  his  own  observations,  to  reject  all  syringes, 
probes,  and  canulas.  It  is  sufficient,  in  his  opinion,  to  throw  once  or  twice  a  day 
some  drops  of  the  medicated  fluid  into  the  ocular  lake,  that  is,  the  greater  pal- 
pebral angle,  and  the  puncta  will  absorb  it  and  direct  it  through  into  the  nose. 

§  3.  Fistula. 

When  the  lachrymal  tumor  is  ulcerated,  or  when  it  resists  the  employment 
of  Anel's,  Laforest's,  Louis's,  or  Mackensie's  plans,  the  general  or  local 
antiphlogistics,  formally  recommended  by  Guerin  and  recently  brought  into 
favor  by  Gama  and  Lisfranc,  as  well  as  anti-syphilitic,  anti-scrophulous,  and 
other  similar  treatment,  it  is  admitted  in  practical  surgery  that  the  operation, 
properly  so  called,  must  be  had  recourse  to.  Yet  it  must  not  be  forgotten  that 
Maitre-Jean  saw  two  fistulas  of  the  most  serious  nature  spontaneously  cured ; 
that  M.  Demours  rarely  uses  a  cutting  instrument  in  treating  it;  that  the 
ancients,  with  their  farrago  of  escharotics,  styptics,  caustics,  and  inefficient 
pharmaceutical  compositions,  also  cured  some  cases ;  and  finally, that  in  our  own 
days  it  has  been  seen  to  disappear  in  those  who  have  only  been  treated  with  local 
bleeding  and  low  regimen.  This  will  be  the  more  important  as  it  will  enable 
us  to  comprehend  the  fact,  that  by  every  plan  proposed,  the  fistula  lachry- 
malis has  been  cured.  As  it  sometimes  cures  itself,  it  is  not  to  be  wondered 
at  that  compression,  which  was  formerly  praised  by  Avicenna,  and  for  the 
accomplishment  of  which  J.  Fabricius,  Hunter,  and  de  la  Vauguyon,  have 
invented  very  ingenious  bandages ;  that  tents  of  charpie  covered  with  oint- 
ment more  or  less  active,  and  that  leeches  and  emollient  cataplasms  have 
favored  the  cure  in  many  cases.  Lately  (November  1831),  a  male  adult 
was  sent  to  me  at  La  Pitie,  by  M.  Grenier,  to  be  operated  upon  for  fistula 


OPERATIVE    SURGERY.  307 

lachrymalis.  It  was  easy  to  prove  the  existence  of  the  disease,which  was  of  some 
months  standing.  Whilst  I  was  preparing  a  canula,  the  fistula  closed,  and 
has  not  since  reappeared.  If  leeching  or  any  other  medication  had  been  used, 
this  cure  would  inevitably  have  been  attributed  to  it,  and  it  is  probable  that  it 
is  in  such  cases  fhey  have  sometimes  been  successful,  Messrs.  Mortehan, 
Caucanas,  &c.,  have  reported  similar  facts.  Be  this  as  it  may,  science  now 
possesses  an  almost  infinite  number  of  methods  of  operating,  adapted  to  the 
almost  certain  cure  of  this  affection.  To  reduce  the  examination  of  these 
various  methods  to  order,  I  shall  divide  them  into  five  varieties  or  kinds. 
In  the  first,  threads,  tents,  or  some  other  foreign  body  is  made  to  pass 
through  the  natural  opening;  in  the  second,  the  lesion  is  to  be  caused  to  dis- 
appear by  means  of  mechanical  dilators,  introduced  through  the  accidental 
opening  -,  in  the  third,  a  metallic  canula  is  left  in  the  nasal  canal ;  in  the 
fourth,  the  disease  is  treated  by  means  of  the  cautery ;  and  in  the  fifth  an  ar- 
tificial passage  is  formed  for  the  tears, 

1st.  IHlatation  of  the  Natural  Passages. 

a.  Mejeari's  Method. — Observing  that  the  employment  of  injections,  and  the 
removal  of  obstructions  in  the  lachrymal  passages  with  the  probe  of  Anel,  only 
destroyed  the  disease  for  a  while,  Mejean  conceived  the  idea  of  applying  to 
the  nasal  canal  the  treatment  by  dilatation,  for  a  long  time  in  use  for  stricture 
of  the  urethra.  By  means  of  a  very  fine  probe,  with  an  eye  to  receive  a 
thread  at  its  superior  extremity,  this  author  explores  the  passage,  like  Anel; 
endeavors  to  engage  the  head  of  the  probe  in  the  hollow  of  a  grooved  director, 
inserted  for  this  purpose  through  the  lower  meatus  of  the  nostril,  and  draws 
it  out  with  the  thread  which  it  carries ;  this  forms  a  kind  of  seton,  the  two 
extremities  of  which  he  fastens  to  a  pin,  which  he  fixes  in  the  cap  or  hair 
of  the  patient.  After  a  day  or  two  he  attaches  two  bits  of  charpie  rolled  up 
in  the  form  of  a  tent,  and  covered  with  cerate  or  medicated  ointment,  and 
to  which  another  thread  is  attached  at  its  lower  extremity.  This  tent  is  thus 
drawn  from  below  upwards  through  the  nose,  into  the  superior  portion  of  the 
lachrymal  sac.  It  is  every  day  renewed,  and  enlarged  by  adding  a  small 
portion  of  charpie.  To  extract  it,  the  dresser  uses  the  thread  suspended  in 
the  nares,  and  which  between  the  dressings  remains  fixed  over  the  cheek  by 
means  of  a  small  patch  of  taffeta. 

By  this  method  the  treatment  may  continue  for  two,  three,  four,  or  six 
months.  The  cure  obtained  is  rarely  permanent.  Out  of  twenty  patients 
treated  in  this  way,  there  were  not  more  than  three  or  four,  according  to  the 
authors  of  the  period,  in  whom  the  disease  did  not  reappear  after  some  months. 
Besides  which,  Mejean- s  method  presents  two  difficulties  not  always  easily 
overcome.  The  probe  often  becomes  embarrassed  in  the  lachrymal  sac,  and 
it  is  not  until  after  long  and  fatiguing  attempts  that  it  can  be  engaged  in  the 
nasal  canal.  Unless  the  surgeon  has  great  experience,  he  will  often  find  it 
very  difficult  to  bring  the  groove  of  the  sound  and  the  eye  of  the  probe  together 
at  the  inferior  horn,  or  to  seize  the  latter  so  as  to  bring  it  out. 

b.  FalluccPs  Method. — Pallucci  thought  that,  by  introducing  a  small  hollow 
sound,  very  flexible,  in  the  place  of  Mejean's  probe,  it  would  be  possible  to  pass 
through  this  sound  a  cat-gut  cord  so  fine  that  the  patient  could  force  it  through 


308  NEW    ELEMENTS    OF 

bj  blowing  his  nose ;  which  was  then  to  answer  the  same  purpose,  and  be 
nsed  in  the  same  manner,  as  the  thread  in  the  preceding  method.  But  it  is 
evident  that  this  modification  complicates  tlie  operation  of  the  French  physi- 
cian, instead  of  simplifying  it,  and  that  it  would  be  much  easier  to  get  through 
the  lachrymal  passages  with  a  probe  than  with  a  canula. 

c.  Process  of  Cabanis. — Cabanis,  a  physician  of  Geneva,  has  proposed  a 
very  ingenious  instrument  with  which  to  take  hold  of  the  probe  of  Mejean  at 
the  inferior  meatus  ;  it  is  composed  of  two  narrow  blades,  susceptible  of  gliding 
upon  each  other,  pierced  with  a  number  of  holes,  passing  through  the  upper 
piate,  but  only  penetrating  to  a  certain  distance  into  the  lower.  This  instru- 
ment is  passed  under  the  inferior  maxillary  cornet.  By  proper  movements, 
the  probe  is  engaged  in  one  of  the  holes  of  the  united  blades;  then  these  are 
made  to  slide  on  each  other,  one  forward,  the  other  backward,  that  the  holes 
may  lose  their  parallelism,  and  the  probe  become  pinched.  Cabanis  also 
recommends  that,  after  the  thread  has  been  drawn  out  at  tlve  nose,  its  extremity 
should  be  attached  to  a  small  flexible  sound,  which  could  thus  be  carried  with 
certainty  into  the  inferior  opening,  and,  after  the  manner  of  Laforest,  into 
the  nasal  canal.  M.  Bermond,  of  Bordeaux,  who  reproduced  this  idea  in  1825 
and  in  1827,  has  correctly  remarked,  that  to  avail  one's  self  of  it,  it  is  suf- 
ficient to  get  the  conducting  thread  of  Mejean  out  by  any  contrivance.  As  the 
instrument  of  Cabanis  is  not  indispensable,  and  as  the  introduction  of  a  probe 
and  thread  b}^  the  punctum  counterbalances  the  advantages  that  could  be 
subsequently  drawn  from  it  by  the  introduction  of  a  sound,  after  the  manner 
of  Laforest,  surgeons  have  not  adopted  these  modifications. 

d.  Guerirvs  Method. — Having  observed  that  a  thread  left  in  the  superior 
lachrymal  ducts,  excoriates,  and  sometimes  tears  the  palpebral  orifice,  Guerin 
recommen.iS  that  the  tent  of  Mejean  should  be  brought  up  to  this  point.  M. 
Desgranges,  who  found  it  better  to  seek  the  extremity  of  the  probe  in  the  nose 
with  a  small  blunt  hook  than  with  the  grooved  sound  or  the  plate  of  Cabanis, 
adopted  this  idea,  which  Dr.  Care  has  recently  endeavored  to  diffuse. 

e.  Process  of  M.  Care. — The  process  of  this  physician  consists  in  passing 
from  below  upward,  with  Mejean's  instruments,  a  tent  of  raw  silk  composed  of 
three,  four,  or  six  strands,  as  many  in  fact  as  can  be  passed,  and  with  them 
dilating  the  conduits  and  puncta.  One  of  its  extremities  is  afterwards  fixed 
upon  the  forehead  of  the  patient,  when  it  has  been  passed  from  below  upward, 
or  on  the  side  of  the  nose,  if  in  a  cfontrary  direction.  A  small  ball  is  formed 
of  the  other  extremity,  which  may  be  fastened  in  the  hair.  M.  Dubois  appears 
to  have  followed  this  course  several  times,  and  I  have  seen  it  used  once  at  the 
Hopital  de  Perfectionnement,  by  M.  Bougon.  Its  partizans  think  that  a  tent  of 
this  size  is  not  liable  to  tear  the  punctum,  and  that  the  dilatation  of  the 
lachrymal  duct  which  it  produces  is  one  of  the  best  means  of  curing  the 
disease  of  the  canal  itself.  We  may  condemn  it,  in  my  opinion,  as  only 
dilating  the  healthy  parts,  without  acting  directly  upon  the  diseased  point  of 
the  organ  through  which  it  passes,  and  also  of  deforming  and  paralysing  the 
puncta  and  their  duct§.  Reason  appears  to  me  altogether  against  the  method  ; 
and  lil  have  not  learnt  that  experience  has  pronounced  in  its  favor,  I  think 
that  it  should  not  be  preferred.  I  cannot  even  see  any  thing  that  should 
induce  us  to  try  it. 


OPERATIVE    SURGERY.  309 


2.  Dilatation  through  an  Accidental  Opming, 

a.  Process  ofJ.L.  Petit, — Petit  was  the  first  who  fully  showed  that  the  ope- 
rator should  endeavor  to  establish  a  passage  for  the  tears  through  the  natural 
channel,  rather  than  create  a  new  one.  His  method  may  be  considered  as  the 
mother  of  all  those  of  the  present  day.  The  assistant,  placed  behind  the 
patient,  draws  tlie  temporal  angle  of  the  lids  outwards  to  steady  them  and 
straighten  the  tendon.  The  operator  then  caiTies  the  point  of  a  bistoury  into 
the  sac,  below  the  tendon  of  the  orbicularis  muscle  ;  makes  an  incision  about 
six  lines  long  at  the  greater  angle  of  the  eye;  slips  in  the  place  of  this  instru- 
ment a  grooved  sound,  which  he  pushes  with  more  or  less  force  into  the  nose, 
in  order  to  destroy  the  obstacles  that  oppose  the  passage  of  the  tears,  and 
introduces  by  its  aid  a  tent  or  conical  bougie  of  wax,  the  extremity  of  which 
must  be  more  or  less  swelled,  and  secured  by  a  thread.  The  bougie  should 
be  changed,  or,  at  least,  cleaned  every  day,  until  the  canal  gives  no  further 
signs  of  suppuration;  that  is,  for  two,  three,  four,  five,  or  six  months.  J.  L. 
Pe'tit  afterwards  thought  that  he  could  dispense  with  the  grooved  sound,  by 
making  a  groove  near  the  back  or  upon  the  anterior  face  of  the  bistoury,  which 
would  serve  to  direct  a  blunt  probe ;  but  as  this  rendered  it  necessary  to 
have  a  particular  bistoury  for  each  side,  operators  have  generally  neglected 
this  supposed  improvement. 

b.  Process  of  Monro. — The  reputation  that  Petit's  method  at  first  gained 
did  not  prevent  some  surgeons  from  combating  it  or  exposing  its  defects. 
According  to  Monro,  it  would  be  imprudent  to  open  the  sac  without  supporting 
its  external  or  anterior  wall.  It  was  for  this  purpose  that  he  proposed  to  pass 
a  small  probe  through  the  inferior  lachrymal  punctum  to  distend  it,  and  to  allow 
of  its  being  opened  without  wounding  th-e  posterior  wall.  Monro  also  recom- 
mends that  the  canal  be  forced  with  an  awl  rather  thaji  a  probe ;  that  the  open- 
ing of  the  sac  be  continued  upv/ards  with  the  scissors,  at  the  risk  of  dividing 
the  straight  tendon ;  and  that,  instead  of  the  bougie  of  Petit,  the  operator  should 
use  a  tent  of  charpie  or  cat-gut.  These  precepts  are  now  disregarded. 
Tiie  wounding  of  the  sac  behind,  besides  being  easily  avoided  in  the  common 
method,  is  not  dangerous,  whilst  tliat  of  tlie  tendon  of  the  orbicularis  muscle 
is  always  so,  and  the  employment  of  an  awl  may,  by  a  slight  misdirection, 
produce  false  passages. 

c.  Pouteau's  Process. — Introduced  from  above  downwards,  the  bougie  ulti- 
mately produces  in  the  great  angle  an  ulcer,  the  edge  of  which  turns  inward, 
and  consequently  leaves  a  cicatrix  strongly  depressed.  Having  attempted 
Mej can's  method  in  vain  for  a  young  woman,  and  not  daring  to  propose  an 
incision  of  the  sac,  after  the  manner  of  Petit,  Pouteau  resolved  to  carry  his 
bistoury  between  the  straight  portion  of  the  edge  of  the  inferior  lid  and  the 
caruncula  lachrymalis,  so  as  to  penetrate  into  the  nasal  canal  without  touching 
the  skin.  There  followed,  says  the  author,  only  a  slight  ecchymosis,  because 
he  made  the  incision  small.  No  person,  however,  has  imitated  him,  from 
the  fear  of  irritating  the  conjunctiva.  Besides,  the  inconveniences  for  the 
remedy  of  which  Pouteau  recommepds  it,  have  been  so  much  reduced  in 
modern  surgery,  that  no  one  now  takes  notice  of  it. 

d.  Process  of  Lecat. — After  having  incised  the  sac,  like  Petit,   Lecat 


310  NEW   ELEMENTS   OF 

uses  tents  of  charpie,  which  he  carries  from  above  downwards  through  the 
nasal  canal  bj  means  of  a  cat-gut  or  Mejean's  probe.  In  this  respect,  he  is 
the  first  who  has  endeavored  to  combine  Mejean's  method  with  Petit's ;  but 
as  his  tent  must  produce  the  curling  down  of  the  edges  of  the  wound,  which 
is  so  much  tlie  subject  of  apprehension,  the  profession  has  never  paid  great 
attention  to  his  precepts. 

e.  DesauWs  Method. — To  obviate  as  many  as  possible  of  the  inconveniences 
of  the  preceding  processes,  Desault  modified  almost  all  of  them,  and  com- 
bined several.  Bj  his  method,  the  incision  of  the  sac  is  made  only  of  two  or 
three  lines  in  extent.  A  grooved  sound  is  then  used  to  overcome  the 
obstruction  in  the  canal.  Then  a  cylindrical  stylet  or  probe  takes  its  place. 
A  small  silver  canula,  from  ten  to  twelve  lines  long,  conical,  and  furnished 
with  a  ring  on  the  side  of  its  pavilion,  is  carried  from  above  downwards,  into 
the  nose  by  means  of  the  stylet  or  probe,  which  represents  a  conductor,  and 
which  is  then  withdrawn.  The  thread  is  then  passed  down,  and  its  extremity 
brought  out  by  the  patient's  blowing  his  nose,  after  which  the  operation  is  not 
different  from  Mejean's. 

/.  M.  Boyer'^s  Modification. — To  make  as  mucli  of  the  thread  descend 
through  Desault's  canula  as  may  be  required,  we  may  imitate  M.  Boyer, 
and  use  a  small  probe  three  or  four  inches  long,  bifurcated  below,  and 
terminated  with  a  ring  above ;  and  afterwards,  to  extract  this  thread  from  the 
nose,  we  may  use  the  little  hook  of  Guerin,  or  the  dressing  forceps,  or  trust 
to  the  patient's  forcing  it  out  by  blowing  his  nose.  If  none  of  these  will  serve, 
it  may  be  left  in  that  organ,  as  the  mucosities  of  the  schneiderian  membrane 
will  almost  always  bring  it  out  in  the  course  of  twelve  or  twenty-four  hours. 
If,  however,  it  should  be  otherwise,  injections  thrown  with  some  force  through 
the  opening  in  the  lachrymal  sac  never  fail  to  bring  it  out. 

g.  Method  of  Pamard. — Opposed  by  the  difficulties  of  extracting  the  liga- 
ture by  Desault's  method,  Pamard,  of  Avignon,  and  Giraud,  almost  simul- 
taneously made  an  improvement  which  surgeons  of  the  present  day  still  prac- 
tice. It  is  a  small  elastic  probe,  made  of  a  watch  spring,  with  a  button  at 
one  end  and  an  eye  at  the  other.  The  head  of  this  spring  is  passed  into  the 
canula,  and  when  it  has  arrived  under  the  inferior  horn,  its  elasticity  naturally 
directs  it  either  to  the  opening  of  the  nares  or  under  the  lobule  of  the  nose, 
where  it  may  be  reached  with  the  fingers,  or  a  pair  of  dressing  forceps. 
M.  Roux  scarcely  ever  uses  any  other  method,  and  it  cannot  be  denied,  that 
he  most  frequently  completes  the  operation  for  fistula  lachrymalis  with  great 
celerity;  yet,  when  the  spring  is  not  well  tempered,  and  even  sometimes  when 
it  is  most  perfectly  finished,  its  extremity  is  disengaged  with  much  difficulty 
from  the  inferior  meatus.  Whence  M.  Boyer  feels  himself  bound  to  adhere 
to  the  method  of  Desault,  although  he  practices  in  the  same  establishment 
with  M.  Roux,  and  although  he  has  frequently  employed  the  spring  needle 
of  Pamard. 

h.  Process  ofJurine. — In  order  to  leave  the  least  possible  deformity  in  the 
angle  of  the  eye,  Jurine  performed  his  operation  with  a  small  trocar  of  gold, 
the  canula  of  v/hich  was  pierced  near  the  point.  He  passes  it  into  the 
nose,  and  then,  after  withdrawing  the 'stylet,  passes  by  its  canula  the  spring 
of  Pamard.  The  rest  is  performed  according  to  the  rules  above  laid  down. 
If,  in  spite  of  its  apparent  simplicity,  this  method  has  not  been  followed,  it  is 


OPERATIVE    SURGERY.  311 

because,  in  reality,  it  is  more  painful  and  difficult  than  several  others.  It  will 
always  be  more  rational  to  open  the  lachrymal  sac  with  a  bistoury  than  with 
a  trocar ;  after  that,  Pamard's  method  is  preferable  to  that  of  Jurine. 

i.  M.  Fournier^s  Method. — An  extremely  ingenious  modification,  and  one 
which  I. am  astonished  not  to  have  seen  in  our  modern  treatises,  is  that  pointed 
out  by  M.  Fournier,  of  Lempde.  This  physician  recommends  to  attach  a  shot 
or  a  grain  of  lead  to  the  ligature  of  Mejean.  By  its  own  weight,  this  will 
pass  through  the  canula  of  Desault,  and  tall  into  the  interior  of  the  nose,  from 
which  the  patient  may  make  it  pass  without  difficulty,  by  taking  the  simple 
precaution  of  leaning  forwards. 

10.  The  editors  of  Sabatier  have,  it  appears  tome,  justly  observed,  that  the 
combination  of  Mejean's  and  Petit's  method  may  do  away  with  all  the  instru- 
ments of  Desault,  Pamard,  Boyer,  and  Roux.  What  need  is  there,  in  fact,  of 
passing  into  the  nasal  canal  successively,  a  probe,  a  stylet,  a  canula,  and  a 
watch  spring?  Why  not  be  satisfied  with  putting  the  thread  in  the  conductor, 
and  passing  the  latter  into  the  nose  as  so(m  as  the  sac  is  opened  ?  The  spring, 
crotchet,  and  canula  of  M.  Benezech,  proposed  in  1807,  for  the  more  easy 
extraction  of  Mejean's  stylet,  have  no  superiority  over  most  of  the  means 
already  spoken  of,  and  consequently  need  no  further  mention. 

j.  Process  of  M.  Jourdan, — Fearing  lie  should  not  otherwise  expose  the 
whole  extent  of  the  disease,  and  wishing  to  avoid  a  cicatrix  of  the  integu- 
ments, M .  Jourdan  proposed  to  open  the  lachrymal  sac  behind  the  internal 
commissure  of  the  eye-lids,  on  the  inside  of  the  caruncle.  M.  Vesigne  is 
wrong,  certainly,  when  he  says  that  most  frequently  it  will  be  impossible  to 
follow  this  advice ;  but  it  is  not  the  less  true,  that  M.  Jourdan's  method  offers 
no  advantages  over  the  others;  that  it  incurs  the  risk  of  wounding  the  inner 
extremity  of  the  lachrymal  conduits,  of  dividing  Horner's  muscle,  and  will 
produce  more  pain  and  present  more  difficulties  than  any  of  those  now  in  use. 

k.  Process  of  Scarpa.^— Whiles  in  France,  we  were  endeavoring  to  spread 
the  method  of  Mejean,  the  surgeons  of  Germany,  Italy,  and  England  con- 
fined themselves  to  modifying  that  of  J.  L.  Petit.  After  clearing  the  sac 
and  can'al  by  means  of  a  tent  covered  with  red  precipitate,  or  of  the  nitrate 
of  silver,  Scarpa  advises  us  to  pass  a  probe  or  conical  nail  of  lead,  terminated 
by  a  flat  head,  more  or  less  inclined  upon  the  shaft,  so  as  to  accommodate 
itself  to  the  inner  angle  of  the  eye.  This  nail  was  to  be  withdrawn  from 
time  to  time,  washed,  and  returned.  During  the  first  few  weeks  the  surgeon 
was  to  take  care  of  this  himself,  and  inject  warm  water  into  the  lachry- 
mal appendage  before  replacing  the  probe,  which  Scarpa  called  the  con- 
ductor of  the  tears.  Afterwards  the  patient  needed  no  assistance  in  per- 
forming this  dressing.  When  the  tears  begin  to  find  their  way  without  obstacle, 
into  the  nose,  and  when  the  nail  ceases  to  exhibit  purulent  matter  on  being 
withdrawn,  it  may  be  laid  aside  ;  yet  it  is  best  to  continue  it  some  weeks 
longer,  for  greater  security  against  a  relapse.  To  some  patients,  says  Scarpa, 
it  produces  so  little  uneasiness,  that  they  would  be  willing  to  continue  its 
use  all  their  lives,  and  who  have  no  repugnance  to  wearing  it  for  eight  or  ten 
months,  or  a  whole  year.  I  have  seen  M.  Dubois  and  M.  Bougon,  in  Paris, 
use  a  cone  of  lead  with  success,  which  differed  from  that  of  Scarpa  only  in 
having  its  superior  extremity  bent  into  a  crotchet,  instead  of  being  flat,  like 
the  head  of  a  nail. 


S12  NEW   ELEMENTS    OF 

/.  Process  of  Wore. — There  are  some  who  prefer  a  silver  style  to  the 
leaden  tent  which  I  have  just  mentioned.  Dr.  Ware,  for  example,  introduced 
among  the  English  surgeons  a  silver  nail  or  style,  almost  exactly  similar  to 
tlie  leaden  one  of  Scarpa,  and  which  M.  Larrey  has,  in  his  turn,  replaced  by 
one  of  cat-gut. 

Permanent  Canula, 

According  to  Louis,  Foubert  conceived  the  idea  of  retaining  a  silver  canula 
in  the  nasal  canal.  It  was  about  an  inch  long,  conical,  and  terminated  in  some- 
thing like  the  bowl  of  a  spoon  above.  Bell  and  Richter  had  also  spoken  of  this 
canula,  but  Louis  having  formally  denounced  it,  it  was  hardly  thought  worthy 
of  trial  among  surgeons  of  that  time,  notwithstanding  the  efforts  of  Pellier, 
who,  in  1783,  announced  himself  as  its  inventor,  and  gave  arguments  in 
his  work  which  plead  strongly  in  its  favor.  Pellier  had  also  modified  it 
very  ingeniously.  His  canula  was  shorter  than  that  of  Foubert,  and  ter- 
minated in  a  smooth  fillet  above  and  a  pen-point  below,  and  had  another 
fillet  round  the  middle,  so  that,  once  in  place,  it  was  impossible  for  it  to  go  up 
or  down.  It  appears  never  to  have  fallen  into  complete  disuse.  M.  Distel 
published,  that  one  of  his  patients  wore  one  for  more  than  fifteen  years, 
and  that  another  of  tin  had  been  in  use  more  than  forty  years.  I  see,  too, 
in  a  thesis  published  in  1803,  that  at  the  hospital  of  Strasburg  no  other 
method  is  followed.  M.  Marschal  has  given  us  new  and  conclusive  obser- 
vations upon  it.  In  Germany  it  was  also  employed  by  Himly  and  Reisinger. 
But  in  the  schools  of  Paris  it  had  been  entirely  forgotten,  when  Dupuytren 
recalled  it  to  the  recollection  of  our  operators.  He  gave  it  but  one  fillet 
instead  of  two.  This  fillet  is  concave  within,  where  it  presents  a  circular 
gi^oove,  and  is  so  made  that,  to  withdraw  the  canula,  if  any  accident  should 
require  it,  it  is  sufficient  to  introduce  into  its  interior  the  point  of  an  elastic 
forceps,  terminated  with  two  little  crooks,  with  the  points  turned  outwards, 
to  draw  it  upwards.  That  of  M.  Brachet,  of  Lyons,  presents  a  second 
swelling  at  its  inferior  extremity.  M.  Taddei;  who  speaks  highly  of  it  in  a 
memoir  published  in  Italy,  approaches  much  nearer  than  any  others  to  the 
views  of  Pellier,  in  advising  a  slight  enlargement  below  its  superior  third. 
M.  Grenier,  who  thinks  that  the  canula  escapes  only  because  it  ceases  to  be 
sufficiently  pressed  by  the  canal,  has  proposed  one  that  will  contract  when 
compressed,  and  enlarge  again,  like  a  spring,  when  left  to  itself. 

To  place  it,  it  is  necessary  to  have  a  stylet  of  steel,  silver,  or  gold — which 
is  a  sort  of  lever  bent  almost  at  a  right  angle — the  inferior  limb  of  which  is  to  be 
fitted  to  the  calibre  of  the  canula,  and  limited  by  a  shoulder.  The  handle  of  the 
instrument  (the  other  limb)  is  more  or  less  flat,  and  two  or  three  inches  long. 
The  lachrymal  sac  is  to  be  opened  as  in  the  other  methods.  The  stylet, 
furnished  with  a  canula  of  suitable  dimensions,  is  then  carried  upon  the  back 
or  anterior  face  of  the  bistoury,  so  as  to  penetrate  the  nasal  canal  as  that 
instrument  is  withdrawn.  When  the  enlargement  of  the  canula  has  been 
passed  within  the  lips  of  the  incision,  it  is  to  be  fixed  at  this  point  by  the  nail 
of  the  first  finger,  whilst  the  style  is  withdrawn.  The  patient  is  then  required 
to  force  out  his  breath,  and  if  any  of  it  pass  by  the  angle  of  the  eye,  the  opera- 
tion is  well  done.     M.  Taddei  thought  that,  before  introducing  the  canula,  it 


OPERATIVE    SURGERY.  SIS 

would  be  proper  to  remove  the  obstructions  in  the  canal  by  a  probe,  or  cylin- 
drical stylet,  and  M.  Cloquet  does  not  introduce  it  until  after  using  tents 
for  some  days*  It  is  said  that  M.  Lisfranc  makes  a  larger  incision  in 
the  integuments  than  M.  Dupuytren  recommends.  But  the  stylet  performs 
exactly  the  office  of  a  probe,  doing  thereby  at  once  what  M.  Taddei  effects 
by  two  different  operations ;  and  it  is  evidently  useless  to  divide  the  parts 
to  a  greater  extent  than  is  absolutely  necessary  for  the  passage  of  the  canula. 
To  penetrate  through  the  inner  face  of  the  lid,  as  recommend-ed  by  M.Yesigne, 
to  prevent  a  cicatrix,  is  certainly  superfluous,  and  this  is  as^iuredly  not  a  case 
for  conforming  to  the  precept  of  Pouteau.  For  the  purpose  of  rendering  the 
operation  still  more  simple  and  speedy,  Daviel  invented  a  sort  of  trocar  or 
stylet,  ending  like  a  lancet  point.  This,  by  carrying  the  canula  with  it  into 
the  canal,  reduced  the  operation  to  a  single  process.  This  ingenious  modi- 
fication, although  applicable  to  the  more  simple  cases,  would  be  often  inconve- 
nient, on  account  of  the  small  opening  it  makes  in  the  skin. 

The  canula  should  be  of  silver,  gold,  or  platina,  and  of  such  strength  as  not 
to  be  easily  altered  in  its  form.  Its  size  and  length  should  vary  to  suit  the 
subject.  It  is  necessary  it  should  exactly  fit  the  calibre  of  the  nasal  canal,  and 
pass  a  little  beyond  its  inferior  extremity.  Consequently,  in  an  adult,  it  should 
be  from  five  to  eight  lines  long,  and  from  one  to  two  lines  thick.  It  should 
also  be  slightly  curved  backwards  and  inwards,  and  its  point,  cut  into  tlie. 
form  of  the  nib  of  a  pen,  should  prolong  the  anterior  and  external,  rather  than 
tlie  nasal  side  of  the  canal.  To  adapt  it  to  the  size  of  different  individuals  and 
to  their  diffei-ent  ages,  M.  Grenier  has  found  a  means  which,  it  appears  to  me, 
exactly  answers  the  purpose.  It  is,  that  the  length  of  the  canal  is  represented 
by  a  line  drawn  from  the  point  of  incision  in  the  angle  of  the  eye  to  the  superior 
depression  in  the  ala  nasi,  at  the  junction  of  the  inferior  edge  of  the  os  malae 
with  the  ascending  apophysis  of  the  maxillary  bone. 

Many  objections  have  been  made  to  this  method.  Here  is  a  foreign  body, 
it  has  been  said,  which  must  necessarily  fatigue  the  part,  produce  cephalalgia, 
more  or  less  uneasiness  in  the  nose  and  face,  erysipelatous  affections,  phlegmon 
abscess,  or  ulceration  of  the  angle  of  the  eye.  It  often  rises  up  under  the 
integuments,  and  requires  to  be  withdrawn.  M.  Darcet  has  stated  twenty- 
seven  cases  where  its  extraction  became  indispensable.  M.  Delpech  has  seen 
it  pass  through  the  arch  of  the  palate.  Mucosities  and  the  snuffs  which  many 
persons  use,  may  obstruct  or  close  the  orifice,  and  thereby  renew  the  disease, 
as  has  been  shown  by  M.  Maunoir.  Finally,  when  it  requires  extraction,  we 
must  have  recourse  to  an  operation  niore  important  than  for  the  fistula  lachry- 
malis  itself. 

All  these  objections  have  some  foundation.  But,  on  the  one  hand,  it  is  in 
most  cases  the  operator,  and  not  the  operation,  that  should  be  blamed  for  any 
ill  consequences  that  may  occur ;  and,  on  the  other  hand,  there  is  no  method 
without  risks  of  this  kind.  No  doubt,  if  the  canula  slip  in  between  the  soft 
parts  and  the  maxillary  bone,  as  I  have  twice  seen,  instead  of  remaining  in  the 
canal  it  will  give  rise  to  more  or  less  important  symptoms,  without  being  of 
any  benefit,  properly  speaking,  to  the  fistula ;  that  this  will  also  be  the  case,  if 
it  be  pushed  into  the  maxillary  sinus,  or  into  the  parieties  of  the  canal ;  if  it 
descend  between  the  bone  and  the  membrane  of  the  canal ;  in  a  word,  if  it  be 
not  exactly  in  the  natural  route  of  the  tears.  It  is  also  clear  that  a  large  canula 
40 


514 

cannot  be  passed  without  danger  through  a  canal  too  small,  and  yet,  that  if  the 
former  be  too  small,  the  operation  will  be  equally  unsuccessful.  But  it  is 
the  duty  of  the  surgeon  to  know  how  to  avoid  these  mistakes,  or  at  least,  when 
he  makes  them,  not  to  charge  their  eifects  upon  the  method  of  operating.  In 
all  other  modes  of  operating,  it  is  necessary  to  renew  the  dressings  each  day 
for  several  months.  There  is  none  of  them  but  what  has  been  attended  by 
cephalalgia,  erysipelas,  &c.  By  Dupuytren's  method,  a  few  seconds  only  are 
necessary  to  complete  the  operation.  The  disease  is  almost  immediately 
cured.  No  dressing  nor  particular  care  is  indispensable.  Most  patients  return 
immediately  to  their  habitual  occupations.  By  this  process  we  can  secure 
success  in  twelve  out  of  twenty  operations.  A  young  woman  whose  lachrymal 
duct  was  so  small  that  I  was  compelled  to  use  considerable  force  in  introducing 
a  canula  of  a  very  small  diameter,  had  a  slight  cephalalgia  for  three  days.  In 
another  case,  that  of  a  young  man  aged  twenty-one,  I  had,  as  it  were,  to 
force  the  duct  in  order  to  pass  the  canula.  I  kept  him  at  La  Pitie  ;  the  next 
day  he  was  well,  and  no  accident  followed.  The  v/orst  that  can  happen,  after 
all,  is  that  we  may  be  obliged  to  withdraw  the  instrument ;  but  this  is  not  so  very 
serious  or  important ;  it  is  done  simply  by  finding  again  the  superior  opening 
of  the  canal,  and  withdrawing  the  oftending  body.  When  any  difficulties  are  met 
with,  the  double  crotchet  and  canula  of  Dupuytren,  the  little  hook  of  Cloquet, 
or  the  two-headed  mandrin  of  M.  Caignou,  will  at  once  obviate  them.  We 
might  also  use  a  pair  of  small  dissecting  forceps,  one  of  the  points  a  little  turned 
inwards.  With  any  one  of  these  instruments,  by  placing  the  hook  in  the 
circular  groove  of  the  expansion,  or  beyond  the  extremity  of  the  canula  within, 
we  can  draw  it  out  quite  easily,  by  making  it  follow  the  same  route  by  which 
it  was  introduced.  I  have  withdrawn  it  four  times,  and  found  the  dissecting  for- 
ceps always  sufficient.  It  should  b^  observed  besides,  that  after  the  extrac- 
tion of  the  canula,  the  patient  is  in  just  the  same  state  as  those  who  have  been 
treated  the  same  length  of  time  by  the  dilating  method  of  Petit,  and  that  many 
find  themselves  even  then  radically  cured,  as  I  have  twice  seen.  I  would  not 
say  that  the  canula  is  suited  to  all  cases.  When  the  canal  has  been  thrown  out 
of  its  natural  direction  by  exostosis ;  when  it  is  much  closed  by  some  hard  sub- 
stance or  by  ulcers ;  or  when  it  is  the  seat  of  more  profound  lesions  still,  it  will 
be  better  to  have  recourse  to  Mejean's  seton,  or  some  other  more  appropriate 
method.  I  would  only  say  that  it  is  practicable  whenever  the  method  of  Petit, 
modified  by  Ware,  Scarpa,  or  Dubois,  can  be  applied,  or  any  mode  of  treat- 
ment depending  upon  mechanical  dilatation,  and  that  it  is  far  preferable  to 
them  all. 

4.  Cautery. 

Fistula  lachrymalis  was  treated  by  injections  and  tents  introduced  into  the 
nasal  canal ;  by  escharotics,  and  even  the  actual  cautery,  before  the  course  of 
the  tears  was  perfectly  known.  These  various  methods  are  clearly  indicated 
in  the  works  of  the  Greek  and  Arabian  physicians,  and  the  authors  of  the 
middle  ages ;  but  it  was  under  the  same  title  with  all  other  fistulous  ul- 
cerations. Their  ignorance  of  the  anatomy  of  the  lachrymal  apparatus  did 
not  permit  them  to  look  upon  it  in  any  other  point  of  view.  For  more  than 
a  century  cautery  had  scarcely  been  thought  of,  when,  in  1832,  M.  Har- 
veng,  of  Manheim,  proposed  to  found  upon  it  a  new  method  of  treatment.    It 


OPERATIVE  SURGERY.  315 

was  soon  seen  that  this  duct  resembled  the  urethra,  and  that  its  coarctations 
might  be  submitted  to  the  same  general  treatment.  At  present  there  are 
two  methods  of  applying  the  cautery  :  one  by  penetrating  from  above  down- 
wards, the  other  by  introducing  it  through  the  nasal  fossa. 

a.  Superior  Operation. — 1.  Process  of  M.  Harveng. — After  opening  the 
lachrymal  sac,  M.  Harveng  advises  to  pass  a  cautery  at  a  white  heat,  or  a  tent 
covered  with  nitrate  of  silver,  through  a  canula  to  the  obstructing  points ;  to 
reapply  it  once,  or  oftener  if  necessary,  and  to  proceed  generally,  as  recom- 
mended by  Ducamp,  in  treating  affections  of  the  urethra.  According  to  M. 
Vail,  who  published  a  thesis  upon  it  in  1824,  Mortier,  of  Lyons,  had  a  long 
time  before  suggested  the  same  idea,  which  was  also  attributed  to  M.  Janson, 
and  that  M.  Taillefer,  who  has  also  been  thought  to  be  its  author,  again  brought 
it  forward,  in  1827. 

2.  Process  of  M.  Deslande. — In  the  month  of  May,  1825,  M.  Deslande  made 
known  another  mode  of  accomplishing  the  same  purpose.  An  ordinary 
mandrin  is  at  first  introduced  into  the  nasal  passage,  to  remove  obstruc- 
tions and  open  the  way  for  the  port-caustique ;  there  is  then  slipt  into  its 
place  another  instrument  of  the  same  form,  with  two  longitudinal  grooves  in 
its  vertical  limb,  filled  with  fused  nitrate  of  silver.  The  instrument  is  turned 
upon  its  axis,  so  that  the  whole  canal  may  be  cauterized,  and  the  operation  is 
finished. 

b.  Inferior  Operation, — I  learn  from  M.  Blanc  that,  in  1824,  M.  Gensoul 
dispensed  with  opening  the  great  angle  of  the  eye,  and  passed  the  nitrate  of 
silver  by  the  inferior  meatus  of  the  nasal  fossae.  M.  Bermond,  of  Bordeaux, 
in  1825,  inserted  a  memoir  into  the  journals  on  the  same  subject.  M.  Valet 
said  something  of  it  in  a  thesis,  in  1826.  And  M.  Ratien,  who  was  no  doubt 
ignorant  of  these  various  attempts,  announced,  in  1828,  that  he  hoped  to  be 
able  to  apply  Ducamp's  method  to  the  treatment  of  fistula  lachrymalis,  by 
penetrating  through  the  inferior  orifice  of  the  nasal  canal.  These  surgeons 
first  propose  to  determine  the  place,  the  forift,  and  the  extent  of  the  disease, 
and  then  to  pass  the  caustic  with  certainty  and  facility.  In  penetrating  by 
the  angle  of  the  eye,  as  recommended  by  Mortier,  Harveng,  and  Taillefer,  the 
operation  presents  no  difficulty ;  but  by  the  other  method,  we  must  begin  by 
making  ourselves  familiar  with  the  method  of  Laforest. 

1.  Process  of  M.  Bermond. — After  having  introduced  from  without  the 
conducting  thread  of  Mejean,  M.  Bermond  attaches  it  to  the  ring  of  a  tent 
covered  with  wax,  which  he  then  draws  into  the  nasal  canal  to  take  an  impres- 
sion of  its  form.  By  means  of  a  thread  attached  to  the  free  extremity  of  this 
little  bougie,  he  withdraws  it  by  the  nose,  and  puts  in  its  place  a  tent  made 
of  charpie,  covered  with  a  thick  paste,  which  is  rendered  caustic  in  the  parts 
corresponding  to  the  obstructions.  This  metliod,  which  is  certainly  the  most 
ingenious,  has  but  one  objection :  it  requires  the  previous  introduction  of  a 
thread  through  the  punctum  lachrymale,  the  canal,  and  the  sac. 

2.  Process  of  M.  Gensoul. — A  small  catheter,  curved  so  as  exactly  to  suit 
the  passage  it  has  to  traverse,  is  at  first  passed  under  the  inferior  corner  and 
into  the  nasal  canal,  to  discover  the  seat  of  the  disease ;  which  is  then  imme- 
diately attacked  with  nitrate  of  silver,  by  means  of  a  port-caustique.  More 
than  three  hundred  cases  have  been  treated  in  this  way  by  M.  Gensoul,  some 
with  complete,  others  with  partial  success,  and  many  without  any  advantage 


516 


NEW  ELEMENTS  OF 


at  all.  In  order  to  give  his  mandrin  and  canula  a  suitable  form,  he  obtains 
an  exact  cast  hj  means  of  the  fusible  alloy  of  Darcet.  Some  instrument* 
made  in  this  waj  were  shown  me,  in  1826,  by  M.  Blanc,  and  I  was  truly 
astonished  at  the  facility  with  which  they  could  be  passed  into  the  lachrymal 
conduits. 

Remarks.' — In  proposing  to  cauterize  the  nasal  canal,  the  surgeons  I  have 
named  have  pretended  to  nothing  more  than  to  apply  Ducamp's  method  to  the 
lachrymal  passages'.  If  cauterization  be  proper  for  the  obstructions  of 
the  urethra,  it  must  be  equally  applicable  to  those  of  the  nasal  canal,  it  is  true; 
but  it  appears  to  me,  that  in  neither  has  the  action  of  the  remedy,  nor  the 
affection  which  we  seek  to  destroy,  been  accurately  known.  As  in  those  of  the 
urethra,  the  contractions  of  the  nasal  canal  are  produced,  and  commonly  con- 
tinued, by  a  more  or  less  extensive,  more  or  less  exactly  circumscribed,  chronic 
phlegmasia.  The  spasmodic  stricture  spoken  of  by  Janise,  and  to  which  Rich- 
ter  attributes  so  much,  is  never  the  cause  of  fistula  lachrymalis.  The  affec- 
tion of  the  lids,  called  in  by  Scarpa,  only  becomes  a  cause  by  spreading  itself 
to  the  lachrymal  sac  and  as  far  as  the  nose,  where,  by  the  engorgement  and 
swelling  it  induces  in  the  mucous  membrane,  it  creates  an  obstruction  of  the 
course  of  the  tears.  In  other  words,  the  fistula  and  lachrymal  tumor  depend 
upon  an  induration,  thickening,  or  simple  chronic  phlegmasia  of  some  point 
in  the  lachrymal  passage.  Now,  in  applying  the  nitrate  of  silver  to  an  organ 
thus  altered,  we  do  not  cure  it  by  producing  merely  an  eschar  or  a  burn,  but 
by  dissipating  the  inflammation,  by  neutralizing  or  destroying  the  stimulus, 
and  producing  thereby  a  resolution  of  the  morbid  engorgement. 

It  follows  from  this,  that  the  nitrate  of  silver  is  the  only  caustic  that  can  be 
reasonably  employed,  and  thp.t  those  casts  or  impressions  of  the  canal  with 
which  physicians  have  been  so  much  occupied,  are  nearly  useless.  The  prin- 
cipal object  is  to  make  the  caustic  reach  the  superior  part  of  the  canal,  if  it 
be  introduced  from  below,  and  the  bottom,  if  introduced  at  the  other  extremity, 
so  as  to  act  upon  nearly  the  whole  extent  of  the  passage.  Whatever  precau- 
tions the  surgeon  may  take  to  prevent  this  general  action,  will  not  avail.  As 
soon  as  the  nitrate  comes  in  contact  with  the  living  and  moist  membrane,  it 
melts  and  spreads  itself  in  such  a  manner,  that  it  is  enough  to  touch  one  point 
of  the  canal  to  make  the  whole  feel  its  effect.  And  much  the  same  may  be 
said  of  dilatation.  When  a  tent  or  bougie,  or  the  like  is  placed  temporarily 
or  permanently  in  the  nasal  canal,  it  appears  to  me  that  it  can  only  be  useful 
in  one  of  two  ways:  by  serving  as  a  vehicle  for  medicinal  agents  proper  to 
dissipate  the  disease,  or  else  by  the  compression  of  the  affected  canal,  which 
is  cured  in  the  latter  case,  not  by  mere  dilatation,  but  by  a  true  resolutive 
pressure,  the  same  as  that  which  cures  oedema,  some  kinds  of  dartre  erysi- 
pelas, &c, 

5.  Formation  of  a  New  Canal, 

We  see  in  Aetius  and  Paulus  iEgineta,  that  Archigenes  pierced  the  os 
unguis  with  a  drill,  to  give  the  tears  a  passage  into  the  nose.  Rhazes  and 
Avicenna  cite  Sabor-Ebn-Saiel,  as  an  eulogist  of  this  method,  but  which  is 
condemned  by  Mesne  and  Guy  de  Chauliac.  Every  thing  favors  the  belief 
that  Celsus,  Abul-Kasem,and  Roger,  of  Parma,  accomplished  the  same  pur- 


OPERATIVE  SURGERY.  SI? 

pose  bj  the  applicatiou  of  the  actual  cautery  to  the  os  unguis.  But  at  least 
G.de  Salicet  advises  us,  when  the  bone  is  diseased,  always  to  cauterize  it  suf- 
ficiently to  allow  tlie  tears  to  pass  into  the  nose ;  which  was  also  the  method  of 
J.  de  Vigo.  This  operation  was  almost  entirely  forgotten  for  several  centu- 
ries, and  owes  its  reintroduction  into  practice  to  Woolhouse.  It  was  almost 
the  only  manner  of  treating  fistula  up  to  the  time  of  Petit  and  Mejean. 

1.  Process  of  Woolhouse. — The  operator  makes  a  semilunar  incision  at  tho 
greater  angle  of  the  eye,  which  comprehends  the  tendon  of  the  orbicularis 
palpebrarum ;  opens  freely  tlie  lachrymal  sac ;  denudes  the  os  unguis,  and 
then  fills  the  wound  immediately  with  lint ;  postponing  the  remainder  of  the 
operation  for  twenty-four  hours,  or  even  two  or  three  days,  in  order  to  be  free 
from  the  embarrassment  produced  by  the  blood.  Then  apointed  wire  is  thrust 
downwards,  inwards,  and  a  little  backwards,  through  the  inferior  part,  or  the 
larchrymal  groove  of  the  os  unguis,  into  the  nasal  fossa.  A  tent,  or  a  small 
conical  canula  is  afterwards  introduced  into  the  opening,  to  prevent  its  closing. 
Then,  when  the  edges  have  cicatrized  and  become  callous,  a  canula  of  gold, 
slightly  contracted  in  the  middle  to  prevent  removal,  is  introduced  and  per- 
manently retained. 

2.  Process  of  Saint  Yves. — Saint  Yves,  who  had  noticed,  as  all  other  opera- 
tors had,  that  Woolhouse's  method  was  almost  always  followed  by  inflamma- 
tion, or  by  an  eversion  of  the  eyelids,  perceived  that  this  inconvenience  could 
be  avoided  by  avoiding  the  tendon  of  the  orbicularis  muscle  in  the  incision 
at  the  angle  of  the  eye.  He  also  prefeiTed  perforating  the  os  unguis  with  the 
actual  cautery,  so  as  to  occasion  an  actual  loss  of  substance. 

3.  Dionis^  Process. — Lacharriere,  Diorys,  and  Wiseman,  also  recommend 
the  cautery,  which  they  passed  through  the  lachrymal  sac,  protected  by  a 
funnel-shaped  canula. 

4.  Process  of  Monro. — Schobinger,  Monro,  and  Boudou,  used  a  trocar  to 
perforate  the  bone,  fearing  less  than  Woolhouse  to  wound  the  ethmoides. 
Ravaton  thought  to  accomplish  the  same  purpose  by  means  of  a  quill,  a  curved 
forceps,  with  which  he  l)roke  away  the  os  unguis  to  a  considerable  extent,  and 
a  leaden  canula;  but  none  of  these  methods  will  be  followed  by  a  perfect 
cure.  Although  the  artificial  opening  may  be  maintained  by  a  tent  or  canula 
for  some  time,  it  almost  always  closes  up  at  last ;  and  it  is  rare  that  the 
canula  of  Woolhouse  can  be  retained  long  enough  to  render  the  new  passage 
permanent. 

5.  Htmter^s  Method. — Hunter  thought  he  should  succeed  better  by  taking 
away  at  the  same  time  a  disc  of  the  os  unguis  and  of  the  two  membranes  that 
covered  it,  so  as  to  form  a  circular  opening  two  lines  in  diameter,  attended 
with  a  complete  loss  of  substance.  To  accomplish  this,  he  invented  two 
instruments ;  one,  a  kind  of  canula  with  a  cutting  extremity,  like  a  harness- 

^  maker-s  punch ;  die  other,  a  flat  piece  of  horn  or  ebony,  curved  so  as  to  be 
passed  into  the  nasal  fossa  to  serve  as  a  support  on  which  the  punch  was  to 
act.  With  these  a  very  neat  opening  could  be  made  in  the  greater  angle  of 
the  eye,  which  it  would  be  enough  to  dress  with  a  plug  of  lint  to  cause  it  to 
cicatrize  and  become  rounded  and  callous.  As  it  is  almost  impossible  to  apply 
the  nasal  plate,  and  as  the  perforation  witli  the  actual  cautery  is  also  accom- 
panied with  loss  of  substance,  without  being. followed  with  success,  n6  per- 


318  NEW    ELEMENTS    OF 

son  has  yet  attempted  the  operation  of  Hunter  upon  the  living  subject,  and 
he  appears  never  to  have  tried  it  himself,  except  upon  the  dead  subject.  But 
if  any  one  should  wish  to  try  it  again,  he  can  very  easily  do  it  with  the  punch- 
ing compasses  of  M.  Talrich,  or  those  of  Sir  Henry.  The  pierced  branch, 
introduced  into  the  nose,  serves  as  a  point  of  support  to  the  perforating  branch, 
which  is  applied  to  the  greater  angle  directly  through  tlie  wound  in  the  canal. 
Then,  by  pressing  them  together,  a  portion  is  removed  without  any  risk  of 
injury. 

6.  Scarpa's  Process, — Scarpa  and  M.  Bouchet  have  lately  returned  to  the 
use  of  the  actual  cautery,  according  to  the  views  of  Saint  Yves.  That  is, 
after  opening  the  greater  angle,  as  in  the  operation  for  simple  fistula,  without 
touching  the  tendon,  they  fill  the  wounds  with  charpie,  and  leave  it  so  for 
twenty -four  hours  or  more.  Then,  with  a  metallic  wire  heated  to  whiteness, 
they  penetrate  from  the  inferior  and  internal  part  of  the  lachrymal  sac  into 
the  nose.  To  secure  the  eye  and  neighboring  soft  parts  from  the  action  of  the 
cautery,  Scarpa  used  not  the  simple  funnel  of  Verduc  or  Dionis,  but  a  conical 
canula,  with  the  sides  very  thick,  and  furnished  with  a  handle  several  inches 
long,  connected  with  the  base  at  a  right  angle,  invented  by  Manoury  and  used 
by  Desault,  and  of  which  the  first  ideas  are  found  in  Roger,  of  Parma. 
Rivard  and  A.  Petit  open  the  sac  behind  the  lid,  like  Pouteau,  whether  de- 
siring to  penetrate  into  the  nose  or  to  stop  at  the  canal.     • 

7.  Process  of  M.  Nicod. — More  recently,  M.  Nicod  has  proposed  to  com- 
bine perforation  with  the  trocar  and  the  actual  cautery. 

8.  Process  of  M.  Pecot. — Supposing  that  he  had  observed  that  M.  Briot,  by 
mistake,  once  introduced  the  canula  through  the  os  unguis,  and  once  in  the 
antrum  highmorianum,  without  any  bad  consequences,  M.  Pecot,  of  Besancon, 
thought  it  would  be  well  to  fix  the  canula  in  the  maxillary  sinus  through  the 
external  and  posterior  wall  of  the  canal,  instead  of  searching  with  painful 
obstinacy  for  the  canal  itself.  This  is  better  than  nothing,  doubtless,  if  nothing 
else  could  be  done ;  but  I  doubt,  notwithstanding  the  reasons  recently  adduced 
in  its  favor  by  M.  Laugier,  whether  such  a  method  will  ever  obtain  many 
advocates.  There  is  no  proof  that  when  the  tears  have  reached  the  sirfus 
they  can  escape  easily  from  thence,  and  that  they  may  not  produce  serious 
symptoms  there.    The  perforation  of  the  os  unguis  lias  fewer  inconveniences. 

Remarks. — Woolhouse's  method,  rejected  by  Marchetti,  Solingen,  Maitre- 
Jean,  and  especially  by  Nannoni,  will  be  but  rarely  adopted  at  the  present 
time.  Wherever  it  is  possible  to  operate  upon  the  natural  passage,  it  would 
be  wrong  to  attempt  the  formation  of  a  new  one.  Where  it  is  not,  it  is  more 
rational  to  imitate  M.  Dupuytren  in  making  a  new  passage  in  the  direction  of 
the  natural  one,  than  to  perforate  the  os  unguis  or  the  sinus,  like  Saint  Yves 
or  M.  Pecot.  When  there  is  necrosis,  the  fistula  sliould  be  treated  by  one  of 
the  other  methods ;  for  the  disease  of  the  bone  requires  no  other  care  than  if 
it  had  had  its  seat  in  any  other  part  of  the  body.  The  employment  of  the 
actual  cautery,  or  of  chemical  escharotics,  is  always  dangerous  so  near  the  eye. 
They  have  more  than  once  produced  obliteration  of  the  lachrymal  conduits, 
and  consequently  incurable  epiphora.  The  value  of  Woolhouse's  method  is 
still  further  lessened,  by  the  fact  that  the  tears  rarely  acquire  the  habit  of 
falling  into  the  nose  even  when  the  route  which  has  been  opened  for  them 


OPERATIVE    SURGERY.  319 

continues  open ;  so  that,  besides  the  deformity  at  the  gi'eater  angle  of  the  eye, 
the  patient  remains  affected  with  a  weeping  most  frequently  beyond  the  reach 
of  art. 

Whatever  method  may  be  preferred,  there  is  one  step  nearly  the  same  in  all ; 
I  mean  the  opening  of  the  sac  and  the  exploration  of  the  canal. 

In  order  to  have  every  possible  assurance  of  reaching  the  canal,  the  ope- 
rator is  to  be  aided  by  an  assistant,  who  draws  the  eyelids  towards  the  temple ; 
with  the  index  linger  corresponding  to  the  diseased  side  he  seeks  in  the 
greater  angle  for  the  anterior  lip  of  tlie  lachrymal  trough,  and  disperses  by 
gentle  pressure  any  gummy  matters  that  may  lie  there.  Then,  seizing  a 
sti'aight,  firm,  and  narrow  bistoury  with  the  other  hand,  he  passes  the  point 
of  it  behind  the  nail  of  the  directing  finger,  and  sinks  it  obliquely  inwards, 
backwards,  and  downwards,  into  the  sac.  Then,  raising  the  handle  of  the 
instrument  towards  the  eyebrows  in  order  to  descend  perpendicularly  into 
the  nasal  canal,  he  calls  for  a  drill  armed  with  a  canula,  if  he  intends  to 
follow  Foubert's  method,  or  a  grooved  sound  or  stylet,  if  he  wiahes  to  imitate 
Petit  or  Desault,  and  carries  its  extremity  upon  the  back  or  the  anterior  face 
of  the  bistoury  in  such  a  manner  that,  while  the  latter  is  being  withdrawn,  it 
serves  as  a  director  for  the  former.  When  the  opening  of  the  fistula  is  suf- 
ficiently large  to  permit  the  passage  of  the  canula  or  the  sound,  the  bistoury 
may  be  dispensed  with.  In  other  cases  the  ulcer  may  be  left  above,  below,  or 
at  the  side  of  the  incision,  acting,  in  fact,  as  if  it  did  not  exist ;  if  it  be  sur- 
rounded with  troublesome  fungi,  they  are  first  removed. 

When  he  does  not  follow  the  process  of  M.  Bermond  for  cauterizing  the 
canal  upwards,  the  operator,  holding  the  catheter  or  probe  as  a  pen,  introduces 
it,  with  the  concavity  turned  downwards  and  outwards,  to  the  depth  of  about 
an  inch;  then,  raising  the  outer  end  a  little,  that  the  other  may  become 
engaged  under  the  inferior  spongy  bone  and  glide  upon  the  nasal  wall,  with  • 
draws  it  gently  to  within  six  or  eight  lines  of  the  opening  of  the  nose ;  turns  its 
concavity  by  degrees  outwards  and  upwards ;  then,  by  a  cautious  swaying 
movement,  endeavors  to  introduce  the  beak  of  the  instrument  into  the  orifice  of 
the  nasal  canal,  whence  the  instrument  may  be  passed  without  difficulty  to  the 
angle  of  the  eye,  or  into  the  lachrymal  sac.  Force  here  is  never  necessary. 
Resistance  can  only  arise  from  a  bad  direction  of  the  instrument,  or  some 
anatomical  variation.  By  inclining  the  sound  too  much  upwards  or  down- 
wards, inwards  or  outwards,  its  summit  may  be  carried  against  the  opposite 
wall,  or  the  circumference  of  the  inferior  orifice  of  the  canal.  The  curva- 
ture of  the  sounds  of  Laforest  is  bad,  making  the  operation  difficult  and 
hazardous.  These  instruments  should  not  form  the  arc  of  a  circle,  but  be 
bent  at  almost  a  right  angle,  and  be  very  blunt.  With  this  form,  the  passage 
of  the  canal  is  really  very  simple,  and  I  think,  with  Versigne  and  Gensoul, 
that  modern  operators  are  wrong  so  entirely  to  neglect  it. 

The  lachrymal  conduits  and  puncta  may  be  obliterated  by  a  variety  of  dis- 
eases, such  as  erysipelas,  small  pox,  &c.,  producing  a  continual  weeping,  as 
stated  by  Anel,  J.  L.  Petit,  &c.  Yet  Gunz  says  that  he  saw  a  case  of  tliis 
kind,  where  the  tears  had  found  a  passage  into  the  canal  by  means  of  poro- 
sities visible  to  the  naked  eye. 

Mejean's  stylet,  passed  from  the  sac  towards  the  lids  when  the  obstacle  is 
near  the  orifice,  or  towards  the  nose  when  it  has  its  seat  lower  down,  will,  in 


S20  NEW  ELEMENTS  OF 

some  cases  re-establish  the  passage  for  the  {cars ;  otherwise  the  di^^^ease  is 
almost  incurable.  Jt  will  be  useless  to  attempt  the  formation  of  a  new  duct 
*  with  a  needle,  drawing  after  it  a  thread  or  seton.  The  tears  will  not  pass  by 
it.  It  cannot  be  kept  open,  nor  made  to  suck  or  absorb  the  lachrymal  secre- 
tion like  the  natural  one.  Nor  is  there  better  reason  to  believe  that  epiphora 
would  be  prevented,  by  making,  like  A.  Petit,  an  opening  into  the  sac 
beliind  the  internal  angle  of  the  eyelids,  because  the  artificial  orifice  never 
acquires  the  organization  of  the  punctum  lachrymale.  Nevertheless,  it  is 
almost  the  only  resource  left  us  in  such  a  case. 

If  an  ulcer,  or  other  lesion,  perforate  the  lachrymal  conduit  towards  the 
eye,  there  results  a  fistula  of  a  peculiar  kind  very  difficult  of  cure.  A  thread 
of  gold  or  silk,  or  better,  of  small  cat -gut,  passed  like  a  seton  through  the 
v/ounded  conduit  from  the  punctum  to  the  sac,  is  the  only  remedy  we  have 
for  such  an  infirmity,  unless  we  lay  open  the  canal  from  the  inside  of  the  lid. 

Instead  of  opening  at  the  greater  angle  of  the  eye,  the  lachrymal  tumor 
sometimes  makes  its  way  into  the  nose  through  the  os  unguis,  of  which  Heister 
gives  an  example.  In  internal  fistulas,  it  is  not  the  re-establishment  of 
the  natural  course  for  the  tears  that  requires  our  assistance,  but  the  cure  of 
the  ulcer.  If  there  be  a  tumor,  even  if  the  conduits  or  puncta  are  closed, 
we  have  no  other  treatment  to  apply  than  that  which  is  necessary  for  an  abscess, 
or  for  chronic  inflammation.  First,  compression,  resolvents,  or  astringents; 
then  an  opening  of  the  cyst  with  the  bistoury,  and  the  subsequent  employment 
of  a  tent  or  detersive  injections,  are  all  that  is  necessary,  unless  we  place  a 
permanent  canula  in  the  canal. 

However  much  the  sac  may  be  distended,  it  is  rare  that  we  shall  have  oc- 
casion to  follow  Mr.  Boyer's  precept,  to  excise  a  portion  with  the  scissors,  or 
that  of  M.  Guerin,  to  resort  to  compression.  Cauterization  with  the  nitrate 
of  silver,  as  recommended  by  Scarpa,  is  evidently  preferable. 


Jirt,  9,.— The  Eyelids, 
§  1.  Ectropion. 

Eversion  of  the  lids  may  be  produced  by  two  causes:  swelling  of  the  con- 
junctiva and  contraction  of  the  skin.  The  latter,  properly  called  ectropion,  is 
the  most  serious.  The  former,  which  is  more  easy  to  cure,  and  more  rarely 
seen,  shows  itself  in  an  acute  or  a  chronic  form.  It  forms  what  is  called  lag- 
ophthalmia.  When  recent,  cauterization  with  a  proner  instrum.ent,  as  directed 
by  G.  de  Salicet,  ordinarily  produces  a  cure.  M.  J.  Cloquet  cured  it  in  this 
way,  when  of  more  than  a  year's  standing.  Saint  Yves  and  Scarpa  praised 
the  nitrate  of  silver  in  such  cases ;  and  a  great  many  dry  collyria  have  been 
u§ed  with  like  success.  Calomel  and  sugar,  tutty,  white  oxide  of  bismuth, 
finely  pulverized,  with  an  equal  part  of  sugar-candy,  have  obtained  me  sur- 
prising and  prompt  success,  applied  by  pinches  night  and  morning  upon  the 
engorged  part. 

When  these  have  been  tried  in  vain,  we  may  imitate  Acrel,  in  passing  a 
thread-through  the  lid  near  its  ciliary  border,  with  which  to  draw  the  lid  into 
its  natural  position ;  or  instead  of  the  thread,  we  may  use  strips  of  adhc- 


OrPERATIVE  SURGERY.  321 

sive  plaster,  as  recommended  by  J.  Frabricius  and  Solingen,  the  free  ex- 
trepiitj  of  which  is  to  be  fixed  upon  the  forehead  fcrr  the  lower  lid,  and  on 
the  cheek  for  the  upper.  But  it  is  much  more  simple,  sure,  and  prompt  to 
excise  the  fungous  conjunctiva  at  once.  It  is  the  method  adopted  by  all  the 
moderns,  and  prescribed  bjAntylus,  and  even  recommended  by  Hippocrates, 
although  confusedly,  where  scarification  has  been  unsuccessful.  While 
the  lid  is  held  everted  by  an  assistant,  the  surgeon  seizes  with  a  dissecting 
forceps,  held  in  the  left  hand,  a  portion  of  the  membrane  large  enough  to 
bring  the  cilia  to  their  proper  situation,  but  not  so  large  as  to  invert  them. 
He  then  cuts  this  fold  from  the  greater  angle  towards  the  smaller  for  the  right, 
and  the  contrary  for  the  left  eye:  endeavoring  not  to  comprehend  in  the 
incision  any  thing  more  than  the  conjunctiva,  and  to  keep  nearer  to  the  globe  of 
the  eye  than  to  the  edge  of  the  palpebra.  For  the  operation  straight  or  curved 
scissors  should  be  used.  A  sharp  bistoury  or  a  good  lancet  would  serve,  but 
scissors  are  best.  The  blood,  which  flows  abundantly  at  first,  soon  stops  of 
itself,  and  the  operation,  properly  speaking,  is  done.  The  treatment  of  the 
rest  is  the  same  as  that  for  an  ordinary  or  traumatic  ophthalmia.  The  cica- 
trization of  the  wound  brings  back  the  tarsus  into  its  natural  position.  Paulus 
Egineta  used  a  thread  passed  transversely  from  one  angle  of  the  eye  to  the 
other,  to  elevate  the  conjunctiva  for  the  incision.  The  scars  left  upon  the 
skin  of  the  face  by  burns,  small-pox,  wounds,  or  ulcers,  often  produce  an 
ectropion  much  more  difficult  to  cure.  Desiccatives  and  caustics  applied 
upon  the  palpebral  conjunctiva  aiFord  no  relief.  It  would  be  in  vain  to 
replace  the  lids  w^ith  a  thread  or  adhesive  strips.  The  actual  cautery,  or  the 
excision  of  the  relaxed  membrane,  is  commonly  useless.  Many  operators, 
even  among  the  moderns,  agree  in  considering  the  disease  incurable.  Until 
the  time  of  Boerhaave  and  Louis,  there  were  a  variety  of  ways  for  lengthening 
the  external  face  of  the  lid  thus  everted.  Since,  with  Demosthenes  of  Mar- 
seilles, Celsus,  and  Pare,  made  a  semilunar  incision  of  the  skin,  having  its 
horns  turned  towards  the  opening  of  the  eye;  others  contented  themselves  with 
a  transverse  incision,  the  lips  of  which  they  endeavored  to  keep  apart  with 
charpie  or  some  other  foreign  substance ;  others  again,  as  Paul  of  Egina,  and 
Olof  Acrel,  carefully  destroyed  all  the  cicatrices  of  the  skin,  either  by 
incision,  excision,  or  strangulation,  by  means  of  a  ligature.  But  it  is  well 
known,  that  so  far  from  being  advantageous  these  various  methods  are  almost 
always  injurious,  and  in  spite  of  every  precaution,  the  resulting  sore  contracts 
the  teguments  of  the  lid  instead  of  favoring  their  elongation. 

1.  Process  of  Antylus. — In  1813,  an  English  oculist,  Mr.  Adams,  proposed  a 
method  of  operating  for  these  difficult  cases,  of  which  he  thought  he  was  the 
originator,  but  which  Mr.  Martin  attributes  to  Dr.  Physick,  of  Philadelphia,  or 
to  M.  Bouchet,  of  Lyons,  and  which  is  found  long  ago  described  by  Aetius, 
who  refers  it  to  Antylus.  A  triangular  piece  of  the  affected  lid,  of  the  form  of 
a  V,  is  to  be  removed,  the  base  corresponding  to  the  cilia  ;  the  sides  of  the 
opening  left  are  then  united  by  means  of  a  suture.  Mr.  Adams's  method  has  been 
followed  in  France,  by  Beclard,  and  more  especially  by  Roux.  I  have  seen 
it  used,  and  used  it  myself  several  times  with  success.  Antylus,  who  made 
his  incisions  from  the  adherent  towards  the  free  edge  of  the  lid,  took  care  to 
divide  nothing  but  the  conjunctiva,  the  tarsus,  and  the  orbicularis  muscle;  in 
a  word,  leaving  the  skin  untouched.  Mr.  Adams  and  M.  Roux  first  seize 
41 


322  NEW   ELEMENTS    OF 

the  lid  with  a  ligature  forceps,  and  then  cut  on  each  side  of  it  through  the 
whole  thickness ;  thus  forming  the  triangle  bj  cutting  from  its  base  to  its 
Jipex.  The  blood,  though  flowing  abundantly  at  first,  because  the  ciliary  or 
palpebral  artery  is  necessarily  divided,  soon  stops.  Mr.  Adams  is  contented 
with  a  simple  stitch  near  the  cilia  to  secure  reunion.  Mr.  Roux  treats  it 
exactly  like  the  hare-lip;  that  is,  he  applies  the  twisted  suture  with  two  short 
strong  pins.  Instead  of  a  bistoury,  I  tliink  it  would  be  better  to  use  a  pair  of 
good  scissors,  as  I  have  twice  done.  With  them  the  operation  is  more  prompt 
and  sure,  and  the  section  of  the  tissues  more  neat  and  easy.  I  see  no  neces- 
sity for  making  the  base  of  the  flap  more  tlian  two  or  three  lines  long,  and 
prolonging  it  beyond  the  cartilage. 

2.  Process  of  M.  Walther. — In  a  case  in  which  the  ectropion  occupied  only 
the  temporal  half  of  the  eye,  Walther,  after  having  plucked  out  the  eye-lashes, 
seized  the  external  extremity  of  the  inferior  lid  with  a  pair  of  forceps,  and 
then  incised  it  through  its  whole  thickness  to  the  temple ;  he  did  the  same  with 
the  superior  lid,  and  removed  the  flap  contained  within  these  limits.  The 
lips  of  the  wound  being  drawn  together,  were  kept  in  place  by  two  stitches, 
and  the  patient  perfectly  cured.  Tliis  method  is  evidently  none  other  than 
that  of  Antylus  and  Mr.  Adams,  applied  to  the  smaller  angle  of  the  eye,  and 
would  be  applicable  only  in  such  cases  as  the  one  that  came  under  the  care  of 
M.  Walther. 

3.  Process  of  Dr.  Key. — In  1826,  Doctor  Key  had  to  treat  a  case  of  ectro- 
pion, which  Messrs.  Travers,  Tyrrel,  and  Green  had  in  vain  attempted  to  cure 
by  the  usual  method.  Imagining  that  the  eversion  of  the  lid  in  this  case 
might  depend  upon  the  spasmodic  contraction  of  the  orbicularis  muscle.  Dr. 
Key  made  a  transverse  incision  through  the  skin,  dissected  carefully  to  the 
convex  edge  of  the  tarsal  cartilage,  directed  an  assistant  to  separate  the  lips 
of  the  incision,  and  then  with  a  forceps  seized  a  fasiculus  of  muscular  fibres, 
whicli  he  divided  with  a  pair  of  fine  scissors.  The  operation  was  completely 
successful.  I  do  not  know  whether  operators  can  fully  adopt  Dr.  Key's  views, 
nor  if  I  have  given  them  exactly ;  but  this  is  certain,  we  cannot  comprehend 
the  existence  of  these  pretended  spasmodic  contractions,  nor  how  the  excision 
of  a  part  of  the  orbicularis  muscle  can  remedy  ectropion.  Yet,  in  surgery 
at  least,  when  a  fact  is  advanced,  whether  it  be  comprehended  or  not,  pru- 
dence requires  us  to  admit  it.  I  have  therefore  felt  myself  bound  not  to  pass 
over  in  silence  the  operation  of  the  English  surgeon. 

4.  Blepharoplastic  Operation^ — This  is  anoperation  very  recently  proposed, 
and  which  two  operators  have  already  tried.  Founded  upon  the  principles  of 
the  Indian  rhinoplastic  operation,  tliis  method  consists  in  excising  tlie  cicatrices 
which  cause  the  ectropion,  and  in  the  formation  of  a  flap  taken  from  the  cheek 
for  the  lower  lid,  and  from  the  forehead  for  the  upper ;  fixing  it  in  the  place  of 
the  excised  tissues  by  means  of  a  suture,  and  taking  care  to  divide  its  root 
about  the  fifth  or  eighth  day.  By  this  means  M.  Frick  was  completely  suc- 
cessful on  a  subject  sixty-three  years  old  ;  but  M.  Juncken  failed  completely 
in  the  two  attempts  which  he  made. 

If  the  ectropion  be  caused  by  a  tumor  of  any  kind  in  the  interior  of  the 
orbit  or  in  the  lid,  it  is  scarcely  necessary  to  say  that  the  surgeon  should 
occupy  himself  with  the  tumor,  and  not  with  the  everted  lid. 


OPERATIVE  SURGERY.  323 

§  2.  Trichiasis,  Entropion^  and  Blepharoptosis. 

When  the  superior  eyelid  becomes  so  far  permanently  depressed  as  to  close 
the  eye  completely,  and  the  cilia  are  not  inverted  ;  whether  it  depends  upon 
a  relaxation  of  the  elevator  muscle  or  any  other  cause ;  if  it  be  of  long  standing, 
and  has  resisted  the  use  of  antiphlogistics,  stimulants,  and  other  therapeutic 
agents,  either  local  or  general,  we  are  then  called  upon  to  oppose  surgical 
means  to  this  blepharoptosis. 

1.  Excision. — The  operation,  which  is  nearly  the  same  as  for  ectropion  and 
trichiasis,  has  been  considerably  varied.  Hippocrates  passed  two  loops  of 
thread  through  the  skin,  so  that  one  end  came  out  near  the  free  edge  the  other 
near  the  base  of  the  lid,  and  tied  these  extremities  together  so  as  to  evert  the 
cilia ;  but  the  method  by  incision  of  a  transverse  cutaneous  flap,  has  attracted 
more  particular  attention.  This  incision  has  been  carefully  described  by 
Celsus  and  G.  de  Salicet,  and  is  variously  performed.  Acrel,  who  proposed 
it  in  his  turn,  recommended  the  removal  of  a  lozenge-formed  flap.  As  this 
did  not  appear  to  him  always  successful,  he  had  the  boldness  to  incise  the 
integuments  above  the  brows,  thus  removing  a  considerable  segment.  Celsus 
and  Galen  traced  the  limits  of  the  portion  they  wished  to  remove  with  ink, 
and  brought  them  together  by  a  single  stitch.  Aetius  recommends  the  upper 
incision  to  be  semilunar,  and  the  lower  straight.  Instead  of  one  stitch,  he 
employed  five.  Paul  of  Egina  commenced  by  a  transverse  incision  of  ikt 
internal  face  of  the  lid,  extending  from  one  angle  of  the  eye  to  the  other. 
Rhazes  used  caustics,  Abul-Kasem  used  a  hot  iron  or  quick-lime,  and 
gave  his  wound  the  form  of  a  myrtle  leaf.  Costeus  and  Scachi  extolled 
the  actual  cautery.  Recently  M.  Heling  and  M.  Quadri  have  spoken  highly 
of  sulphuric  acid.  The  Neapolitan  professor  begins  by  moderately  separating 
the  lids,  which  he  washes,  wipes,  and  dries  carefully  with  fine  linen  or  a 
sponge.  Then,  with  the  aid  of  a  small  piece  of  polished  wood,  he  places  the 
acid  upon  that  part  of  the  skin  that  corresponds  to  the  lowest  portion  of  the 
tarsal  cartilage,  spreading  it  from  four  to  six  lines  transversely ;  waiting  some 
seconds  for  the  first  application  of  the  acid  to  combine  with  the  tissues,  he 
reapplies  it  a  second,  third,  and  even  fourth  time,  or  until  the  lid  is  slightly 
shrunk  outwardly ;  taking  proper  precaution  in  the  mean  time  that  the  caustic 
may  not  penetrate  into  the  eye. 

ITie  excision  of  the  skin  and  cauterization  with  sulphuric  acid,  produce 
evidently  the  same  ultimate  results.  By  both  methods  there  is  a  loss  of  sub- 
stance. It  is  necessary  that  the  lips  of  the  wound  s.hould  approximate,  to 
produce  cicatrization ;  and  by  this  means  a  contraction  or  shrinking  of  the 
lid,  and  principally  of  its  external  face,  is  obtained.  After  making  the  inci- 
sion, to  which  an  extent  may  be  given  suited  to  the  degree  of  retraction 
desired,  should  we,  like  those  who  first  employed  it,  as  well  as  Beer  and 
Langenbeck,  have  recourse  to  the  simple  or  quilled  suture ;  or,  like  Scarpa, 
content  ourselves  with  plain  dressings,  and  wait  for  a  reunion  by  the  second 
intention.  This  appears  to  me  a  matter  rather  of  choice  than  of  neces- 
sity. 

2.  Extraction  and  Cauterization  of  the  Cilia. — One  of  the  most  ancient 
methods  of  curing  trichiasis,  and  especially  destichiasis,  is  the  extraction  of 
the  erratic  haira.     Popius,  according  to  Galen,  was  its  inventor.    Nothing 


324  NEW  ELEMENTS   OF 

can  appear  more  natural,  as  a  remedy  for  the  pain  and  inflammation  which  the 
eje  suffers  in  this  disease,  than  a  removal  of  the  cause.  Unhappily,  we  are 
soon  taught  that  this  remedy  is  only  palliative,  curing  it  only  for  a  while ; 
and  that  the  renewed  cilia  almost  constantly  take  the  former  vicious  direc- 
tion. Still  it  is  almost  the  only  plan  adopted  by  Vauguyon,  Maitre-Jean,  De 
la  Motte,  and  even  Richter,  when  the  tarsus  itself  is  not  diseased.  To  guard 
against  the  recurrence  of  the  malady,  some  operators  apply  caustic  to  the 
roots  of  the  hairs  after  extracting  them.  Sulphuric  acid,  butter  of  antimony, 
and  nitrate  of  silver,  have  been  in  turn  extolled.  Seeing  that  none  of  these 
will  suffice,  some  have  used  the  actual  cautery,  according  to  the  advice 
of  Rhazes.  M.  de  Champesme,  in  our  own  times,  has  found  nutliing  better  for 
trichiasis  than  an  improvement  of  the  cauterization  used  by  many  of  the 
ancients.  The  form  of  the  ancient  cauterizin<>;  instrument  did  not  allow  the 
heat  to  be  carried  sufficiently  deep.  Hisis  terminated  by  a  point  some  lines 
long,  supported  by  a  large  ball,  and  resembles  somewhat  the  cautery  called 
the  sparrow's  head.  Heated  to  whiteness,  the  point,  although  small,  long 
retains  heat  enough  to  form  escars  promptly  wherever  applied.  M.  de  Cham- 
pesme affirms,  that  he  has  many  times  cured  trichiasis  radically  with  his 
instrument,  and  no  one  can  deny  its  advantages  when  cautery  is  decided 
upon. 

3.  Eversion  of  the  Cilia. — A  means  less  cruel,  and  one  v.l.Ich  appears  to 
have  been  attended  with  some  success,  consists  in  everting  or  turning  out 
the  strayed  eye-lashes  upon  the  skin  of  the  lid.  Heraclide,  who  passes  for 
its  inventor,  maintained  them  in  that  position,  like  Acton,  by  means  of  plasters, 
I  used  this  method  in  a  case  which  resisted  the  excision  of  the  integuments. 
Celsus  and  Galen  say,  that  in  their  time  some  persons  operated  by  passing  a 
woman's  hair,  doubled,  through  the  skin  with  a  needle,  in  such  a  way  as  to 
secure  the  erratic  lashes  in  the  curl  of  the  hair.  According  to  Rhazes,  we 
may  succeed  as  well  by  crisping  them  with  a  hot  iron. 

Remarks, — The  excision  of  the  skin,  so  strongly  recommended  by  Borde- 
nave,  Louis,  Scarpa,  and  almost  all  of  the  moderns,  is  an  operation  too  simple 
and  too  frequently  successful,  not  to  be  a  first  resort.  The  surgeon,  placing 
himself  in  front  of  the  patient,  seizes,  with  an  ordinary  forceps,  the  fingers, 
or  Beer's  forceps,  a  fold  of  the  integuments  sufficiently  large  to  return  the 
cilia  to  their  proper  place  outwards  and  upwards.  If  the  Ibid  be  too  large, 
he  exposes  himself  to  produce  ectropion ;  if  too  small,  to  an  incomplete  cure 
of  the  trichiasis.  It  is  to  be  excised  in  the  same  manner,  and  with  the  same 
precautions,  as  the  fold  of  the  conjunctiva  in  lagophthalmia  or  simple  ectro- 
pion. After  the  operation,  Scarpa  recommends  that  the  skin  of  the  face  for 
the  lower  lid,  and  of  the  brows  and  forehead  for  the  upper,  should  be  forced 
towards  the  orbit,  and  kept  tliere  by  graduated  compresses  or  adhesive  strips 
extending  from  the  cheek  high  upon  the  forehead.  The  next  day,  he  says, 
the  patient  can  open  his  eye ;  and  if  any  granulation  or  fungous  growths  show 
themselves,  they  should  be  repressed  by  the  lajm  infemalls.  M.  Beer  and 
M.  Langenbeck  recommend  the  use  of  the  suture,  that  the  eye  may  be  relieved 
as  soon  as  possible  from  the  effects  of  the  presence  of  the  cilia.  As  the  di- 
vided skin  is  very  thin  and  elastic,  as  nothing  is  easier  tlian  to  take  a  stitch  in 
it,  and  as  it  is  always  better  to  unite  it  immediately  without  crowding  in  the 
neighboring  integuments,  like  Scarpa,  I  cannot  see  why  there  should  be  any 


OPERATIVE    SURGERY.  S^5 

repugnance  to  the  use  of  a  simple  suture,  were  it  but  for  twenty-four  hours, 
as  recommended  bj  Langenbeck. 

Avenzoar  speaks  of  some  operators  who  preferred  compressing  the  flap  of 
the  integuments  between  two  splints,  until  it  produced  mortification.  Bartisch 
has  reproduced  this  idea  under  another  form ;  he  engages  the  fold  between 
two  plates  of  iron  united  by  a  hinge.  Adrianson,  according  to  Heister, 
invented  a  method  still  more  strange:  with  an  instrument  very  similar  to  that 
of  Bartisch's,  garnished  with  holes,  he  pinched  up  a  large  fold  of  skin ;  he  then 
passed  threads  through  the  base  and  the  holes  of  the  instrument,  removed 
the  latter,  and  tied  the  threads  as  so  many  ligatures. 

4.  Excision  of  the  Edge  of  the  Palpebra. — In  some  obstinate  cases,  Dr. 
Schreger  removes,  with  curved  scissors,  a  triangular  flap  of  the  edge  of  the 
lid,  comprehending  the  erratic  hairs ;  and  even  went  so  far,  says  Mr.  S.  Cooper, 
as  to  advise  the  excision  of  all  the  inverted  portion  of  the  tarsus.  But  we 
cannot  see  in  what  this  method,  also  eulogized  by  Heister  and  D.  Gendron,  is 
superior  to  a  simple  excision  of  the  palpebral  integuments. 

a.  Mr.  Crampton's  Method. — After  dividing  the  free  edge  of  the  lid  to  the 
right  and  left  of  the  deviating  hairs  perpendicularly,  Mr.  Crampton  united 
these  two  incisions  by  a  third  transverse  one  of  the  conjunctiva  ;  then  drew 
the  included  portion  of  the  cartilage  to  its  natural  position,  and  maintained  it 
there  by  adhesive  strips,  or  other  appropriate  dressing.  Mr.  Travers,  who 
has  partly  adopted  Mr.  Crampton's  views,  thinks  that  in  certain  cases  it  would 
be  better  to  remove  the  little  trapezoidal  portion  of  the  tarsus.  The  phy- 
sicians of  Bimarestan,  of  whom  Rhazes  speaks,  and  who  incised  the  cartilage 
and  pierced  it  with  a  thread,  with  which  they  everted  it ;  Richter,  who  advises 
us  to  make  a  transverse  incision  of  the  tarsus  in  obstinate  entropion ;  and  Paul 
of  Egina,  who  advises  to  cut  through  the  lid  by  the  inner  face,  have  given 
birth,  we  see,  to  the  idea  on  which  Mr.  Crampton's  operation  is  founded.  At 
best,  this  is  only  a  resource  in  extreme  cases. 

b.  Mr.  Guthrie^s  Method. — Mi:.  Guthrie  also  cut  the  tarsus,  but  near  the 
angles  of  the  eye ;  with  the  finger  he  then  everted  it  towards  the  forehead,  or 
the  cheek,  according  to  the  lid  affected.  If,  on  being  allowed  to  fall  on  the 
eye  again,  it  continue  inverted,  Mr.  Guthrie  recommends  to  divide  it  trans- 
versely, and  to  remove  a  portion  of  it,  along  with  the  skin  that  covers  it. 
Without  being  good  enough  to  merit  great  confidence,  this  method  seems  less 
objectionable  than  the  preceding. 

c.  Saunder^s  Method. — The  surest  way,  says  Dr.  Saunders,  is  to  remove 
almost  the  whole  of  the  diseased  organ.  A  thin  plate  of  lead,  or  silver, 
curved  to  suit  the  lid,  being  first  placed  between  it  and  the  part,  the  eye  being 
stretched  by  an  assistant,  ^he  operator  divides  the  skin  and  orbicularis  muscle, 
a  little  beyond,  and  in  the  direction  of  the  tarsus,  behind  the  cilia.  The  inconve- 
niences of  such  a  plan  are  but  too  evident.  It  would  be  better  to  follow  the 
advice  first  given  by  M.  Jaeger,  of  Vienna,  and  afterwards  by  M.  Flarer,  of 
Pavia,  to  excise  the  cutaneous  portion  of  the  free  edge  of  the  lid,  and  with 
it,  the  erratic  hairs  and  their  roots. 

d.  Method  of  Vacca-Berlinghieri. — The  operation  of  Vacca  seems  to  me 
much  more  reasonable.  In  a  most  obstinate  case  of  trichiasis,  this  surgeon 
thought  he  could  expose  the  roots  of  the  hairs,  and  destroy  them,  either  with  a 
cutting  instrument  or  nitric  acid.    A  thin  concave  plate,  with  a  transverse 


326  New  tLEMEKfTs  o? 

groove  upon  its  convex  face,  is  placed  upon  the  globe  of  the  eje.  An  assist- 
ant holds  the  lid  with  the  free  edge  in  the  groove  of  the  plate.  J5j  means  of 
two  vertical  incisions,  one  line  long,  united  by  a  transverse  one  which  com- 
prehends the  skin  only,  the  operator  forms  a  small  parallelogram,  which  he 
turns  forwards  towards  the  opening  of  the  eyelids;  by  this  means  the  cartilage 
is  exposed  ;  he  then  seeks  the  bulbs  of  the  diseased  liairs  with  the  pincers ; 
excises  them  with  the  scissors,  or  cauterizes  them ;  replaces  the  flap,  and 
maintains  it  in  place  with  plasters.  The  ciliary  branches  of  the  palpebral  artery 
are  cut,  and  bleed  abundantly ;  but  the  hemorrhage  is  unimportant,  and  stops 
of  itself.  M.  Delpech,  who  also  eulogizes  the  cauterization  of  the  cilia,  not 
of  the  bulb,  but  the  neck,  depends  principally  upon  the  formation  of  an  elastic 
cicatrix,  a  layer  of  imperforated  tissue,  and  consequently  preferred  union  by 
suppuration. 

Recapitulation. — In  simple  blepharoptosis,  excision  of  the  integuments  is 
almost  always  successful.  It  is  also  the  most  efficacious  remedy  in  ordinary 
entropion.  In  trichiasis,  the  turning  out  of  the  hairs,  after  the  manner  of 
Heraclides,  when  their  length  permits,  or  of  Hippocrates,  can  be  first  tried. 
Then  comes,  1st,  the  excision  of  the  integuments,  which  Dr.  Physick  advises 
to  be  made  very  near  the  free  edge  of  the  palpebra,  and  which  I  have  just 
seen  fail  in  a  very  simple  case;  2d,  cauterization  of  the  skin  after  the 
manner  of  Helling  and  Quadri,  which  I  have  once  used  with  success ;  3d, 
Vacca's  method  for  more  serious  cases ;  4th,  and  lastly,  excision  of  the  car- 
tilage, according  to  the  views  of  M.  Guthrie,  Schreger,  Travers,  Saunders, 
Crampton;  or  even  by  the  process  of  Mr.  Adams. 

§  3.  Tumors. 

I.  Cysts. — If  any  tumor,  occupying  either  lid,  does  not  disorganize  but  only 
deform  the  lid,  the  tumor  should  be  destroyed  without  removing  the  natural 
organ.  Encysted  tumors  come  under  this  head.  If  the  vinous  solution  of 
the  muriate  of  ammonia,  recommended  by  Morgagni  and  M.  Boyer,  should 
fail,  and  the  patient  desires  to  be  relieved  of  the  affection,  it  is  time  to  think 
of  the  operation,  properly  so  called.  Ligature,  incision,  cautery,  and  extirpa- 
tion have  been  proposed.  The  ligature  has  been  for  a  long  time  justly 
abandoned.  Simple  cauterization  has  shared  the  same  fate,  at  least  when 
not  combined  with  incision.  A  needle  fixed  like  a  seton  in  the  tumor,  as 
recominended  by  M.  Jacquemin,  would,  I  think,  only  succeed  by  chance.  So 
that  it  is  only  extirpation  that  is  worthy  of  our  attention. 

To  effect  this,  it  is  useless  to  pass  a  thread  through  the  tumor,  as  Bartisch 
advised,  so  as  to  act  upon  it  more  securely.  Whei;  it  is  small,  and  has  its  seat 
apparently  nearer  the  conjunctiva  than  the  skin,  Richter  recommends  that  the 
offending  body  be  removed  by  the  inner  face  of  the  lid,  because  it  then  leaves 
no  visible  cicatrix  after  the  cure.  The  great  prominence  which  it  presents 
outwards  should  not  mislead  us,  for  this  projection  more  frequently  depends 
upon  the  pressure  of  the  globe  of  the  eye  than  the  seat  of  the  tumor.  The 
cures  are  therefore  very  few — when  the  skin  is  altered  and  thinned,  for  in- 
stance, or  when  it  is  too  difficult  to  evert  the  lid,  in  which  we  are  obliged  to 
divide  the  external  integuments. 

First  Process. — With  the  thumb  upon  the  inner  face  of  the  tarsus,  and  the 


OPERATIVE    SURGERY.  327 

index  fiho;er  applied  upon  the  skin,  the  surgeon  takes  hold  of  and  everts  the  lid ; 
then,  pressing  upon  the  tumor  to  give  it  prominence,  he  lajs  it  bare  with  a 
transverse  incision,  seizes  it  with  a  hook  which  he  confides  to  an  assistant, 
and  then  with  a  bistoury  dissects  it  out.  The  small  wound  resulting  requires 
very  little  care ;  cicatrization  takes  place  in  a  few  days.  AVhen  the  tumor 
is  secured  by  the  hook,  if  it  be  small  and  easily  raised  up,  it  may  be  removed 
by  a  single  cut  with  a  pair  of  flat  curved  scissors.  Yet  it  is  important  to  pre- 
serve the  conjunctiva  and  subjacent  tissues,  because  their  destruction  exposes 
the  patient  to  entropion. 

Second  Process. — When  from  necessity  or  choice  we  would  remove  the  tumor 
through  the  skin,  the  index  finger  takes  the  place  of  the  thumb,  and  the  thumb 
the  finger.  By  pressing  the  tumor,  the  finger  stretches  the  lid,  and  protects 
the  eye  much  better  than  the  cupola  of  lead  or  silver  formerly  used,  or  the 
plate  of  lead,  gold,  or  copper,  still  recommended  by  Chopart  and  Desault. , 
The  integuments  are  then  cautiously  dissected,  to  prevent  the  opening  of  the 
morbid  body.  The  rest  offers  nothing  particular.  Short  strips  of  taft'eta  or 
diachylon  plaster  maintain  the  lips  of  the  wound  in  contact,  and  we  have 
rarely  to  wait  more  than  three  or  four  days  for  a  cure. 

Care  should  be  taken  in  both  these  processes  to  avoid  cutting  through  the 
lid,  or  wounding  if  it  can  be  avoided  the  tarsal  cartilage ;  because  it  may 
retard  the  cure,  and  even  produce  a  fistula,  or  some  other  deformity. 

Modified  Cauterization. — Maitre-Jean,  Heuermann,  and  Nuck,  commenced 
by  opening  the  tumor  freely  so  as  to  empty  it,  and  then  applied  the  actual 
cautery  to  its  interior.  Chopart  and  Desault,  who  professed  the  same 
opinions,  used  a  pencil  of  lapis  infernalis.  M.  Dupuytren,  in  adopting  this 
plan,  founds  his  preference  upon  its  greater  ease  and  security — preventing  a 
perforation  of  the  lid;  and  upon  its  being  the  only  one  that  can  be  used,  when 
in  spite  of  all  precautions  the  cyst  has  been  opened  in  endeavoring  merely 
to  expose  it.  The  operation  is  very  simple.  The  organ  is  held  as  in  the 
preceding  methods.  With  one  stroke  of  the  bistoury  we  divide  the  skin  and 
the  little  sac,  which  empties  itself,  or  should  be  emptied  ;  its  whole  inner 
surface  is  then  cauterized  with  a  stick  of  nitrate  of  silver,  pressed  upon  it 
v/ith  some  force  ;  the  heterogeneous  crust  soon  comes  away,  and  the  wound 
heals  quite  readily.  All  things  equal,  excision  is  to  be  preferred.  But  M. 
Dupuytren's  method  is  hardly  less  advantageous,  and  would  be  very  appli- 
cable upon  refractory  subjects.     I  have  employed  both  with  equal  success. 

Cancerous  Tumors. — Experience  has  sufficiently  proved  that  cauterization 
is  a  bad  means  of  destroying  cancerous  tubercles  of  the  eyelids.  If  the 
tumor  be  of  a  less  alarming  nature,  still  it  is  better  to  attack  it  with  the  cutting 
instrument  if  the  degeneration  has  extended  to  the  natural  tissues.  Here,  as 
elsewhere,  it  would  be  better  to  do  nothing  than  leave  a  portion  of  the  disease 
for  fear  of  cutting  into  healthy  parts.  When  there  exists  but  one  tubercle 
well  defined,  occupying  only  the  border  of  the  tarsus,  it  is  best  to  isolate  it  by 
means  of  two  incisions  uniting  in  a  V,  thereby  removing  a  triangular  flap  with 
it ;  using  the  twisted  suture  to  bring  together  the  edges  of  the  wound.  If  the 
alteration  be  more  extended  transversely  than  vertically,  so  that  after  extirpa- 
tion we  should  think  it  impossible  to  bring  together  the  edges  of  the  incision, 
we  should  then  make  a  semilunar  incision  of  greater  or  less  length  and  depth, 
either  with  a  good  bistoury,  or,  as  M.  Richerand  prefers,  with  curved  scissors ; 


328  NEW  ELEMENTS   OF 

taking  all  possible  care  not  to  injure  the  lachrymal  puncta  or  conduits.  The 
solution  of  continuity  cicatrizes  by  suppuration.  The  integuments  slowly 
increase  upon  the  eye,  and  terminate  by  forming  a  kind  of  hood,  which  par- 
tially replaces  the  lost  lid. 

§  4.  Anchyloblepharon  and  Symblepharon. 

The  adhesions  that  occur  between  the  lids  and  globe  of  the  eye  have  been 
long  observed.  To  destroy  them  Heraclides  used  a  bistoury,  recommend- 
ing the  edge  of  the  instrument  to  be  inclined  rather  towards  the  lid  than 
the  globe ;  and  to  prevent  the  reproduction  of  the  disease,  advises  the  patient 
to  move  the  eye  frequently  in  every  direction.  When  the  adhesions  are  weak, 
or  small  in  extent,  it  is  sometimes  possible,  as  Alex  directs,  to  destroy  them 
with  a  sound  or  stylet.  If  they  assume  the  form  of  bridles  or  lamellag,  beyond 
which  a  grooved  sound  may  be  passed  on  the  globe,  they  may  be  divided,  ac- 
cording to  the  advice  of  Maitre-Jean  and  M.  Boyer  upon  this  instrument,  with- 
out danger.  No  one  now,  as  in  the  days  of  Bartisch,  thinks  of  raising  the  lid 
with  a  thread  or  ligature  to  dissect  it  from  the  ball.  The  most  important 
matter  is,  not  to  break  these  connexions,  but  to  prevent  their  reproduction. 
The  constant  motion  recommended  by  Heraclides,  the  plates  of  lead,  gold,  or 
copper,  recommended  by  Solingen  and  others  to  be  placed  between  the  eye  and 
lid,  but  rarely  accomplish  this  purpose.  The  best  plan  is  to  pass  from  time  to 
time  a  ring  or  a  large  pin-head  between  the  contiguous  surfaces,  so  as  to  cause 
them  io  cicatrize  separately.  It  is  an  operation  after  all  which  should  only 
be  attempted  upon  those  who  have  a  healthy  transparent  cornea,  or  at  least 
those  whose  cornea  is  in  that  state  in  the  part  opposite  the  pupil. 

Congenital  or  acquired  adhesion  of  the  edge  of  the  lids,  always  less  import- 
ant, may  be  complete  or  incomplete,  and  may  exist  alone  or  in  conjunction 
with  the  preceding  disease.  In  the  first  case,  instead  of  opening  with  the  bis- 
toury the  whole  extent  of  the  line  which  the  natural  state  should  present  from 
before  inwards,  we  should  make  a  small  opening  near  the  temple,  in  order 
to  introduce  a  grooved  silver  probe,  a  little  concave  on  its  back,  that  it 
may  accommodate  itself  to  the  convexity  of  the  eye.  The  bistoury,  guided 
by  this  conductor,  is  passed  without  danger  from  one  palpebral  commissure  to 
the  other  in  the  track  made  by  the  junction  of  cilia.  In  the  second  case,  the  pre- 
paratory incision  is  unnecessary.  After  separating  the  lids,  if  there  exist  anchy- 
loblepharon,  it  should  be  destroyed  according  to  the  rules  abovementioned . 
Instead  of  the  bistoury  and  sound,  it  is  possible  to  use  a  pair  of  scissors,  guarded 
by  a  small  ball  of  wax,  as  recommended  by  J.  Fabrice,  or  a  small  button,  as 
advised  by  Scultet,  at  the  end  of  that  blade  which  is  to  pass  next  the  ball  of 
the  eye.  But  it  would  be  trifling  to  pass  a  wire  of  brass  behind  the  abnormal 
connexion  and  bring  together  its  two  halves,  like  Duddell,  in  order  to  separate 
the  adhesions  insensibly.  Nor  would  any  person  expose  himself  to  the  ridi- 
cule of  imitating  F.  de  Hilden,  who  tied  the  two  extremities  of  this  wire 
together,  and  attached  to  it  a  weight  to  draw  it  out  by  degrees.  As  after  every 
method  the  disunited  edges  retain  a  great  propensity  to  reunite,  the  surgeon 
should  not  omit  to  place  between  them  some  pieces  of  charpie  covered  with 
cerate,  near  the  commissures,  nor  to  separate  them  frequently  with  a  wire  or 
ring  of  gold  or  silver. 


OPERATIVE    SURGERY.  S29 

Encanthis, — Scirrhous,  or  other  degeneration  of  the  caruncula  lachrymalis 
and  the  greater  angle  of  the  eye,  can  only  be  cured  by  extirpation.  This  is 
an  operation  which  the  proximity  of  the  sac,  the  conduits  and  puncta,  as  well 
as  the  globe  of  the  eye,  renders  very  delicate.  An  assistant  placed  at  the 
back  of  the  patient  is  charged  with  keeping  the  lids  apart.  The  operator, 
placing  himself  in  front,  seizes  the  tumor  with  a  hook  or  a  pair  of  forceps,  and 
dissects  it  carefully  with  the  point  of  a  sharp  bistoury,  first  from  below,  then 
within,  then  towards  the  eye,  and  then  from  above,  penetrating  as  far  as  the 
disease  requires,  and  removing  it  as  quickly  and  completely  as  possible.  It 
was  thus  that  Marchetti  detached  a  melicerous  tumor  that  covered  even  a  part 
of  the  cornea ;  but  he  had  recourse  to  the  scissors  to  complete  the  operation. 

Orbital  Cavity. 

Lupi,  encephaloid  masses,  &c.,  may  develop  themselves  in  the  interior  of 
the  orbit.  The  lachrymal  gland  sometimes  acquires  a  considerable  size  in 
passing  into  the  scirrhous  state.  These  various  lesions,  whose  peculiar  cha- 
racteristics are,  the  projection  of  the  globe  of  the  eye  from  the  socket,  audits 
inclination  at  the  same  time  in  a  direction  opposed  to  the  side  where  the  tumor 
exists,  most  frequently  require  the  extirpation  of  that  organ.  Yet,  whenever 
it  is  not  itself  implicated  in  the  degeneration,  we  can  save  it.  This  is  proved 
by  a  beautiful  operation  of  Acrel,  and  the  practice  of  Dupuytren.  An  old 
work  of  Daviel  and  Guerin,  of  Bordeaux,  recently  published,  proves  also  that 
the  lachrymal  gland  had  been  often  successfully  extirpated  by  these  two 
surgeons.  There  are  even  osseous  tumors  that  may  be  removed  without 
injury  to  the  eye,  either  with  a  chisel  and  mallet  or  well  directed  traction,  as 
is  proved  by  a  fact  related  by  M.  Saltzen.  The  rules  for  the  extirpation  of 
the  lachrymal  gland,  or  any  other  tumor  in  the  orbit,  must  necessarily  vary 
with  size,  form,  nature,  and  seat  of  the  disease.  If,  for  example,  it  were  a 
cyst,  full  of  more  or  less  liquid  matter,  it  would  be  sufficient  to  pierce  it  with 
a  bistoury,  and  keep  the  cavity  open  by  means  of  a  tent  of  charpie.  M. 
Schmidt  and  Rutdhorlfer,who  have  often  seen  such  cases,  think  that  even  a  punc- 
ture with  a  trocar  is  sufficient.  Guerin,  of  Bordeaux,  in  endeavoring  to  extir- 
pate the  lachrymal  gland,  or  a  cancer,  acknowledges  that,  after  passing  the  lids, 
he  came  upon  a  tumor  filled  with  semi-liquid  matter;  he  opened  and  emptied 
it,  and  introduced  a  tent;  and,  in  twenty-one  days,  the  cyst  came  away. 
Spry,  who  made  a  similar  mistake  in  1755,  might  probably  have  saved  the 
vision  of  the  patient,  if,  instead  of  continuing  the  extirpation  of  the  eye,  he 
had  had  the  prudence  of  M.  Guerin. 

As  to  solid  bodies,  there  are  two  methods  of  removing  them : — 
1.  AcrePs  Method. — The  lid  is  to  be  divided  through  its  whole  thickness  near 
its  base,  in  a  direction  corresponding  to  its  natural  curve,  and  over  the  most 
projecting  part  of  the  disease ;  an  assistant  separates  the  lips  of  the  incision  ; 
then,  with  a  narrow  bistoury,  directed  by  the  index  finger  of  one  hand,  the 
surgeon  detaches  the  tumor  from  the  orbit,  seizes  it  with  a  hook,  dissects  its 
internal  face  so  as  to  separate  it  from  the  eye  with  the  finger  of  the  cutting 
instrument,  and  tries  to  turn  it  from  its  summit  towards  its  base.  Daviel 
and  Guerin  followed  this  method  with  success.  Although  in  one  case  the 
tumor  presented  on  one  of  its  faces  a  groove  moulded  upon  the  optic  nerve, 
42 


330  NEW   ELEMENTS   OF 

and  in  another,  the  operation  was  followed  by  an  enormous  swelling  of  the  lids 
and  high  fever,  they  succeeded  in  preserving  the  sight.  At  first,  we  might 
doubt  if  the  lachrymal  gland  itself  had  really  been  extracted  ;  but  Guerin  dis- 
sected one  after  an  operation,  and  even  made  a  plaster  model  of  one,  the  original 
of  which  he  exhibited,  preserved  in  alcohol,  at  the  Academy  of  Surgery.  It  is, 
besides,  at  the  present  day  a  well-known  operation.  Messrs.  Todd,  Lawrence, 
and  O'Beirne  have  recently  practised  it  in  England  with  not  less  striking 
success  than  Daviel  and  Guerin.  M.  Mackensie's  treatise  acquaints  us  with 
two  other  examples,  and  Warner  as  well  as  Travers  has  performed  it.  The 
method  they  used,  however,  is  not  free  from  objections. 

2.  Another  Method, — It  seems  to  me  that  the  end  would  be  better  attained  by 
prolonging,  at  the  commencement,  the  external  commissure  towards  the  temple, 
so  as  to  enable  us  to  evert  the  lids.  Some  experiments  on  the  dead  subject 
have  convinced  me  that  by  this  means  we  may  very  easily  expose  the  two 
external  thirds  of  the  orbital  circumference.  This  being  done,  the  surgeon 
separates  the  tumor  which  he  wishes  to  remove  from  the  bony  cavity  that 
encloses  it,  by  dividing  the  cellular  tissue  from  its  external  face ;  then  dis- 
sects down  to  its  greatest  depth,  and  detaches  it,  with  the  utmost  caution, 
from  the  muscles,  the  optic  nerve,  or  the  globe  of  the  eye,  and  removes  it  with 
the  finger  or  hook.  Occasionally  the  operation  is  followed  by  a  swelling  so 
great,  as  to  make  the  eye  appear  after  three  or  four  days  as  prominent  as  before ; 
but  this  is  not  long  in  disappearing.  In  the  space  of  from  ten  to  thirty  days 
every  thing  assumes  its  natural  position,  and  the  cure  is  commonly  complete. 

Union  by  the  first  intention  should  not  be  attempted  after  either  process, 
because  the  cavity  left  in  the  orbit  cannot  be  immediately  filled,  and  because 
the  tissues  which  have  been  torn  rather  than  cut,  must  unavoidably  suppurate. 
In  one  case  in  which  the  incision  closed  too  soon,  Guerin  observed  such 
alarming  symptoms,  that  he  was  obliged  to  destroy  the  cicatrix  with  a  sound. 
It  is,  therefore,  sufficient  to  dress  with  a  pledget,  or  tent  of  lint  covered  with 
cerate,  to  draw  together  the  incision  of  the  palpebral  angle,  if  such  have 
been  made,  and  cover  the  whole  with  a  pledget  and  compress  supported  by 
the  suitable  bandage.  When  suppuration  is  established,  the  dressings  should 
be  renewed  every  day.  Injections  are  often  necessary,  and  every  thing 
should  be  done  to  make  the  cavity  fill  from  the  bottom.  If  by  cutting  through 
the  lids  the  operation  can  be  made  more  easy,  it  should  be  preferred,  although 
the  deformity  it  produces  be  so  much  greater ;  but  unless  the  tumor  has 
acquired  great  size,  this  is  not  the  case.  In  a  case  that  fell  under  the  notice  of 
Mr.  Hope,  a  tumor  of  seven  years'  standing  had  so  elongated  the  optic  nerve, 
that  it  was  necessary  after  its  removal  to  press  the  eye  back  into  its  place 
with  the  hand,  and  maintain  it  there  with  a  bandage.  Success  was  neverthe- 
less complete.  In  the  case  of  a  young  woman  who  was  utterly  intractable, 
Mr.  Wardrop  abstracted  fifty  ounces  of  blood  in  order  to  produce  syncope, 
during  which  he  performed  the  operation  with  such  facility  and  success,  that 
the  patient  on  reviving  could  scarcely  believe  her  eyes. 


OPERATIVE    SURGERY.  331 


Art,  A.'^Globe  of  the  Eye, 

§  1.  Foreign  Bodies. 

A  gold  or  silver  ring,  the  head  of  a  long  pin,  a  small  roll  of  paper,  an  ear- 
pick,  or  any  other  smooth  and  rounded  instrument,  is  sufficient  to  remove  the 
various  solid  foreign  bodies  that  remain  loose  beneath  the  lids ;  but  these  will 
not  always  serve  for  particles  of  metal,  stone,  wood,  &c.,  which,  having  been 
projected  against  the  eye,  become  fixed.  Then,  if  there  be  no  fear  of  injuring 
the  eye,  a  quill  cut  into  the  form  of  a  tooth-pick,  or  some  other  such  instrument, 
will  often  answer  the  purpose.  In  other  cases  we  must  have  recourse  to  the 
point  of  a  lancet,  and  in  some  others,  even  have  to  use  a  pair  of  small  forceps 
or  pincers.  It  is  only  in  rare  cases,  when  the  particle  of  iron  is  scarcely  at  all 
attached,  that  the  magnet,  recommended  by  F.  de  Hilden  (who  highly  extolled 
its  success  in  the  hands  of  his  wife),  can  be  advantageously  employed.  The 
same  may  be  said  of  a  stick  of  sealing-wax  or  amber,  for  removing  particles 
of  straw,  chaft',  &c.  When  an  operation  has  been  decided  upon,  an  assistant 
is  charged  with  keeping  the  lids  apart ;  with  the  point  of  a  lancet,  or  very 
pointed  bistoury,  the  surgeon  isolates  the  foreign  body  from  the  cornea  to  a 
certain  depth ;  then  lays  hold  of  it  with  a  pair  of  fine  and  accurate  forceps,  and 
removes  it  carefully  for  fear  of  breaking  it.  The  subsequent  treatment  is 
the  same  as  that  for  an  ordinary  ulcer,  or  simple  ophthalmia.  It  is  an  opera- 
tion that  presents  little  difficulty,  requiring  only  address  and  great  precision 
in  the  movements.  When  the  body  to  be  extracted  has  sunk  deep  into  the 
coats  of  the  eye,  without  penetrating  into  the  chambers,  we  may  almost  always 
succeed  in  removing  it  by  means  of  the  edge  or  point  of  a  lancet. 

§  2.  Pterygium. 

When  proper  medicinal  applications  have  failed  to  dissipate  pterygium, 
and  it  advances  upon  the  cornea  so  much  as  to  cause  the  loss  of  sight,  it 
should  be  removed  with  the  bistoury  or  scissors.  The  division  of  the  ves- 
sels that  supply  it,  as  recommended  by  Beer ;  strangulation  by  means  of  a 
thread  passed  between  the  conjunctiva  and  sclerotica,  which  la  Vauguyon 
preferred ;  and  cauterization,  have  all  been  more  than  once  successful ;  but 
as  all  these  means  are  fallible,  and  more  difficult  than  excision,  they  are  gene- 
rally abandoned. 

To  remove  it,  the  operator  takes  hold  of  it  with  a  pair  of  forceps  at  one 
or  two  lines  from  its  point.  By  drawing  it  a  little  towards  him,  as  if  to 
detach  it,  he  soon  hears  it  make  a  slight  crack  like  a  piece  of  parchment. 
Then  it  is  easy  to  cut  it  away  from  point  to  base,  or  in  the  contrary  direc- 
tion, with  a  bistoury  or  small  scissors.  As  the  cornea  but  rarely  regains 
its  transparency  opposite  the  cut,  M.  Boyer  recommends,  I  think  properly, 
that  when  its  point  has  reached  so  far  as  the  pupil,  not  to  extend  the  incision 
so  far  as  that,  but  to  excise  only  its  posterior  four-fifths.  Emollient  lotions 
for  some  days,  then  such  resolvent  applications  as  are  used  in  all  the  chronic 
phlegmasiae  of  the  eye,  constitute  the  consecutive  treatment. 

When  the  pterygium  is  not  very  thick,  Scarpa  thinks  it  will  be  most  fre- 


SS2  NEW   ELEMENTS    OP 

quently  sufficient  to  excise  a  semilunar  flap  of  it  opposite  the  point  of  union  of 
the  sclerotica  and  cornea,  and  that  in  other  cases  it  should  be  destroyed 
entirely ;  but  to  escape  a  disagreeable  cicatrix,  that  the  point  should  first  be 
detached,  and  then  the  base,  so  as  to  terminate  the  operation  in  the  middle. 
But  I  do  not  think  this  last  precaution  of  much  importance,  and  the  partial 
excision,  which  I  have  tried  three  times,  has  always  mailed.  It  is  prudent  in 
every  case  to  follow  the  advice  of  M.  Boyer  to  forewarn  the  patient  that,  not 
withstanding  the  operation,  he  may  not  be  perfectly  cured,  because  a  kind  of 
opacity  but  too  frequently  follows. 

§  S.  Cataract, 

1.  History. — Although,  from  the  days  of  Celsus  (who  was  the  first  to  speak 
clearly  concerning  it)  to  the  present  day,  it  is  known  that  but  few  cases  of 
confirmed  cataract  have  been  cured  any  other  wise  than  by  an' operation,  yet 
it  would  be  wrong  to  deny  absolutely  the  efficacy  of  all  other  means  of  treat- 
ment. Those  which  occur  upon  scrofulous,  scorbutic,  or  syphilitic  subjects,  or 
are  caused  by  an  inflammation,  or  some  other  disease  of  the  parts  contiguous  to 
the  eye,  have  more  than  once  either  spontaneously  disappeared  with  the  ori- 
ginal disease,  or  from  the  influence  of  a  well-directed  local  and  general  treat- 
ment; of  which  Maitre-Jean,  Callisen,  Alberti,  Gendron,  Murray,  Richter, 
Ware,  and  many  others  have  cited  examples.  Henbane  applied  to  the  eye, 
according  to  Nostier,  and  a  seton  at  the  nape  of  the  neck,  with  M.  Cham- 
pesme,  have  quite  recently  triumphed  over  cataracts  very  far  advanced.  M. 
Dietrich  recommends  that  it  should  be  arrestftd  in  its  development  by  repeated 
puncture  of  the  eye ;  and  M.  Schwartz  has  cured  three  cases  by  means  of 
revulsives,  &c.  Like  Messrs.  Rennes,  P.  Delmas,  and  Manoury,  I  have  seen 
it  disappear  spontaneously.  Messrs.  Larrey  and  Gondret  affirm  that  they 
have  obtained  the  same  result  from  moxas,  actual  cautery,  or  ammoniacal 
pomatum,  applied  upon  different  parts  of  the  head,  especially  the  sinciput;  but 
to  judge  properly  of  the  value  of  these,  it  is  necessary  to  have  certain  proof 
that  the  alterations  which  have  been  made  thus  to  disappear  were  true  cata^-  ' 
racts,  and  not  that  which  is  now  known  as  the  false  cataract. 

Although  Galen  and  the  Arabians  had  indicated  the  nature  of  cataract,  some 
centuries  passed  before  it  became  generally  known.  The  pellicle  that  con- 
stitutes the  disease  is  placed  by  Celsus  between  the  iris  and  the  lens ;  on  the 
contrary,  G.  de  Chauliac,  G.  de  Salicet,  &c.,  place  it  between  the  iris  and 
cornea.  That  which  contributed  most  to  maintain  and  propagate  such  errors, 
was  the  generally  conceived  opinion  that  the  lens  itself  was  the  seat  of  vision. 
However,  when  Kepler  showed,  in  1604,  that  the  lens  was  only  a  refracting 
agent,  a  prompt  revolution  in  favor  of  truth  occurred  on  this  point  of  surgery. 
Gassendi,  who  wrote  in  1660,  as  well  as  Palfyn  and  Mariotte,  attributes  to  R. 
Lasnier,  or  F.  Quare,  the  honor  of  having  first  contended  that  cataract  does 
not  depend  upon  an  accidental  pellicle,  but  upon  the  opacity  of  the  lens. 
Schellamer  learned  it  of  a  surgeon  of  the  Hotel  Dieu.  Brisseau,  Mery,  P.  du 
Petit,  Borel,Tozzi,  Geoffroy,  Albinus,  Bonnet,  and  Freytag,  doubtless  obtained 
it  from  the  same  source.  We  owe  to  Maitre-Jean,  however,  the  settlement 
of  the  question  beyond  dispute.  But  in  escaping  from  one  error,  surgeons 
were  on  the  point  of  falling  into  another.    Instead  of  not  seeing  the  cataract  ^ 


OPERATIVE    SURGERY.  3S3 

in  the  lens,  they  nearly  passed  into  the  other  extreme,  of  never  seeing  it  any 
where  else.  Ph.  de  la  Hire,  Freytag,  Morgagni,  had  much  difficulty  in  per- 
suading the  profession  that  this  disease  may  also  be  produced  by  the  opacity 
of  the  capsule.  It  was  reserved  to  S.  Muralt,  Didier,  Heister,  and  Chapu- 
zeau  to  put  beyond  question  that  it  is  always  produced  by  the  opacity  of  the 
lens,  of  its  capsule,  or  of  the  matter  in  which  it  lies,  and  not  by  either  one  of 
these  exclusively.  From  the  highest  antiquity  surgeons  have  attempted  the 
destruction  of  cataract  by  certain  instruments.  Celsus  even  gives  us  to  un- 
derstand that,  among  the  physicians  of  Alexandria,  there  were  many,  amongst 
the  rest  a  certain  Philoxemes,  who  had  acquired  great  skill  in  this  particular. 
2.  Conditions. — If  the  cataract  be  simple,  if  it  be  situated  in  the  chrystal- 
line,  or  have  contracted  no  adhesions  to  the  neighboring  parts,  if  the  iris 
retain  its  faculty  of  contracting  and  expanding,  if  the  patient  can  still  distinguish 
light  from  darkness,  if  there  be  no  inflammation  either  of  the  eye  or  within 
the  orbit,  if  there  be  no  cephalalgia,  catarrh,  nor  general  disorder,  if  the  eye 
be  neither  too  prominent  nor  too  sunken,  if  the  patient  be  not  too  much 
advanced  in  years,  if  he  be  quiet  enough  to  submit  to  all  the  necessary  cares, 
then  the  chances  of  success  are  as  numerous  as  one  can  desire.  When, 
on  the  contrary,  the  patient  is  wasted  with  age,  there  exist  nebulas  of  the 
cornea,  the  pupil  unchangeable,  the  bottom  of  the  eye  is  of  a  greenish  hue, 
there  are  frequent  or  permanent  deep-seated  pains  of  the  eye,  and  a  chronic 
ophthalmia,  or  some  other  chronic  disease  difficult  to  cure,  and  more  or  less 
serious,  exists  in  the  neighborhood  of  the  eye,  then  we  should  not  count  upon 
success.  In  other  words,  whenever  the  lens  and  its  capsule  aldne  are 
diseased;  when,  except  the  cataract,  the  organ  is  in  a  natural  state,  and 
when  the  orbit  contains  nothing  that  can  prevent  the  restoration  of  vision ; 
whether  the  cataract  be  true  or  false,  lenticular,  capsular,  or  capsulo- 
lenticular,  membranous,  anteriorly  or  posteriorly,  hard  or  soft,  milky  or 
chalky,  permanent  or  movable,  star-like,  pearly,  three -branched  or  central, 
purulent,  putrid,  spotted,  or  reticulated,  marbled,  dry  or  husky,  bloody, 
stony,  yellow,  brown,  or  black,  the  operation  may  be  recommended.  But 
in  other  cases  it  should  never  be  tried  but  as  a  last  resort,  and  after  notifying 
the  sufferer  of  the  little  chance  of  success.  Still  v/e  should  not  be  too  much 
alarmed  by  appearances.  The  immobility  of  the  pupil  is  not  more  certainly  a 
sign  of  amaurosis,  than  its  mobility  is  of  a  healthy  state  of  the  retina.  Wen- 
zcl,  Richter,  Larrey,  Watson,  S.  Cooper,  &c.,  have  shown  us  that  the  adhesion 
of  the  iris  to  the  capsule  of  the  lens,  or  the  contraction  of  its  opening  after 
iritis,  can  leave  it  immovable,  as  well  as  a  paralysis  of  the  retina  can  leave  it 
the  contractile  power.  Certain  subjects  who  could  not  distinguish  day  from 
night,  have,  after  the  operation,  recovered  their  sight.  The  black  cataract 
observed  by  G.  de  Chauliac,  Morgagni,  and  Freytag,  and  of  which  Maitre-Jean 
Pellier,  Arrachard,  Wenzel,Coze,  Cloquet,  and  Riobehave  given  us  examples, 
is  too  rare,  even  supposing  that  it  can  exist  without  changing  the  tint  of 
the  pupil,  to  arrest  an  intelligent  operator.  In  a  word,  when  no  organic 
lesion  nor  serious  symptom  renders  the  operation  dangerous,  I  cannot  see 
why,  if  the  patient  be  completely  blind,  we  should  refuse  to  attempt  the 
operation.  The  patient  can  lose  nothing,  and  if  he  have  but  one  chance  in  a 
thousand  of  recovery,  it  would  be  inhuman  to  withhold  that  one.  Neverthe- 
less, we  should  absolutely  abstain  from  operating  wlicn  there  is  a  certainty 


334  NEW  ELEMENTS  OF 

of  deep-seated  alteration  of  the  eye.  In  a  man  in  this  state,  and  to  whose 
entreaties  I  at  last  yielded,  the  lens  escaped  gently  of  itself,  enveloped  in  its 
capsule  some  moments  after  opening  the  cornea,  when  the  vitreous  humor 
showed  itself  so  fluid,  that  it  would  have  escaped  like  water  if  I  had  not 
instantly  applied  some  compresses  of  lint  upon  the  eye.  Some  cerebral 
disturbances  followed,  and  even  so  serious  for  several  days  .as  to  give  me  . 
much  inquietude.  The  left  eye  is  filled  with  pus,  and  the  right,  although 
perfectly  clear,  remains  insensible  to  light.  False  cataracts,  which  are 
almost  always  complicated  with  affections  of  the  iris  or  some  other  membrane 
of  the  eye,  are  less  easy  to  destroy  tlian  the  true  ones.  All  things  equal,  the 
cataract  of  the  lens  itself  is  not  so  bad  as  that  of  the  capsule,  or  of  the  liquor 
Morgagni.  In  children,  although  the  operation  is  difficult,  we  succeed  better 
than  in  adults;  and  after  tliat,  in  a  ratio  with  the  distance  of  the  subjects 
from  decrepitude. 

S.  Ages. — Almost  all  authors  think,  with  Sabatier,  that  the  operation  should 
only  be  attempted  on  those  who  can  know  its  utility,  and  that  is,  that  it  should 
not  be  used  before  the  tenth  or  fifteenth  year  for  instance.  The  indocility  of 
children,  the  little  desire  they  evince  to  see  the  light,  the  dangers  to  which 
they  are  exposed  in  the  attempt  to  operate  against  their  will,  and  the  diffi- 
culty of  making  them  submit  to  the  necessary  precautions.  Are  the  principal 
motives  upon  which  this  doctrine  has  been  established.  At  the  present  epoch 
it  is  not  to  be  admitted.  If  the  operation  be  more  delicate  and  hazardous 
in  infancy,  the  membranes  of  the  eye  are  also  more  tender,  thinner,  and  ' 
less  dense,  and  more  easy  to  penetrate;  the  eye  is  less  movable,  the  pupil 
larger,  and  the  subjects,  fearing  only  the  pain,  do  not  trouble  themselves  about 
what  follows.  As  the  operation  is  rarely  attended  with  acute  suffering,  I  can 
see  nothing  very  alarming  in  such  cases.  Besides,  it  is  always  possible  to 
confine  the  youngest  subjects,  and  to  separate  their  lids.  The  eye  is  an  organ 
essential  to  the  development  of  intelligence,  and  the  source  of  the  greatest 
number  of  ideas.  If  its  functions  are  abolished  from  birth,  its  development 
commonly  remains  incomplete;  it  acquires  slowly  an  excessive  mobility, 
that  renders  the  operation  much  more  delicate,  and  lessens  the  chances  of 
success.  In  a  word,  when  we  think  of  its  importance  to  the  education  of  chil- 
dren, it  is  really  difficult  not  to  admit,  witli  Ware,  Lucas,  Saunders,  Travers, 
Beer,  and  Jager,  the  necessity  of  destroying  the  cataract  as  soon  as  possible.  < 
Yet,  I  do  not  therefore  think  that  we  should  choose  the  age  of  two  years,  as 
Fame  recommends,  nor  of  six  Aveeks,  like  Lawrence,  rather  than  one  or  three 
years.  In  old  men,  as  the  disease  is  almost  always  a  natural  consequence  of 
age,  the  operation  is  not  permitted  unless  it  be  ardently  desired,  and  the 
patient  be  in  other  respects  in  the  best  possible  condition.  I  have,  however, 
just  performed  it  for  a- subject  eighty  years  old,  with  a  success  which  we  are 
far  from  always  obtaining  in  younger  subjects. 

4.  Simple  or  Double. — When  the  cataract  occupies  but  one  eye,  there  are 
some  operators  who  object  to  operating.  With  one  eye  perfectly  sound, 
the  subject,  they  say,  sees  almost  as  well  as  with  two;  well  enough,  at 
least,  to  move  about,  read,  and  fulfill,  in  fine,  all  the  duties  that  society  re- 
quires. In  this  case  an  operation  might,  by  producing  inflammation,  affect  the 
healthy  eye,  as  M.  J.  Cloquet  has  seen,  and  produce  a  complete  blindness.  ^^ 
But,  provided  it  succeeds,  the  luminous  rays  not  falling  on   both  retinas  7" 


OPERATIVE  SITRGERY.  355 

harmomously,  the  discordance  is  necessarily  followed  by  confusion  of  vision. 
To  these  reasons  it  may  be  objected,  that  if  the  healthy  eye  sometimes 
inflames  and  is  lost  after  an  operation,  it  is  an  accident  that  but  rarely  happens ; 
and  that  sight  is  undeniably  better  with  two  eyes  than  one,  and  that  the 
presence  of  a  cataract  on  one  side  seems  to  have  an  agency  in  producing  a 
second  on  the  other.  .  As  to  the  difference  which  it  was  supposed  would 
exist  in  the  field  of  vision,  after  tlie  removal  of  the  cataract,  experience  has 
now  demonstrated  that  it  is  not  manifest.  Maitre-Jean,  Saint  Yves,  Wenzel, 
&c.,  relate  some  observations  in  which  they  make  no  mention  of  it,  al- 
though they  had  under  their  care  patients  on  whom  they  operated  onlj 
on  one  side.  I  have  published  some  facts  of  the  same  kind,  collected  hi 
the  Hopital  de  Perfectionnement.  M.  Lusardi  writes  me  that  he  possesses 
many  such ;  and,  in  line,  M.  Roux,  who  has  often  extracted  the  cataract 
when  it  existed  only  on  one  side,  has  not  seen  that  the  patients  needed 
any  thing  else  after  it  than  glasses  of  a  different  form  for  each  eye.  Con- 
sequently, if  the  subject  be  young  and  healthy,  and  he  urgently  desires  it,  the 
operation  should  be  performed,  although  one  of  the  eyes  be  perfectly  sound. 

Cataract  commonly  exists  some  time  in  one  eye  before  completing  itself  in 
the  other.  In  this  case,  should  we  wait,  or  would  it  be  better  to  operate  as 
soon  as  the  first  is  completely  formed  ?  Many  recommend,  that  we  should 
temporize  until  the  second  eye  distinguishes  objects  confusedly.  They  found 
their  advice  upon  the  fact,  that  the  operation  may  not  be  followed  by 
success,  and  may  aggravate  the  state  of  the  other  eye  so  much,  that  the 
patient  will  be  worse  after  than  before  the  attempt.  But  supposing  it  may  be 
successful,  and,  as  has  been  often  observed,  this  same  eye  should  lose  its 
powers  again  after  some  years,  the  other  treated  in  the  same  manner  offers 
another  resource.  I  know  not  how  far  this  reasoning  may  be  good ;  but  this 
is  certain,  that  a  cataract  once  formed  cannot  remain  in  the  eye  with  impu- 
nity, and  that  the  subject  of  it  in  one  eye  has  much  difficulty  of  comprehend- 
ing the  advantage  of  waiting  for  the  attainment  of  the  same  state  in  the  other ; 
therefore,  if  vision  is  so  far  embarrassed  in  the  second  eye  as  to  induce  the 
sufferer  to  call  upon  us  for  our  assistance,  it  would  be  inhuman,  in  my 
opinion,  to  refuse  it  to  him. 

Formerly  it  was  admitted  that  cataract  passed  through  different  degrees  of 
consistence  ;  that  it  was  soft  and  diffluent  at  first,  and  became,  slowly,  firm 
and  solid  ;  in  a  word,  that  it  could  be  ripe  or  unripe.  It  is  now  known  that 
cataract  may  be  solid  at  the  commencement,  and  become  liquid  after  the  lapse 
of  many  years :  the  very  reverse  of  what  the  ancients  thought.  Yet,  it  is  not 
the  less  true  that  the  contrary  is  often  observed,  and  that  the  idea  of  its  matu- 
irty  or  immaturity  is  not  altogether  without  foundation.  As  it  is  almost  always 
the  result  of  an  internal  morbid  cause,  cataract  is  really  only  complete,  when 
that  cause  ceases  to  act  upon  the  eye,  in  which  the  opaque  body  holds  the  same 
place  as  a  necrosis  in  some  other  part  of  the  system;  that  is,  it  becomes  a 
foreign  body.  It  is  not,  therefore,  because  it  is  too  soft  or  too  hard,  that  it  is 
prudent  to  await  its  complete  development ;  but  rather  because,  its  progress  not 
being  completed,  there  is  less  chance  of  success  then  than  at  a  more  advance^ 
period,  when  its  formation  is  entirely  finished. 

Scarpa,  M.  Dupuytren,  and  many  other  able  oculists,  have  advanced  the 
opinion  that  it  is  better,  when  a  cataract  occupies  both  eyes,  to  operate  first 


336  NEW  ELEMENTS  OF 

on  one  side,  and  wait  for  a  cure,  before  attempting  it  on  the  other.  If  it  suc- 
ceed, the  patient  may  content  himself  with  it,  if  the  eye  do  not  become  too 
weak ;  if  it  fail,  there  is  left  another  resource.  The  sufferer  bears  the  second 
operation  more  firmly  than  the  first.  When  the  two  eyes  are  operated  upon 
at  the  same  time,  the  inflammation  of  one  almost  always  aggravates  that  of 
the  other ;  reaction  is  more  lively,  and  the  risk  of  unpleasant  consequences 
much  greater.  Messrs.  Boyer  and  Dupuytren  observe  on  this  subject,  that 
a  double  ophthalmia,  once  developed,  rarely  fails  of  fixing  itself  permanently 
upon  one  eye,  where,  changed  in  some  manner  from  what  it  was,  it  terminates 
most  commonly  in  the  destruction  of  the  organ.  All  this  is  somewhat  doubt- 
ful, and  as  the  single  operation,  even  in  the  happiest  cases,  but  incompletely 
restores  the  sight ;  as  patients  prefer  bearing  the  two  operations  in  immediate 
succession  to  leaving  a  long  interval  between  them ;  as  an  operation  on  the  one 
side  sometimes  determines  inflammation  on  both,  and  as  the  double  operation 
offers  numerous  favorable  chances  for  one,  at  least,  if  not  both  of  the  eyes,  I 
conclude,  with  Wenzel,  Demours,  Forlenze,  Boyer,  Roux,&c.,  that,  all  other 
things  equal,  it  is  better  to  adopt  the  latter. 

5.  The  Preparations  to  which  the  ancients  subjected  the  subjects  of  this 
disease,  are  almost  entirely  abandoned  by  the  moderns.  At  present,  a  more 
or  less  strict  regimen  for  some  days,  venesection,  some  laxative  or  gentle  pur- 
gative, diluent  drinks,  or  calming  and  anti-spasmodic  preparations  are  em- 
ployed, according  as  the  patients  may  give  signs  of  plethora,  disorders  of 
the  digestive  functions,  or  excessive  irritability  of  the  nervous  system.  As  a 
means  of  preventing  inflammation,  some  make  use  of  a  vesicatory,  or  some 
other  derivative,  upon  the  skin.  Scarpa  applies  it  upon  the  nape  of  the 
neck,  fifteen  days  beforehand.  M.  Roux  on  the  same  place,  just  at  the  time 
of  operation.  M.  Forlenze  preferred  it  upon  the  arm.  I  doubt  if  it  be  not 
more  dangerous  than  useful.  Many  operators  dispense  with  it  apparently 
without  disadvantage.  Adopted  generally,  it  must  be  often  injurious.  In 
the  first  few  days,  it  sometimes  produces  fever,  heat  of  the  skin,  irritation, 
and  other  consequences  dangerous  to  the  eyes.  If  it  should  be  placed  upon 
the  neck,  then  it  would  be  well  to  follow  the  advice  of  Scarpa  and  Dupuy- 
tren, who,  when  Ihey  thought  it  appropriate,  allowed  an  interval  of  fifteen 
days  between  its  application  and  the  operation.  Upon  the  arm,  it  is  very  evi- 
dent that  it  may  produce  no  inconvenience,  but  on  the  other  hand,  it  does  not 
seem  to  promise  the  least  advantage.  As  to  myself,  I  use  it  after  the  opera- 
tion, provided  particular  circumstances  require  it,  nor  can  I  see  that  this 
plan  offers  any  thing  reprehensible. 

6.  ASert-so/is.-— -Spring  and  autumn  have  been  chosen  as  seasons  more  favor- 
able to  the  success  of  operations  for  cataract,  than  summer  and  winter. 
These  periods  have  certainly  some  advantages  for  the  patient,  but  less  on 
account  of  the  seasons,  properly  speaking,  than  because  of  the  temperature, 
which  is  commonly  more  mild  and  more  regular  then  than  in  the  other  parts  of 
the  year.  Yet,  as  these  conditions  maybe  met  with  or  secured  at  all  times,  the 
operation  may,  strictly  speaking,  be  performed  at  any  season.  However,  a 
decision  should  be  made  with  great  care,  if  there  exist  any  serious  epidemic 
at  the  time,  especially  if  it  affect  particularly  the  mucous  membrane.  If 
catarrhal  affections,  ophthalmias,  measles,  or  even  erysipelas  exist,  prudence 
dictates  that  we  should  abstain  from  operating. 


OPERATIVE    SURGERT.  337 


Methods  of  Operating, 

The  opaque  lens  is  either  depressed,  that  is,  placed  in  such  a  situation  that 
it  will  disappear  under  the  influence  of  the  laws  of  the  organization,  or  it  is 
removed  entirely  out  of  the  eye.    These  constitute  the  two  methods. 


A.  Depression. 

The  first  method,  known  by  the  name  of  depression,  is  performed  in  different 
ways.  It  takes  the  name  of  scleroticonyxis,  when  the  needle  is  passed 
between  the  iris  and  vitreous  body ;  hyalonyxis,  when  passed  intentionally 
through  the  hyaloid  membrane,  and  that  of  ceratonyxis,  when  passed  tlirough 
the  anterior  chariber  and  cornea. 

1.  Preliminary  Mentions. — On  the  eve  of  the  operation,  the  patient,  who 
should  have  taken  but  very  light  food,  should  receive  an  injection,  if  his 
bowels  be  not  very  free.  An  aqueous  solution  of  the  extract  of  belladonna 
instilled  between  the  lids  of  the  eye  an  hour  before,  obliges  the  pupil  to  dilate 
largely,  allows  us  to  follow  with  the  greatest  security  every  movement  of  the 
needle,  enables  us  to  avoid  the  iris,  and  to  push  with  less  difliculty  into  the 
anterior  chamber  some  portions  of  the  cataract,  when  it  may  be  deemed  neces- 
sary. The  irritation  that  the  application  produces  is  too  slight  to  require 
notice.  The  momentary  paralysis  which  it  causes  soon  disappears,  without 
affecting  the  functions  of  the  organ.  The  advantages  which  it  furnishes  are 
of  the  highest  importance,  and  not  to  be  sacrificed  through  any  idle  apprehen- 
sions. With  irritable  or  timorous  subjects,  whose  eyes  are  very  unsteady,  it 
is  well  to  accustom  the  organ  to  the  contact  of  foreign  bodies ;  touching  it 
frequently  for  several  days  with  a  blunt  instrument  of  some  kind,  or  with  the 
finger. 

The  Apparatus  consists  of  two  needles  at  least,  so  that  if  one  fails  us,  the 
operation  may  be  continued  with  the  other ;  of  a  cap  or  band  that  will  exactly 
embrace  the  head ;  a  rolled  bandage  two  or  three  ells  long  and  two  inches 
wide,  to  secure  the  cap ;  a  long  compress  to  cover  the  sound  eye,  whilst 
operating  on  the  other ;  some  oval  pieces  of  fine  linen,  cut  full  of  small  holes, 
to  be  placed  over  the  eye  after  the  operation,  to  prevent  the  lint  from  imme- 
diately touching  the  lids ;  a  bandage,  folded  double,  long  enough  to  pass  round 
the  head,  and  of  from  four  to  five  fingers  in  breadth,  offering  at  the  middle, 
near  its  edge,  an  incision  like  a  T  inverted,  to  receive  the  nose ;  and  a  bandage 
of  black  taffeta  to  cover  this  last;  then  a  good  sponge,  warm  water,  and  pins; 
the  whole  to  be  disposed  in  the  order  in  which  they  will  be  needed. 

Instruments. — As  it  is  more  especially  for  extraction  that  the  speculum, 
V  elevators,  and  ophthalmostats  have  been  proposed,  I  shall  say  nothing  of  them 
here.  In  the  needle  there  is  the  greatest  variety.  That  of  Celsus  was  shaped 
like  a  lance-head,  straight,  and  two  inches  long.  Later,  a  round  one  was  found 
more  convenient.  Then  came  the  triangular  form.  In  fact,  almost  every 
operator  has  his  own.  Scarpa's,  which  is  only  eighteen  lines  long,  is  termi- 
nated by  a  point  a  little  enlarged  and  curved  in  the  arc  of  a  circle,  plane  on 
its  convex  side,  ground  to  a  rounded  edge,  or  rather  ridge,  on  its  concave 
43 


338  NEW  ELEMENTS  OF 

side,  and,  like  all  others,  mounted  upon  a  handle,  having  on  its  back  a  mark 
of  a  difterent  color.  M.  Dupuytren  rejected  the  kind  of  crest  found  on  the 
concave  face  of  Scarpa's  needle.  He  made  his  smoother  on  this  side  than  oa 
the  back,  so  as  to  embrace  the  lens  more  securely,  and  not  expose  it  to  being 
divided  in  the  attempt  to  sink  it  to  the  bottom  of  the  eye.  He  also  recom- 
mends that  it  should  have  less  breadth,  and  that  its  shank  should  be  slightly 
conical,  so  as  to  keep  the  way  opened  by  the  point  constantly  filled,  in  order 
to  prevent  the  escape  of  the  humor  of  the  eye  during  the  operation.  The  point 
of  the  one  adopted  by  M.  Bretonneau,  though  short,  is  as  large  as  that  of 
Scarpa's;  its  shank,  of  cast-steel,  is  more  slender,  and  almost  cylindrical, 
and  passes  freely  and  without  the  least  effort  through  the  puncture  of  the 
sclerotica.  This  is  an  advantage  which  M.  Dupuytren's  does  not  offer,  but 
which  exposes  the  eye  to  lose  some  of  its  fluids.  Beer's  needle,  which  many 
of  the  German  oculists  use,  is  straight  and  lance-shaped,  differing  from  M. 
Er-etonneau's  in  having  its  shank  conical  and  thicker.  Hey  exhibited  one 
which  was  not  more  than  ten  or  twelve  lines  long,  approaching  more  the  form 
of  a  cliisel  than  that  of  a  needle.  It  is  a  mere  modification  of  Hilmer's,  which 
is  conical,  and  its  free  extremity,  flat,  terminated  by  a  semilunar  convexity, 
is  the  only  cutting  part.  Its  sides,  straight  and  round,  and  its  want  of  point, 
render  it  difllcult  to  wound  the  iris  in  pushing  it  towards  the  pupil ;  whilst  its 
flattened  form  renders  the  depression  of  the  lens  less  embarrassing.  But  v/ith 
this  instrument  it  is  almost  impossible  to  destroy  a  membranous  cataract,  or 
even  to  make  a  suitable  opening  in  the  anterior  capsule  for  the  escape  of  a 
lenticular  one;  and  as  the  laceration,  for  which  the  inventor  more  especially 
intended  it,  can  be  very  well  effected  with  any  other  needle,  there  is  no 
reason  for  preferring  this.  Messrs.  Gragfe,  Langenbeck,  Himly,  Schmidt, 
tNcC,  have  each  modified  the  needle  to  suit  himself.  But  that  is  not  the  dif- 
ficulty. In  the  hands  of  a  good  operator  all  are  good.  Scarpa's,  Dupuytren's, 
and  Bretonneau's  as  much  so  as  the  rest. 

2.  Operalion. — Up  to  the  eighteenth  century  the  patient  was  made  to  sit 
astride  of  a  bench.  Bartii  and  Arnimann  preferred  to  have  him  standing. 
Poyet,  A.  Petit,  and  Dupuytren  recommend  the  horizbntal  position.  In  France 
the  subject  is  generally  placed  upon  a  firm  and  solid  chair  of  medium  height. 
Beer  recommends  a  stool,  whilst  Richter  prefers  a  chair  with  a  perpendicular 
back.  In  England  a  musician's  stool  has  the  preference.  There  is  nothing 
settled  upon  this  point.  Although  the  horizontal  position  is  evidently  best, 
yet  the  others  may  be  used  without  inconvenience. 

a.  Ordinary  Method. — The  surgeon  either  places  himself  facing  the  patient 
upon  the  same  bench,  Mdth  his  knees  between  the  latter's  thighs,  and  a  pad  to 
support  his  elbow,  as  recommended  by  J.  Fabricius,  or  standing,  like  Dubois, 
Dupuytren,  and  many  others,  or  seated  upon  a  chair  somewhat  elevated,  with 
the  foot  upon  a  stool,  and  a  cushion  on  the  knee  for  the  elbow,  as  prescribed 
by  Scarpa.  If  seated,  we  have  greater  certainty  in  the  movements,  because 
the  elbow  is  supported  ;  but  standing  we  have  more  freedom  and  ease.  The 
operator,  therefore,  may  be  left  to  choose  the  position  that  best  suits  his  taste 
or  address. 

Some  surgeons,  dispensing  with  assistants,  separate  the  lids  themselves. 
Barth  operated  in  no  other  way.  Mr.  Alexander,  who  is  much  extolled  for 
his  skill  in  this  method  in  London,  is  surpassed,  we  are  told,  by  M.  Joeger,  in 


OPERATIVE    SURGERY.  339 

Germany.     The  thing  is  possible,  no  doubt;  but  neither  tricks  of  dexterity 
nor  imprudent  boastings  make  a  rule.     Nothing  in  surgery  stands  more  in 
need  of  an  assistant  than  the  operation  for  cataract.     It  is  necessary  that 
he  should  have  a  light  hand,  comprehend  perfectly  every  step  of  the  opera- 
tion, every  movement  of  the  operator,  and  have  had  as  much  previous  practice 
as  possible.      Placed  behind  the  patient,  he,  with  one  hand,  embraces  his 
head  and  brings  it  against  his  own  breast  for  support,  while  he  elevates  the 
upper  lid  of  the  eye  with  the  other.      If  an  instrument  should  be  preferred 
to  uncover  the  eye,  the  double  hook  of  Berenger,  or  the  crotchet  of  som« 
others,  can  be  very  well  replaced  by  the  elevator  of  silver  wire  of  Pellier. 
In  general  the  finger  is  best,  whether,  as  with  Scarpa,  it  be  used  to  elevate 
and  keep  the  free  edge  of  the  lid  against  the  arch  of  the  orbit,  or  whether,  as 
advised  by  Boyer  and  Roux,  it  be  sunk  to  the  posterior  edge  of  this  arch  by 
bending  the  last  phalanx  of  the  finger.     By  the  latter  method  the  lid  is  more 
firmly  secured,  but  the  angle  formed  by  the  phalangeal  articulation  interferes 
more  with  the  operator,  and  the  eye  runs  greater  lisks  of  being  compressed. 
Forlenze  was  in  the  habit  of  drawing  all  the  palpebral  teguments  towards > 
the  l)row.      By  this  means  the  ciliary  border  and  the  tarsal  cartilage  are 
raised  as  high  as  possible,  and  the  skin  escapes   less    easily  from   under 
the  pulp  of  the  finger.     A  means  more  sure  of  preventing  the  latter  is,  to 
place  a  little  piece  of  fine  dry  linen  between  the  finger  and  the  integuments 
to  absorb  the  moisture  of  the  two  contiguous  cutaneous  surfaces.      If  the 
patient  be  in  a  recumbent  posture,  the  surgeon,  placing  himself  on  tlie  right 
side  for  the  left  eye,  and  on  the  left  for  the  right  eye,  puts  on  the  cap  and  fixes 
it  with  the  band ;  covers  the  eye  on  which  he  is  not  to  operate  with  a  little  lint 
and  the  long  compress,  which  is  passed  obliquely  around  the  head.    The  assist- 
ant, standing  or  sitting  on  a  chair  at  the  bolster  of  the  bed,  prepares  himself 
to  elevate  the  upper  lid.     With  the  index  finger  corresponding  to  the  diseased 
side,  the  operator  depresses  the  lower  one  and  fixes  the  eye.    With  the  other 
hand  he  holds  the  needle  in  the  manner  of  a  pen ;  carries  the  point  of  it  per- 
pendicular upon  the  sclerotica  af  a  line  and  a  half  or  two  lines  from  the  cor- 
nea, a  little  below  the  transverse  diameter  of  that  part;  turns  its  concavity 
downwards,  and  one  cutting  edge  towards  the  cornea,  the  other  towards  the 
orbit,  in  order  to  penetrate  by  separating  rather  than  cutting  the  wall  of  the 
eye,  inclines  the  handle  at  first  downwards  and  forwards,  and  elevates  it 
again  in  the  opposite  direction  as  it  passes  into  the  posterior  chamber ;  the 
last  two  fingers  of  the  hand  resting  meanwhile  between  the  parotid  and  cheek 
bone.    Before  sinking  the  instrument  any  deeper,  it  is  turned  upon  its  axis  so 
as  to  present  its  concavity  backwards,  that  it  may  pass  without  risk,  first 
under  and  then  before  the  lens,  penetrating  inwards  and  forwards,  without 
touching  the  iris  or  the  capsule  of  the  lens,  if  possible,  through  the  pupil  into 
the  anterior  chamber;  then  the  point,  with  a  kind  of  circular  motion,  is 
applied  repeatedly  upon  the  anterior  face  of  the  lens,  until  its  envelope  is  torn 
up  as  completely  as  possible.     This  done,  the  surgeon  applies  the  axis  of  the 
needle  upon  the  anterior  face  of  the  lens,  pushes  it  with  a  swaying  motion 
downwards,  outwards,  and  backwards  into  the  depths  of  the  eye,  below  the 
pupil  and  the  vitreous  humor,  where  he  holds  it  for  half  a  minute  to  prevent 
its  disengaging  itself;  then  withdraws  the  instrument  gently  by  slight  rotatory 
movements;  gives  it  again  the  horizontal  position  ;  turns  its  convexity  again 
upwards,  and  withdraws  it  the  same  way  it  had  been  introduced. 


340  NEW   ELEMENTS    OF 

i?cmarA:5.— Several  points  in  this  operation  merit  particular  attention.  Ii 
the  needle  be  carried  above  the  transverse  diameter,  as  some  operators  propose, 
it  becomes  almost  impossible  to  depress  the  lens  freely,  or  to  avoid  leaving  it 
more  or  less  near  to  the  centre  of  the  eye.  By  applying  it  upon  the  external 
extremity  of  this  diameter,  the  surgeon  cannot  fail  of  wounding  the  long 
ciliary  artery,  and  producing  an  internal  hemorrhage ;  therefone  the  lower 
point  should  be  selected.  When  the  convexity  of  the  instrument  is  turned 
forwards,  as  Scarpa  recommends,  the  fibres  of  the  sclerotica,  as  well  as  some 
of  the  ciliary  nerves  and  vessels,  are  necessarily  divided ;  while  nothing  of 
the  kind  takes  place  if  the  preceding  precepts  are  followed. 

J.  Fabrice  taught  that  the  needle  should  be  entered  at  the  junction  of  the 
cornea  and  sclerotica.  Others,  with  Purman,  say  a  half  line  from  the  former ; 
some  at  a  line  and  a  half;  many  at  two,  two  and  a  half,  and  three  lines. 
There  are  some  who  say  the  breadth  of  the  straw,  the  middle  of  the  white  of 
the  eye,  &c.  Those  who  prefer  such  a  considerable  distance,  are  fearful  of 
wounding  the  ciliary  circle  or  processes.  Among  others,  there  are  some,  who, 
like  Platner,  dread  injuring  the  tendon  of  the  abductor  muscle,  or  the  sixth 
pair  of  nerves.  The  object  of  Fabricius  in  going  so  near  the  cornea  was  to 
arrive  more  directly  in  front  of  the  cataract,  whilst  most  others  are  more 
careful  to  avoid  the  retina.  But  as  to  the  truth  in  this  case,  two  tilings  are 
certain:  that  the  pricking  of  the  tendon  of  the  straight  muscle  produces  no 
inconvenience ;  and  that  the  wounding  of  the  retina  is  inevitable,  when  we 
penetrate  through  the  sclerotica,  whatever  may  be  the  distance  from  the  cor- 
nea; it  therefore  follows  as  a  general  rule,  that  there  is  less  danger  in  enter- 
ing too  far  from,  than  too  near  to  the  ciliary  bodies. 

The  object  in  view  in  turning  the  back  of  the  needle  forwards  while  it 
passes  under  and  before  the  cataract,  and  thence  into  the  anterior  chamber 
through  the  pupil,  is  to  preserve  the  retina  and  iris  as  much  as  possible  from 
the  action  of  its  point  or  edges.  It  is  passed  into  the  anterior  chamber,  that 
it  may  give  assurance  that  it  is  not  entangled  between  the  capsule  and  lens. 
The  tearing  of  the  capsule  is  more  delicate  and  more  important  than  generally 
imagined.  It  should  be  begun  at  the  circumference.  If  it  be  commenced  at 
the  centre,  it  will  afterwards  be  very  difficult  to  detach  the  shreds  and  prevent 
a  secondary  cataract.  The  best  plan  is  certainly  to  depress  both  the  lens 
and  its  capsule  together,  without  any  laceration,  as  some  authors  have  recom- 
mended ;  but  how  are  we  to  get  a  membrane  so  thin  to  the  bottom  of  the  eye 
without  dividing  it,  however  slight  its  adhesions  ? 

To  depress  the  opaque  body,  it  is  not  sufficient  barely  to  seize  it  with  the 
point  of  the  needle.  The  concavity  of  the  instrument  must  exactly  embrace 
it;  otherwise  it  will  become  reversed  with  the  least  pressure,  either  upwards 
or  downwards.  The  depression  once  commenced,  the  needle  becomes  a 
lever  of  the  first  kind,  its  fulcrum  being  the  opening  in  the  sclerotica;  to 
continue  its  action  outwards,  backwards,  .and  downwards,  it  is  necessary  that 
the  convex  side  of  the  point  of  the  instrument  should  be  gradually  turned 
upwards,  at  the  same  time  that  we  are  performing  the  other  movements  before 
mentioned. 

When  the  cataract  is  depressed,  some  recommend  the  patient  to  turn  his  eye 
upwards  and  inwards,  believing  thereby,  but  erroneously,  that  the  lens  will 
be  sunk  deeper.  By  not  withdrawing  the  needle  for  some  seconds,  the  com- 
pressed cells  of  the  vitreous  humor  are  allowed  to  take  theirnatural  positiop 


OPERATIVE  SURGERY.  S41 

and  imprison,  as  it  were,  the  cataract,  which  would  almost  necessarily  return 
if  it  were  left  immediately.  The  slight  rotatory  movements  that  are  given  to 
the  instrument  before  withdrawing  it,  are  intended  to  detach  it  with  the 
slightest  possible  disturbance  of  the  lens,  so  as  the  more  surely  to  leave  that 
body  in  its  new  situation. 

If,  in  spite  of  all  these  precautions,  the  cataract  rises  again,  it  is  necessary 
to  seize  it  anew,  and  to  depress  it  more  deeply ;  continuing  to  do  so  until  it 
rises  no  more.  If  it  be  soft  the  instrument  bursts  it,  and  then  it  is  but  rare 
that  the  whole  is  depressed  below  the  pupil.  In  that  case,  if  it  be  impossible 
to  carry  the  pieces  backwards,  the  operator  should  endeavor  to  reduce  it  to 
small  morsels,  and  then  force  it  into  the  anterior  chamber,  to  be  dissolved  by 
the  aqueous  humor  and  absorbed.  Any  opaque  mass  that  may  remain  after  a 
depression  of  the  lens,  should  also  be  carried  there.  This  is  easily  done  with 
such  portions  as  are  completely  free.  This  unhappily  is  not  the  case,  however, 
when  we  have  to  do  with  pieces  of  the  capsule  of  the  lens.  Then  practice 
and  address  are  requisite  to  pierce  them,  near  the  centre  of  their  base,  with 
the  point  of  the  needle,  and  tear  them,  by  rolling  them  on  themselves  or  by 
dragging  them  away.  It  is  important  to  leave  none  such  in  the  visual  axis, 
for  their  opacity  will  necessarily  compromise  more  or  less  the  success  of  the 
operation.  If  the  capsule  adhere  to  the  iris,  it  must  first  be  separated,  taking 
as  much  care  as  possible  of  the  iris.  If  any  circumstance  prevents  this  dis- 
junction, we  are  reduced  to  the  necessity  of  displacing  the  lens  first,  and 
then  to  operate  upon  this  portion  of  the  capsule,  as  above  directed. 

If  the  cataract  be  milky,  and  the  capsule  be  affected,  as  is  almost  always  the 
case,  it  is  indispensable  to  carry  the  instrument  to  the  centre  of  the  pupil 
before  dividing  any  thing.  Otherwise,  the  opaque  liquid  escaping  into  the 
eye,  clouds  the  humors  and  prevents  the  operator  from  seeing  what  he  is 
doing.  Yet,  if  this  inconvenience  should  occur,  whether  the  needle  were  or  were 
not  in  the  anterior  chamber,  he  should  simulate  as  exactly  and  with  as  much 
prudence  as  possible  the  movements  necessary  to  tear  away  all  that  may 
require  removal. 

b.  Process  of  Petit  and  Ferrein.' — At  the  beginning  of  the  last  century  some 
authors  maintained,  against  Hecquet,  de  la  Hire,  &c.,  that  the  seat  of  the 
cataract  is  always  in  the  chrystalline  lens,  and  not  in  its  membrane.  Petit, 
the  physician,  adopting  this  hypothesis,  thought  of  depressing  the  opaque  body 
without  touching  the  anterior  leaf  of  the  capsule.  After  thrusting  the  needle 
into  the  posterior  chamber  to  attain  his  object,  Petit  inclined  one  edge  out- 
wards and  backwards,  by  which  means  he  opened  the  vitreous  body,  and  then 
carried  it  to  the  external,  inferior,  and  posterior  part  of  the  capsule,  which  he 
tore ;  then  grappled  the  lens  and  conducted  it  into  the  hyaloid  body,  conform- 
ing otherwise  to  the  general  rules  of  depression. 

This  modification,  which  was  revived  some  years  after  by  Ferrein,  who 
claimed  the  honor  of  its  invention,  was  afterwards  defended  by  Henkel, 
Gunz,  Gentil,  Walborn,  &c.  By  leaving  the  anterior  capsule  untouched, 
they  expected  to  establish  sight  more  perfectly  than  by  the  common  method. 
It  was  thought  that  by  falling  upon  a  convex  membrane,  the  luminous  rays 
would  scarcely  perceive  the  absence  of  the  lens ;  that  the  accordance  of  the 
focus  of  vision  would  be  maintained,  and  that  there  would  be  no  need  of 
glasses  after  the  operation.   To  these  reasons  it  was  objected,  that  the  capsule 


34£  NEW   ELEMENTS  OP 

itself  was  often  tiie  seat  of  the  affection,  either  alone  or  conjointly  with  the 
lens;  that  still  more  frequently  it  would  become  opaque  after  the  operation, 
and  produce  a  secondary  membranous  cataract;  and,  consequently,  so  far  from 
attempting  to  save  it,  it  should  be  as  completely  destroyed  as  possible ;  and, 
finally,  that  by  depositing  it  in  the  vitreous  humor,  instead  of  depressing  it, 
the  patient  is  exposed  to  serious  accidents. 

c.  Process  of  the  Jtuthor. — The  last  objection  adduced  by  the  adversaries 
of  Petit  is  the  only  one  destitute  of  foundation.  If  the  rupture  of  the  vitreous 
body  be  dangerous,  the  operation  by  depression  could  scarcely  ever  succeed, 
for  it  is  almost  impossible  to  prevent  this  effect.  If  the  lens  be  not  drawn  in 
some  manner,  in  spite  of  the  operator,  into  the  vitreous  body,  how  would  it 
ever  remain  depressed,  repulsed,  as  it  would  be  continually  by  the  natural 
elasticity  of  the  hyaloid  membrane  ?  Besides,  in  passing  it  between  the  shell 
and  the  humors  of  the  eye,  how  can  it  be  prevented  from  tearing  the  retina, 
and  making  a  havoc  an  hundred  times  worse  than  the  incision  of  the  vitreous 
humor?  Starting  from  this  idea,  M.  Bretonneau  has  adopted  the  method  of 
Petit,  with  a  slight  modification ;  that  is,  after  forming  a  passage  for  the  lens 
in  the  vitreous  humor,  he  tears  it  away  from  before  as  in  the  ordinary  process. 
Having  witnessed  the  success  of  this  method  in  the  hospital  of  Tours,  in  1818 
and  1819,  I  have  since  used  it  on  all  occasions,  and  have  never  had  cause  of 
regret.  I  perform  it  in  the  following  manner ;  the  needle  is  directed  as  if  to 
pass  behind  the  cataract;  when  it  has  penetrated  about  four  lines  deep  before 
changing  the  position,  it  is  to  be  inclined  downwards,  backwards,  and  outwards, 
in  order  to  open  largely  the  hyaloid  mass ;  the  back  is  then  turned  to  the 
iris,  and  by  elevating  the  handle,  the  point  is  made  to  pass  under  the  inferior 
edge  of  the  lens,  to  be  afterwards  brought  into  the  pupil ;  the  anterior  leaf 
of  the  capsule  is  then  torn  up,  the  opaque  body  seized  and  pushed  with  a  regu- 
lar swaying  motion  in  the  direction  of  a  line  from  the  great  angle  of  the  eye  to 
the  mastoid  apophysis  on  the  same  side.  By  this  means  we  escape  wounding 
the  iris ;  the  elasticity  of  the  vitreous  body,  which  is  sometimes  very  great, 
cannot  offer  the  least  resistance,  and  the  cells  of  the  membrane  immediately 
closing  the  passage,  oppose  successfully  the  reascension  of  the  opaque  body. 

Hyalonyxis. — An  itinerant  oculist,  Mr.  Bowen,  has  published  a  pamphlet 
in  which  he  brings  forward  a  method  which  he  calls  hyalonyxis,  and  which  he 
thinks  preferable  to  all  others.  His  aim  is  to  traverse  the  vitreous  body  from 
behind  forwards,  and  downwards ;  then  open  the  posterior  leaf  of  the  capsule 
and  displace  the  lens,  after  the  manner  of  Petit  and  Ferrein,  without  touching 
the  anterior  portion  of  the  envelope.  To  accomplish  this,  Mr.  Bowen  pierces 
the  sclerotica  at  four  lines  from  the  cornea;  then  pushes  the  needle  towards 
the  cataract,  behind  which  he  stops ;  breaks  open  the  capsule,  without  going  as 
far  as  the  pupil ;  seizes  the  opaque  body  and  buries  it  among  the  cells  of  the  hya- 
loid sac,  using  the  instrument  throughout  as  a  crotchet  or  lever.  The  results, 
according  to  the  book,  are  highly  favorable  to  hyalonyxis,  scarcely  averaging 
two  failures  in  twenty  cases.  From  it  we  may,  at  least,  conclude  that  there 
is  little  danger  in  wounding  the  retina  and  vitreous  bo.ly.  For  the  rest,  I  see 
no  advantage  in  going  so  far  from  the  cornea,  nor  need  I  reiterate  the  incon- 
veniences of  leaving  undestroyed  the  anterior  support  of  the  lens.  Besides, 
nothing  prevents  us  from  preserving  it  by  the  method  I  have  already  indi- 
cated. 


OPERATIVE    SURGERY.  343 

Scleroticotomy. — Some  years  ago,  I  scarcely  know  why,  M.  Gensoul  intro- 
duced a  strange  operation,  which  he  soon  after  abandoned,  but  which  M.  lloux 
has  thought  proper  to  attempt  at  La  Charite,  in  Paris.  The  original  idea 
belongs,  I  think,  to  B.  Bell.  A  small  incision  is  first  made  behind  the  iris,  at 
the  junction  of  the  sclerotica  with  the  cornea;  through  it  the  surgeon  intro- 
duces a  kind  of  curette  before  the  lens,  depresses  that  body,  and  the  operation 
is  finislied.  The  only  advantage  of  so  large  an  opening  of  the  sclerotica, 
would  be  in  remedying  more  easily  than  by  a  simple  puncture  a  too  great 
fullness  of  the  eye.  But  the  division  of  the  ciliary  body,  the  possible  escape 
of  the  humors,  and  the  impossibility  of  carrying  the  cataract  far  enough 
back,  are*  sufficient  a  priori  to  make  us  reject  it,  if  even  the  attempts  of  its 
inventor,  and  of  M.  Roux,  had  not  shown  its  inconveniences  and  dangers. 

/.  Retroversion  or  Reclination. — After  Pott,  some  English  and  German  ope- 
rators, Willburg  and  Schifferli  among  others,  have  advanced  the  idea,  that 
instead  of  depressing  the  lens  it  would  be  better  to  turn  it  over.  It  cannot 
be  denied  that  this  modification  renders  the  manual  part  of  the  treatment 
more  simple  and  easy.  After  the  anterior  capsule  has  been  torn,  it  is  siifii- 
cient  to  apply  the  needle  a  little  nearer  the  upper  than  the  lower  edge  of  the 
lens.  Then,  by  pressing  upon  it,  the  lens  is  instantly  turned  upon  its  trans- 
verse axis,  its  anterior  face  being  upwards,  and  its  superior  edge  behind.  But 
if  the  opaque  body  is  to  be  carried,  besides,  into  or  under  the  vitreous  humor, 
as  recommended  by  Beer,  Weller,  &c.,  this  operation  is  then  evidently 
changed  into  the  ordinary  one;  whilst,  if  it  be  left  below  the  centre  of  the 
pupil,  in  the  posterior  aqueous  chamber,  it  is  clear  that  in  most  cases  it  will 
either  rise  again,  or  produce  such  irritation  of  the  iris  and  the  rest  of  the  eye, 
as  to  occasion  the  most  serious  consequences. 

g.  Cutting  or  Breaking  up  of  the  Lens. — After  demonstrating  that  when 
once  in  contact  with  the  aqueous  humor,  the  lens  is  dissolved  and  finally  disap- 
pears. Pott  wished  also  to  prove  that  it  is  not  indispensable  to  depress  it  below 
the  visual  axis,  but  that,  as  Warner  had  advanced,  to  reduce  it  to  fragments, 
or  even  to  open  the  capsule,  was  sufficient  to  destroy  the  disease.  Experi- 
ence has  often  confirmed  this  idea;  for  the  examples  of  dissolution  and  absorp- 
tion of  a  whole  or  a  divided  lens  are  not  rare.  As  this  method  removes  the 
most  delicate  portion  of  the  ordinary  operation,  it  is  not  strange  that  many 
oculists  have  adopted  the  opinions  of  Mr.  Adams,  who  recommends  it  in  all 
cases.  Yet  I  would  say  the  same  of  it  as  of  retroversion.  It  may  be  used 
when  the  cataract  is  soft  or  too  difficult  to  displace,  but,  in  spite  of  the  eulo- 
gies of  M.  Parmi,  it  is  less  certain  than  depression,  properly  so  called.  If  it 
be  true  that  the  fragments  of  the  lens  sometimes  dissolve  very  rapidly,  it  is 
equally  true  that  they  often  persist  for  many  months,  and  even  indefinitely, 
thereby  preventing  the  restoration  of  sight.  If  there  then  be  less  injury  done 
the  vitreous  humor,  it  is  less  easy  to  escape  injuring  the  iris.  Supposing  there 
are  some  advantages  in  leaving  the  cataract  to  be  slowly  dissolved,  they  are 
counterbalanced  by  the  inquietude  of  the  patient,  and  the  loss  of  time  between 
the  operation  and  the  restoration  of  vision. 

To  execute  this  operation  any  needle  will  serve ;  but  that  of  Beer,  or  the 
small  needle  of  M.  Lusardi,  in  the  form  of  a  pruning  hook,  seems  better  than 
that  of  Hey,  Dupuytren,  or  even  of  Scarpa  or  Bretonneau.  Although  the  lens 
may  be  broken  up  from  its  posterior  face,  it  is  as  well  to  prefer  the  anterior. 


344  NEW   ELEMENTS    OF 

that  we  may  more  surely  see  what  we  do,  and  more  certainly  avoid  the  iris.  In 
this  direction,  when  the  instrument  reaches  the  pupil,  and  when  the  capsule 
is  sufficiently  torn,  the  lens  is  cut  into  two  parts  by  the  point  and  edge  of  the 
instrument,  and  these  again  divided  into  as  small  fragments  as  possible,  the 
largest  of  which  we  endeavor  to  push  into  the  anterior  chamber.  When  the 
operation  is  performed  through  the  posterior  face  of  the  capsule,  and  with  a 
straight  needle,  the  breaking  up  is  really  more  easy,  because  the  anterior 
lamina  of  the  capsule  remains  entire,  and  because  the  lens,  enclosed  as  it 
were  in  a  sac,  is  unable  to  escape  the  action  of  the  instrument;  but  the  vitre- 
ous humor  suffers  much  more  than  by  the  other  process ;  and,  besides,  it  is  not 
uncommon  to  pierce,  at  the  first  motion,  through  and  through  the  lens  and  its 
envelope. 

h,  Tlie  Lens  passed  into  the  Anterior  Chamber. — At  the  moment  of  the  ope- 
ration the  lens  may  slip  through  the  pupil  into  the  anterior  chamber,  in  conse- 
quence of  some  movement  of  the  operator  or  the  patient.  It  also  sometimes 
gets  there  in  consequence  of  a  blow,  a  fail,  jolt,  or  any  thing  that  can  jar  the 
head,  or  produce  i/Ii  any  way  the  rupture  of  the  capsule.  This  accident  does 
not,  however,  oblige  us  absolutely  to  operate  by  extraction,  as  some  have 
thought,  to  remove  the  displaced  disc.  As  it  passed  the  pupil  to  get  into  its 
new  position,  it  certainly  may  be  made  to  repass  it  into  the  old  one ;  and  it 
would  always  be  more  agreeable,  to  both  operator  and  patient,  to  finish  the 
operation  whilst  the  needle  is  in  the  eye,  than  to  withdraw,  and  complete  the 
operation  by  incision  of  the  cornea.  In  cases  where  nothing  has  been  attempted 
before  the  accident,  it  is  no  obstacle  to  depression,  if  the  pupil  remain  dilat- 
able, and  there  be  very  little  inflammation.  M.  Dupuytren  and  Lusardi  have 
used  the  ordinary  needle  in  such  cases,  passing  it  through  the  sclerotica  and 
pupil  into  the  anterior  chamber,  securing  the  lens,  opaque  or  not,  and  then 
returning  with  it  into  the  posterior  chamber. 

t.  Ceratonyxis. — Depression,  retroversion,  and  breaking  up  of  thelens,which 
are  commonly  performed  by  scleroticonyxis,  or  sclerotico-hyalonyxis,  are  also 
sometimes  done  by  ceratonyxis ;  that  is,  by  penetrating  through  the  transpa- 
rent cornea.  This  method,  which  many  moderns  claim  the  honor  of  invent- 
ing, is  far  from  being  new.  Avicenna  speaks  of  some  operators  who  first 
opened  the  cornea,  penetrating  from  thence  to  the  lens,  which  they  then  de- 
pressed by  means  of  a  needle  which  they  called  al-mokadachet.  Abul-Kasem 
says,  positively,  that  he  had  followed  this  method.  Manget  also  gives  the 
history  of  an  English  woman  who  cured  the  cataract  by  piercing  the  cornea. 
In  Haller's  collection  a  thesis  is  found,  defended  by  Col.  de  Villars,  in  which 
this  mode  of  operating  is  much  extolled.  It  is  thus,  says  the  author,  that  birds 
recover  their  sight,  by  sinking  a  thorn  into  the  eye;  and,  according  to  Galen, 
a  goat  pointed  out  to  man  the  method  by  which  he  should  operate  for  cataract. 
In  the  eighteenth  century  Smith  revived  the  operation  of  the  Arabians.  '  Der- 
dell,  the  disciple  of  Woolhouse,  imagining  that  the  cataract  was  almost 
always  membranous,  recommended  to  pass  through  the  cornea  to  the  anterior 
lamina  of  the  capsule,  and  to  remove  thence  a  circular  disc,  leaving  a  sort  of 
window  for  the  passage  of  the  light.  Taylor  and  Richter  have  frequently 
performed  ceratonyxis  in  cases  of  milky  cataract.  Gleize,  in  France,  and 
Conradi,  in  Germany,  spoke  of  it  in  1786.  In  1785  Beer  had  tried  it  twenty- 
nine  times.     M.  Demours  had  recourse  to  it  in  1803;  the  epoch  at  which 


OPERATIVE    SURGERY.  345 

Reil  called  public  attention  to  it,  and  gave  it  the  name  it  now  bears.  But  the 
united  efforts  of  Buchorn,  from  1806  to  1811  j  of  Langenbeck,  from  1811  to 
1815 ;  of  Dupuytren,  Guille,  and  Walther,  in  1812;  Wernecke,  in  1 823;  Textor 
and  Pergin,  in  1 825,  were  necessary  to  give  it  a  place  among  the  regular 
operations  I 

The  patient  and  assistants  are  placed  as  if  for  scleroticonyxis.  A  needle, 
such  as  Bretonneau's,  for  example,  or  Langenbeck's,  which  is  sharper  and 
with  less  extent  of  cutting  edge,  is  presented  at  about  one  line  from  the  scle- 
rotica, and,  supported  by  the  back  of  the  finger  that  depresses  the  lower  lid, 
sunk  into  the  anterior  chamber  through  the  inferior  and  external  part  of  the 
cornea,  reaches  the  pupil.  The  operator  now  turns  the  concavity  of  the  instru- 
ment downwards,  having  until  then  held  it  in  the  opposite  direction  to  escape 
the  anterior  face  of  the  iris ;  opens  the  capsule  freely,  detaches  the  lens,  catches 
its  superior  edge,  and  pushes  it  down  and  turns  it  backwards,  and  endeavors 
to  sink  it  below  the  pupil  into  the  vitreous  humor,  or  what  is  better,  breaks  it 
up,  and  depresses  the  principal  fragments  when  they  cannot  be  drawn  into 
the  anterior  chamber.  He  then  turns  the  back  of  the  needle  again  downwards, 
and  withdraws  it  in  the  same  manner  that  it  was  introduced. 

Remarks. — Ceratonyxis  must  not  be  attempted  until  the  pupil  has  been 
made  to  dilate  as  much  as  possible ;  and  even  then  it  is  very  difficult  to 
avoid  pulling  its  borders  while  we  seek  to  depress  the  lens.  It  is  to  escape 
this  inconvenience,  and  especially  that  of  pricking  the  iris,  that  amongst  us 
the  straight  needle  has  been  proscribed,  and  that  we  penetrate  at  some  dis- 
tance from  the  sclerotica,  taking  care  not  to  go  too  near  the  centre  of  the 
cornea.  Neither  the  pyramidal  needle  of  Beer,  the  shoulder  which  Graefe 
has  added  to  the  ordinary  needle  to  prevent  its  penetrating  too  far,  nor  the 
needle  of  Himly,  Schmidt,  &c.,  offers,  in  reality,  any  advantage  over  those 
commonly  used  in  France,  nor  merits  further  notice.  In  animals  this  method 
is  preferable  to  all  others,  for  reasons  that  need  not  be  pointed  out.  Although 
in  the  human  species  it  may,  strictly  speaking,  be  employed  whenever  de- 
pression would  be  proper,  yet  it  should  be  chosen  only  for  the  milky  cataract 
with  children ;  with  intractable  persons,  when  the  eyes  are  very  movable, 
irritable,  or  deeply  sunk.  The  same  hand  may  be  used  on  both  eyes.  There 
is  no  risk  of  dividing  nerve  or  vessel.  The  retina  is  untouched.  The  iris  is 
not  more  endangered  than  by  the  posterior  method.  The  tissues  traversed 
have  little  sensibility,  and  the  membrane  of  the  aqueous  humor  that  Wardrop, 
Langenbeck,  and  Chelius  appeared  to  fear  so  much  to  wound,  enjoys  but  a 
very  feeble  vitality.  The  operation  is  therefore  but  a  simple  puncture,  and 
may  be  repeated  a  certain  number  of  times  without  serious  inconvenience. 
But  to  these  advantages  may  be  opposed  defects  not  less  numerous.  Adhe- 
sion of  the  capsule,  contraction  of  the  pupil,  flatness  of  the  cornea,  projec- 
tion of  the  iris,  hard,  chalky,  or  stony  cataract,  seem  all  unsuited  to  its  appli- 
cation. Properly  it  is  only  for  breaking  up  or  retroversion  of  the  lens,  that 
this  method  should  be  used.  Although  it  has  succeeded  seven  times  in  eight 
in  the  hands  of  M.  Textor ;  although  it  has  failed  but  twenty-six  times  in 
three  hundred  and  forty  five  cases  with  M.  Walther ;  once  in  six  times  with 
M.  Dupuytren,  and  four  times  in  one  hundred  and  twelve  cases  with  M.  Lan- 
genbeck, still  it  has  been  abandoned  as  a  general  method  even  by  its  warmest 
partisans.  It  is,  in  fact,  incapable  of  replacing  scleroticonvxis,  which  alone 
44 


846  NEW   ELEMENIS    OF 

permits  us  to  carry  the  lens,  without  extraction,  out  of  the  visual  axis  and 
permanently  to  fix  it  there ;  therefore  this  method  can  only  be  considered  one 
of  exception. 

j.  As  to  the  simple  puncture  of  the  cornea,  formerly  performed  by  Lehoe, 
and  more  recently  by  Wernecke,  for  the  purpose  of  favoring  the  absorption 
or  dissolution  of  the  cataract,  there  is  not  enough  proved  in  its  favor  to  entitle 
it  to  be  formally  recommended.  Nevertheless,  if,  as  cannot  be  doubted,  the 
decomposition  of  the  lens,  separated  from  its  capsule,  is  a  phenomenon  much 
more  chemical  than  vital,  we  cannot  see  why  the  evacuation  of  the  aqueous 
humor,  saturated  with  the  anomalous  substance,  would  not  favor  the  disap- 
pearance of  the  cataract  by  permitting  the  solvent  to  be  renewed.  Such  a 
practice  seems  to  me  applicable  only  to  the  consequences  of  ceratonyxis  and 
breaking  up  of  the  cataract;  that  is,  v/hen  a  greater  or  less  portion  of  the 
opaque  body  remains  out  of  the  posterior  chamber  without  disappearing. 

k.  In  Children. — In  early  age  we  can  scarcely  think  of  operating  by  extrac- 
tion. Then  the  evacuation  of  the  eye  could  scarcely  be  prevented,  as  has 
been  proved  by  Scarpa,  Ware,  Saunders,  Gibson,  M.  Lusardi,  &c.  Both 
congenital  and  accidental  cataracts  in  young  subjects  are  almost  always  liquid 
and  membranous.  Consequently  there  is  nothing  to  depress  or  to  extract. 
The  object  to  be  accomplished  is  to  lacerate  the  anterior  leaf  of  the  capsule 
as  completely  as  possible,  and  to  evacuate  it  of  tlie  matter  it  encloses.  It  is 
then  almost  immaterial  whether  we  operate  by  ceratonyxis  or  scleroticonyxis, 
at  least  when  the  pupil  is  large,  as  it  commonly  is  in  such  patients. 

The  most  difficult  matter  is  to  hold  the  patients.  Ware  laid  them  upon  a 
table,  their  heads  elevated  with  pillows ;  held  them  in  that  position  by  the  aid 
of  assistants,  and  fixed  the  eye  with  the  fingers,  whilst  another  person  elevated 
the  upper  lid  by  means  of  Pellier's  elevator.  Gibson  gives  first  an  opiate ; 
then  secures  the  refractory  in  a  sort  of  sack  open  at  both  ends,  which  is  closed 
by  draw-strings  above  the  shoulders  and  below  the  feet.  M.  Lusardi  finds  it 
more  convenient  to  set  them  upon  the  angle  of  a  table,  after  having  secured 
the  arms  around  the  body;  placing  their  legs  between  the  thighs  of  the  ope- 
rator. The  head  and  the  rest  of  the  body  is  held  by  assistants.  Then  with 
one  hand,  furnished  with  a  speculum  which  he  calls  contentive,  M.  Lusardi 
fixes  the  eye  and  holds  apart  the  lids,  whilst  he  uses  the  needle  with  the  other. 

Whether  we  penetrate  through  the  cornea  or  sclerotica,  it  is  always  necessary 
to  produce  a  true  loss  of  substance  in  the  anterior  lamina  of  the  capsule,  and  not 
a  mere  rent,  if  we  would  avoid  the  risk  of  soon  seeing  a  secondary  cataract. 
If  the  lens  possesses  much  consistence,  or  if  it  appears  necessary  to  tear  up  the 
capsule,  we  must,  as  for  the  adult,  sink  the  fragments  into  the  vitreous  humor 
or  carry  them  into  the  anterior  chamber,  where  absorption  operates  more 
promptly  than  behind  the  iris.  At  tlie  end  of  fifteen  or  twenty  days,  if  there 
remain  any  opaque  portions  at  the  place  of  the  lens,  Ware  recommends  us  to 
repeat  the  operation.  He  is  said  to  have  practised  four  or  five  times  upon  the 
same  child  with  ultimate  success.  Such  a  plan  should  be  followed,  if  the 
operator  is  convinced  that  the  fragments  of  the  cataract  cease  to  diminish. 
Perhaps  this  would  be  a  proper  case  to  try  Wernecke's  method  of  evacuating 
the  aqueous  humor  by  means  of  a  puncture  of  the  cornea. 

When  instead  of  the  left  eye,  as  I  have  heretofore  supposed,  we  operate  on 
the  right,  the  left  hand  should  be  used,  unless  it  be  in  ceratonyxis,  where. 


OPERATIVE    SURGERY..  547 

as  we  have  seen,  this  precept  is  not  necessarj.  If  both  eyes  be  aflected, 
as  soon  as  the  operation  is  finished  on  the  first,  it  is  to  be  covered  with  the 
bandage  which  till  now  has  covered  the  other,  and  that  is  immediately  to  be 
treated  in  the  same  way  as  the  first. 

Consecutive  Treatment, — When  all  is  finished,  the  patient  is  desired  to  hold 
the  lids  lightly  closed.  The  practice  of  presenting  some  object  to  be  assured 
of  the  result  of  the  operation  should  be  abandoned.  By  suddenly  reaching 
the  bottom  of  the  eye,  the  light  irritates  the  retina  too  much,  and  the  proof 
is  only  necessary  to  satisfy  a  vain  curiosity.  Especially  when  the  needle  is 
employed  it  entirely  fails  of  its  object,  for  the  disturbance  which  has  just  been 
produced  in  the  ocular  chambers  will  render  sight  at  first  very  confused, 
although  it  may  subsequently  become  very  good.  No  one  at  the  present  day 
would  think  of  following  Purman's  advice  of  applying  a  small  piece  of  gold- 
leaf  upon  the  puncture  of  the  sclerotica,  with  the  intention  of  preventing  the 
escape  of  the  aqueous  or  vitreous  humor.  Brandy  and  the  white  of  an  egg, 
employed  by  the  ancients,  and  a  thousand  other  topical  applications,  extolled 
without  cause,  are'  equally  rejected.  It  is  sufficient  to  dry  the  lids  with  a 
sponge  or  a  fine  compress,  and  then  place  over  the  eye  an  oval  piece  of  linen 
cut  in  holes,  dry  or  covered  with  cerate,  and  over  that  a  soft  fold  of  lint,  a 
bandage  with  a  T  incision  for  the  nose,  and  secured  behind  with  pins  to  the 
cap ;  and  finally,  the  taffetta  bandage,  which  covers  the  whole.  It  is  im- 
portant that  none  of  these  pieces  should  be  so  tight  as  to  compress  the  contents 
of  the  orbit.  It  would  even  be  better,  perhaps,  to  imitate  Ware,  who  applied 
a  simple  piece  of  linen  to  the  eye,  and  proscribe,  as  some  others  do,  every 
thing  that  could  embarrass  the  head.  In  no  case  must  the  subject  be  allowed 
to  make  any  effort  or  movement.  He  is  to  be  carried  to  bed,  and  laid  upon 
his  back,  his  shoulders  and  head  raised  with  pillows.  He  is  to  be  surrounded 
by  dark  thick  curtains  so  as  to  prevent  the  ingress  of  light,  and  recommended 
to  the  most  perfect  repose  of  mind  and  body.  He  must  be  allowed  only  light 
soups  for  three  or  four  days.  If  the  bowels  be  not  regular,  glysters,  or  even 
laxatives,  should  be  given.  He  may  be  allowed  relaxing  drinks,  such  as  whey, 
barley-water,  veal  soup,  decoction  of  tamarinds,  and  the  like.  Bleeding  must 
be  used  upon  the  occurrence  of  fever, or  when  pain  in  the  head  indicates  it.  When 
nausea  or  vomiting  comes  on,  laudanum  in  the  dose  of  a  demigros  in  an 
injection,  as  recommended  by  Scarpa,  produces  a  happy  effect.  In  ordinary 
cases  the  infusion  of  linden,  violet,  or  poppy,  sweetened  with  syrup,  are  the 
drinks  commonly  used.  Insomnia  and  nervous  agitation  are  combated  by 
an  ounce  of  syrup  of  poppies  in  a  julep.  When  no  serious  consequences 
have  followed  the  operation,  the  eyes  may  be  uncovered  on  the  fourth 
day.  The  patient  begins  by  sitting  up.  The  linens  being  removed,  the  lids 
are  moistened  and  cleansed  by  the  patient  himself,  with  a  piece  of  sponge 
and  warm  water.  As  soon  as  they  are  dried  the  patient  may  open  his  eyes, 
the  curtains  being  carefully  closed  at  the  same  moment.  When  the  pupil 
shows  well,  it  is  not  prudent  at  that  time  to  inquire  further  into  the  restoration 
of  sight ;  the  dressing  is  to  be  renewed  each  day  in  the  same  way  as  for  simple 
ophthalmia,  as  long  as  the  eye  continues  red.  If  every  thing  goes  on  well,  a 
little  more  light  every  day  is  admitted  to  the  eye,  so  that  at  the  end  of  from 
twelve  to  twenty  days  they  may  be  uncovered  entirely,  except  a  shade  of  colored 
taffeta.     The  diet  need  not  then  continue  so  strict,  and  in  the  course  of  the 


348  NEW   ELEMENTS   OF 

second  week  the  patient  may  be  allowed  by  degrees  to  resume  his  usual  regi- 
men. If  it  be  otherwise,  it  is  necessary  to  attend  to  the  symptoms  which 
present  themselves ;  using  appropriately  either  bleeding,  local  or  general,  pur- 
gatives, revulsives,  or  such  collyria  as  would  be  suited  to  the  same  kind  of 
disease  produced  from  any  other  cause. 

B. — Extraction. 

Cataract  was  as  yet  but  imperfectly  known,  as  to  its  nature  or  situation, 
when  its  removal  was  first  undertaken.  Antylus,  according  to  Sprengel, 
opened  the  cornea,  and  seized  the  opaque  pellicle  through  the  pupil,  in  order 
to  extract  it  by  means  of  a  needle.  Lathyrus  operated  in  the  same  manner. 
Ali-Abbas  and  Avicenna  speak  of  extraction  as  a  customary  method.  Abul 
Kasem  says  he  learned  of  an  inhabitant  of  Irack,  that  in  that  country  they 
introduced  into  the  anterior  chamber  a  short  needle,  which  served  to  pump 
the  cataract.  Avenzoar  and  Iza-Ebn-Ali,  who  rejected  it,  assert  that  in 
their  time  exti'action  was  customary  in  Persia.  G.  de  Chauliac  himself  has  not 
forgotten  it,  and  Galeatius,  the  commentator  on  Rhazes,  who  extols  it  highly, 
represents  himself  as  the  inventor.  Completely  unknown  to,  or  abandoned 
by  the  authors  of  the  middle  ages,  this  method  of  operating  seems  not  to  have 
been  restored  to  practice  until  towards  the  close  of  the  seventeenth  or  com- 
mencement of  the  eighteenth  century.  In  1694,  Freytag  opened  the  cornea 
after  the  manner  of  the  Arabians,  and  then  drew  from  the  eye  an  opaque  mem- 
brane, which  was  doubtless  the  anterior  leaf  of  the  capsule  of  the  lens.  Wool- 
house  passed  the  anterior  chamber  with  a  needle  so  constructed  as  to  be 
susceptible  of  transformation  at  pleasure  into  forceps,  which  served  him  for 
seizing  the  opaque  body  and  abstracting  it.  Petit,  performing  in  the  presence 
of  Mery  the  extraction  of  a  cataract  which  had  fallen  into  the  anterior  cham- 
ber, surprised  his  assistants  by  showing  them  an  opaque  lens  instead  of  the 
pellicle  they  expected  to  see.  Saint  Yves  attempted  to  extract  the  lens,  but 
without  success,  which  induced  him,  we  cannot  see  why,  to  maintain  more 
strongly  than  ever  that  the  cataract  has  not  its  seat  in  the  body  of  the 
lens. 

Yet  these  various  attempts  had  scarcely  fixed  public  attention,  when  Daviel, 
in  1748,  submitted  his  new  method  to  thejudgmentof  the  academy,  endeavor- 
ing to  prove  that  extraction  is  infinitely  preferable  to  depression.  With  a  broad 
flexible  lance-shaped  needle  he  opened  the  inferior  part  of  the  cornea,  and 
then  enlarged  the  opening  by  means  of  another  needle,  smaller  than  the  first, 
cutting  on  both  sides,  or  with  a  pair  of  small  curved  scissors.  A  spatula  of 
gold  to  separate  the  lips  of  the  incision,  a  needle  of  the  same  metal  to  oj)en 
the  capsule,  a  curette  to  favor  the  escape  of  the  lens  or  its  integuments,  were 
also  necessary.  The  lens  having  fallen  into  the  anterior  chamber,  he  was 
"bliged  to  put  his  plan  in  use  for  the  first  time,  in  1745 ;  after  that  he  entirely 
renounced  depression.  One  hundred  and  eighty-two  successful  cases  out  of 
two  hundred  and  six  operations  announced  to  the  academy,  made  a  lively 
impression  there,  as  well  as  upon  the  public  generally ;  and  although  Caque, 
of  Rheims,  could  report  but  seventeen  completely  successful  cases  out  of 
thirty-four  operations,  each  of  them  was  eager  to  repeat  his  attempts. 

Pallucci,  who  pretended,  in  1752,  to  have  practised  extraction  before  Daviel, 


OPERATIVE    SURGERY.  349 

opened  the  cornea  from  the  less  to  the  greater  angle  with  a  knife,  the  point 
of  which,  being  considerably  elongated,  r'esembled  a  sort  of  needle.  Pojet 
invented  a  narrow  instrument,  pierced  near  the  point  so  as,  in  traversing  the 
eye,  to  pass  a  thread  suited  to  sustain  this  organ  while  he  completed  the  flap 
of  the  cornea.  La  Faye  proposed  to  supersede  all  the  instruments  of  Daviel 
by  a  knife  in  the  form  of  a  lancet,  a  little  straightened,  slightly  swelled  on  one 
of  its  faces,  the  back  dull  almost  to  the  point ;  he  added  a  cystitome — a  kind 
of  triangular  pike  supported  by  a  spring,  and  inclosed  in  a  sheath  swelled  in  the 
middle  so  as  to  resemble  the  body  of  a  syringe.  Soon  after  Berenger  modi- 
fied the  ceratotome  of  La  Faye,  giving  it  greater  breadth ;  he  made  one  side 
plane,  the  other  convex  and  much  thicker  towards  its  back.  Siegerist  gave 
still  greater  length  to  the  point  of  the  knife  of  Pallucci,  in  order  to  open  the 
capsule  whilst  crossing  the  anterior  chamber.  But  Jung  has  well  remarked, 
that  a  cataract  needle  is  the  best  cystitome.  At  tiiis  juncture  in  the  state  of 
the  professional  mind  upon  the  subject,  appeared  Richter,  in  Germany ;  Wen- 
zel,  in  France;  and  Ware,  in  England;  who  have  decisively  established  the 
rules  for  extraction. 

Operation. — Two  methods  have  been  proposed  for  extracting  cataract.  One, 
little  known  in  France,  is  called  scleroticotomy ;  the  other,  almost  the  only 
one  used,  is  called  ceratotomy.  The  same  preparations  are  applicable  to  both. 
The  dressings  are  similar  to  those  necessary  for  depression.  Nevertheless, 
the  position  of  the  patient,  the  assistants,  and  the  operator  require  precautions 
a  little  more  minute  than  in  the  latter  method.  It  is  for  extraction  especially 
that  Richter  and  Beer  insist  upon  the  necessity  of  a  solid  and  vertical  back 
to  the  seat,  against  which  it  will  always  be  more  easy,  they  say,  to  maintain 
immovably  the  head  of  the  patient,  than  against  the  breast  of  an  assistant.. 
The  horizontal  position,  proposed  by  some  one,  boasted  of  by  Rowley  and 
Pamard,  and  which  appears  to  offer,  in  fact,  some  advantages,  by  rendering 
it  less  easy  for  the  humors  to  escape  at  the  moment  of  the  operation,  is,  how^ 
ever,  but  rarely  preferred ;  no  doubt  because  it  is  somewhat  embarrassing  to 
the  surgeon.  I  have  tried  it  twenty-five  times,  and  I  must  confess  I  have  not 
been  able  to  comprehend  why  it  has  not  been  more  frequently  used.  In 
operating  in  this  way  it  is  necessary  for  the  surgeon  to  place  himself  on  the 
side  of  the  affected  eye.  But  if  the  patient  is  to  be  seated,  it  is  then,  if  not 
indispensable,  at  least  more  convenient  for  the  surgeon  to  operate  standing 
up  before  him  than  seated. 

The  speculum  invented  by  F.  de  Aquapendente,  afterwards  used  by  Sharp, 
modified  by  Heister,  De  Witt,  &c. ;  the  ring  of  Bell  and  Assalini,  which  M. 
Lusardi  has  mounted  on  a  handle  and  reproduced  under  a  new  form ;  the  ele- 
vators of  Sommer,and  all  other  instruments  invented  to  separate,  raise,  or  de- 
press the  eyelids — ^useful  if  we  have  not  suiSlciently  adroit  assistants — are  ad- 
vantageously superseded  by  the  fingers.  Almost  all  are  liable  to  compress  and 
empty  the  eye.  The  same  may  be  said  of  theophthalmostats,  amongst  which 
may  be  distinguished  the  forceps  of  Ten-Haaf ;  the  pike  of  Pamard,  which 
latter  Casamata  curved  into  the  form  of  an  S,  that  it  might  better  accommodate 
itself  to  the  nose — which  Rumpelt  fixed  upon  a  tliimble,  that  he  might  use  it 
with  the  middle,  whilst  the  index  finger  of  the  same  hand  pressed  down  the 
inferior  eye-lid,  and  which  Demours  wished  still  further  to  modify  by  mount- 
ing it  on  a  thimble  open  at  both  ends.    Yet  I  do  not  know  that  the  trefoil  of 


S50  NEW   ELEMENTS   OF 

M.  Pamard,  such  as  the  grandson  of.  the  inventor  represented  it  to  us,  in  1825, 
really  merits  the  reproaches  that  have  been  cast  upon  it.  Its  point,  a  line  and 
a  quarter  long,  is  limited  by  a  transverse  shoulder-piece.  Curved  in  such  a 
manner  as  to  be  applied  without  pain  to  the  nose,  its  shank  is  mounted  upon 
a  handle,  which  is  seized  in  the  same  manner  as  a  pen  in  >vriting,  so  as  to  force 
with  one  hand  the  point  into  the  cornea,  one  line  from  the  sclerotica,  at  the 
same  time  that  with  the  other  we  carry  the  knife  to  a  point  diametrically  op- 
posite, at  one  half  of  a  line  only  from  the  circle  of  the  iris.  The  inventor 
intended,  very  correctly,  that  these  two  instruments  should  be  applied  and 
withdrawn  together.  In  this  manner  we  could  operate  with  the  same  hand 
on  both  sides,  and  I  can  conceive  that  a  great  deal  of  practice,  and  a  perfect 
accordance  in  the  action  of  the  trefoil  and  the  ceratotome,  could  render  such 
an  instrument  much  more  useful  than  is  generally  imagined.  I  find  it  less 
dangerous,  for  example,  than  the  two  fingers  of  the  assistant  and  the  operator 
placed  at  the  larger  angle  of  the  eye,  as  directed  by  Ware,  to  prevent  it  from 
rolling  inwards,  and  to  compress  it  until  the  moment  the  knife  finishes  the  flap 
of  the  cornea. 

1st.  Sderoticotomy.  — After  experiments  on  the  dead  body,  B.  Bell  asserted 
that  it  was  possible  to  extract  the  cataract  by  the  sclerotica  as  well  as  through 
the  cornea.  This  idea,  which  Earl  was  the  first  to  practise  on  the  living  sub- 
ject,  being  revived  by  L.  Lebel,  has  been  definitely  adopted  by  M.  Quadri, 
of  Naples,  who  founds  upon  it  his  new  method — sderoticotomy.  An  incision 
three  lines  long  is  first  made  witlf  any  ceratotome  whatever  upon  the  sclero- 
tica, two  lines  from  the  cornea.  The  lens  and  its  envelope  are  then  seized 
by  means  of  a  small  pair  of  forceps,  and  the  whole  removed  by  the  external 
angle  of  the  eye.  Pursuing  this  plan,  M.  Quadri  affirms  he  has  had  but  four 
unsuccessful  cases  out  of  twenty-five  operations.  The  first  step  of  this  is 
less  delicate,  and  perhaps  less  exposed  to  immediate  accidents,  than  the  same 
in  the  ordinary  methods.  It  cannot  be  very  diflicult  to  seize  the  cataract ;  but 
liow  is  it  to  be  held  so  surely  as  to  make  it  pass  through  the  opening  without 
great  danger  of  emptying  the  eye  ?  How  can  we  believe  that  so  large  an  inci- 
sion of  the  three  principal  tunics  of  the  eye  will  not  be  most  frequently 
a-ccompanied  by  internal  hemorrhage,  by  wounds  of  ciliary  nerves  or  vessels, 
and  be  followed  by  consequences  much  more  serious  than  those  which  succeed 
liie  opening  of  the  transparent  cornea  ? 

2d.  Ceratotomy. — Extraction,  properly  so  called,  is  divided  into  three  prin- 
cipal steps :  the  incision  of  the  cornea,  the  opening  of  the  capsule,  and  the 
expulsion  or  extraction  of  the  lens.  The  instruments  used  for  effecting  it 
have  been  greatly  varied,  and  are  as  yet  far  from  being  the  same  in  the  hands 
of  all  operators.  In  France  the  knife  of  Wenzel  is  in  common  use ;  it  differs 
from  that  of  La  Faye  only  in  having  its  faces  alike  and  perfectly  plain.  Some 
operators,  however,  prefer  the  ceratotome  of  Richter,  the  blade  of  which, 
being  very  sharp,  enlarges  gradually  from  the  point  to  the  handle,  so  that  it 
can  cut  or  divide  one  half  of  the  circumference  o§  the  cornea,  whilst  crossing 
the  anterior  chambei-.  That  of  A.  Pamard  resembles  the  half  of  a  myrtle 
leaf,  and  has  on  its  superior  edge,  which  is  straight  and  dull,  a  small  rib  to  aug- 
ment its  strength.  The  knife  of  Ware,  generally  used  in  England,  is  almost 
similar  to  that  of  Richter,  and  the  instrument  of  Beer,  so  much  boasted  of 
ifi  Germany,  differs  from  it  only  in  the  greater  breadth  of  its  point  and  some- 


OPERATIVE    SURGEUY.  S51 

ivhat  less  length  of  blade,  which  is  also  a  little  broader.  Berenger  has  pro- 
posed an  instrument,  convex  on  one  side,  plane  on  the  other,  and  a  little  wider 
than  that  of  La  Faye.  Lobstein  widened  it  still  more,  and  lengthened  the 
point.  With  this  form,  its  convex  face  turned  behind  protects  the  iris,  whilst 
its  plane  face  glides  verj  easily  behind  the  cornea.  Slightly  modified  by  B. 
Bell,  this  knife  has  since  been  improved  by  Jung,  one  of  the  ablest  cotempo- 
raries  of  Beer.  According  to  Sprengel,  the  ceratotome  of  Jung,  convex  on  both 
faces  and  cutting  with  both  edges,  is  very  short,  and  a  little  broader  than  is 
necessary  to  divide  at  one  cut  the  semicircle  of  the  cornea.  On  the  contrary, 
according  to  M.  Harel,  it  should  be,  like  that  of  Lobstein,  convex  only  on  its 
posterior  face,  and  resembling  a  sort. of  guillotine.  Finally,  that  of  Barth  is 
distinguished  from  the  preceding  by  the  furrow  which  it  presents  near  the 
back,  on  one  of  its  faces. 

In  the  midst  of  such  abundance,  the  most  important  matter  is  the  selection 
of  an  instrument  of  such  form  and  dimensions  as  will  permit  the  complete 
division  of  one  half  of  the  cornea,  whilst  traversing  in  a  direct  line  the  an- 
terior chamber,  and  without  permitting  the  escape  of  the  aqueous  humor 
before  the  completion  of  the  incision.  To  accomplish  this  object,  its  blade 
must  be  of  a  triangular  form,  one  inch  long,  three  lines  wide  at  the  heel, 
slightly  convex  on  both  sides,  a  little  stronger  towards  its  back  than  towards 
its  edge,  and  becoming  thicker  by  degrees  from  the  point  to  the  handle. 
Accordingly,  the  knife  of  Richter,  a  little  shortened,  as  Beer  recommended, 
appears  to  me  preferable  to  all  others  ;  to  that  of  Wenzel  in  particular,  and 
even  that  of  Lobstein,  as  modified  by  Jung.  Yet  it  is  evident,  that  in  a  case 
of  absolute  necessity,  we  might  accomplish  our  pui^ose  with  a  simple  lancet, 
the  little  hooked  knife  of  Sharp,  a  sharp  bistoury,  or,  in  fine,  with  an  instru- 
ment of  almost  any  kind.  We  therefore  speak  of  what  is  most  convenient, 
not  of  what  is  absolutely  necessary. 

The  second  step  in  the  operation  has  also  given  much  exercise  to  the  indus- 
try of  surgeons.  The  needle  of  Thuraud,  the  lancet  of  Tenon,  that  of  Hell- 
man,  Durand,  and  Grandjean,  the  stylet  of  Mursinua,  the  cystitome  of  La 
Faye  himself,  with  or  without  the  modifications  of  Rey,  are  generally  aban- 
doned. The  hook  of  Boyer  would  have  fallen  into  equal  desuetude,  if  the 
curette  of  Daviel,  which  is  yet  sometimes  used,  were  not  mounted  with  it 
on  the  same  handle.  The  new  cystitome  proposed  by  M.  Bancal,  founded 
on  the  same  principles  as  that  of  La  Faye,  from  which  it  differs,  however,  in 
the  flattened  form  of  its  body,  and  in  incising  the  capsule  from  the  greater 
towards  the  smaller  angle,  in  a  semilunar  direction,. and  not  by  a  simple 
puncture,  will  probably  share  the  same  fate.  The  reasons  urged  in  its  favor 
do  not  prevent  the  substitution  of  the  point  of  a  ceratotome,  or  a  common 
needle.  A  straight  and  delicate  forceps,  carrying  a  hook  at  the  end,  like 
that  of  Reisenger  ;  the  straight  forceps  of  Blemer;  or  the  toothed  forceps  of 
Beer — such  ocular  forceps,  in  fine,  as  may  be  found  at  any  cutler's — a  crooked 
needle,  a  small  spatula  or  curette  of  gold,  and  the  syringe  of  Anel,  which 
may  be  useful  for  detaching  or  bringing  away  some  of  the  shreds  of  the  cap- 
sule or  pieces  of  the  lens,  after  the  extraction — may  also  be  placed  with  the 
knife  and  the  needle  beside  the  operator. 

a.  Inferior  Keratotomy. — First  Step. — Tlie  patient  and  the  assistants  being 
placed  as  for  deoression,  the  surgeon  draws  down  the  inferior  eye-lid  with  the 


352 


NEW  ELEMENTS    OF 


index  finger,  which  he  applies  at  the  same  time  upon  the  caruncula  lachry- 
malis,  in  order  to  sustain  the  globe  of  the  eje  on  the  inside  ;  then  seizing  the 
cataract  knife  with  the  other  hand,  and  placing  the  point  at  a  half  line  or  a 
line  fi'om  the  sclerotica,  and  resting  the  end  of  the  little  finger  on  the  temple, 
he  pushes  the  knife  without  hesitancy  into  the  anterior. chamber,  perpendicu- 
larly to  the  axis  of  the  cornea,  a  little  above  its  transverse  diameter,  and 
from  the  side  of  the  external  angle  of  the  eye.  Immediately  after,  he  in- 
clines the  handle  of  the  knife  backwards,  without  which  precaution  the  point 
could  not  fail  to  wound  the  iris,  and  pushing  it  horizontally,  with  firmness, 
to  the  point  of  the  cornea  directly  opposite,  until  it  pierces  it  .again  from 
within  outwards,  urges  it  forward  in  this  same  line  without  pressing  upon  its 
cutting  edge ;  taking  care  never  to  turn  it  outwards,  but  keep  one  of  its  faces 
exactly  parallel  with  the  anterior  face  of  the  iris,  whilst  the  other  looks 
towards  the  front  of  the  eye,  until,  by  the  continuance  of  its  progress,  it  has 
entirely  divided  the  inferior  half  circle  of  the  cornea  as  near  as  possible  to 
the  sclerotica  ;  that  is  to  say,  at  a  line,  or  a  half  line  from  the  great  circum- 
ference of  the  iris.  At  the  moment  the  knife  terminates  the  section,  the  least 
pressure  would  be  extremely  dangerous,  requiring,  consequently,  the  greatest 
caution  to  avoid  it.  At  that  instant  the  assistant  must  let  go  the  eye-lid, 
which  the  patient,  to  whom  are  accorded  some  seconds  to  recover  his  self- 
possession,  closes  gently. 

Second  Step. — After  having  gently  wiped  the  region  of  the  eye,  the  sur- 
geon, or  the  assistant,  raises  a  second  time  the  upper  eye-lid,  taking  great 
care  not  to  touch  the  globe  of  the  eye,  and  presenting,  with  the  other  hand, 
the  back  of  the  cystitome  of  Boyer,  or  a  cataract  needle,  at  the  lowest  point 
of  the  incision,  he  penetrates  from  thence  through  the  pupil  at  its  upper 
part,  and  carries  the  instrument  from  one  side  to  the  other  in  such  a  manner 
as  to  divide  the  envelope  of  the  chrystalline  freely  with  the  point  of  the 
instrument,  the  concavity  of  which  should  be  kept  downM^ards.  When  both 
eyes  are  to  be  operated  on,  we  stop  here  on  the  first  until  we  have  opened 
the  cornea  and  capsule  of  the  second. 

Third  Step. — If  the  cataract  do  not  of  itself  appear  in  the  anterior  chamber, 
we  determine  its  escape  by  gentle  and  well  directed  pressure.  The  operator 
applies  the  index  finger  of  the  left  hand  against  the  inferior  part  of  the  eye ; 
with  the  right  he  places  the  handle  of  a  ceratotome,  or  the  back  of  Daviel's 
curette,  on  and  across  the  superior  eyelid,  so  as  to  execute  with  gentle  pres- 
sure some  slight  movements  to  and  fro  over  the  ciliary  circle,  in  the  direction 
of  a  line  from  that  point  towards  the  union  of  the  anterior  two-thirds  with  the 
posterior  inferior  third  of  the  sclerotica,  passing  downwards  between  the  lens 
and  the  vitreous  humor.  We  soon  see  the  lens  passing  out  at  the  pupil  and 
presenting  itself  by  its  edge  at  the  incision  in  the  cornea,  which  it  clears,  or 
which  we  cause  it  to  clear  by  gentle  pressure  from  above.  It  is  taken  away 
with  a  curette,  needle,  or  the  point  of  a  knife,  and  the  operation  is  ordinarily 
finished.  If  any  opaque  shreds  of  the  capsule,  so  large  as  to  affect  the  success 
of  the  operation,  can  be  seen,  they  are  to  be  seized  and  extracted  by  the 
forceps.  All  other  fragments  may  be  taken  away  in  the  same  manner,  if  the 
spatula  or  the  curette  be  insufficient.  As  to  those  which  fall  into  the  ante- 
rior chamber,  at  least  such  as  are  not  too  large,  it  would  be  better  to  leave 
them  to  the  solvent  action  of  the  humors  than  to  rub  the  posterior  surface  of 


OPERATIVE    SURGERY.  353 

the  cornea  so  often  as  would  be  necessary  to  take  them  away  by  the  little 
spoon  of  Daviel.  The  same  may  be  said  of  the  diffluent  lamina  which  so  often 
detaches  itself  from  the  lens  while  it  escapes  from  the  anterior  chamber,  and 
remains  arrested  about  the  incision  in  the  cornea.  Whether  the  contact  of 
the  instrument  with  the  membrane  of  the  aqueous  humor  inflames  this  lamella, 
as  has  been  asserted  by  Sommer,  or  whether  it  may  be  injurious  in  some  oth£r 
manner,  certain  it  is,  that  such  a  proceeding  is  frequently  followed  by  an 
immediate  and  complete  opacity  of  the  anterior  portion  of  the  eye. 

Remarks. — Instead  of  commencing  the  incision  just  at  the  extremity,  or 
a  little  above  the  transverse  diameter  of  the  eye,  Wenzel  prefers  entering  the 
knife  at  the  middle  of  the  superior  and  external  quarter  of  the  cornea,  making 
it  to  pass  out  by  the  corresponding  point  in  the  inferior  and  internal  quarter. 
His  reason  is,  that  in  this  way  the  greater  angle  and  the  root  of  the  nose  run 
less  risk  of  being  wounded,  and  that,  as  the  flap  is  oblique,  the  eye-lids  are 
forced,  in  closing,  to  compress  its  two  extremities,  thereby  preventing  either 
of  them  from  becoming  engaged  in  its  lips.     This  precept  is  generally  admitted 
in  France,  but  is  far  from  having  fixed,  in  the  same  degree,  the  attention  of  other 
nations.     In  Germany,  for  example,  it  is  so  little  known,  that  Weller,  who 
advises  it,  seems  to  wish  to  appropriate  it  to  himself.     We  should  not  be 
wrong,  perhaps,  to  follow  it  where  the  eye  is  very  large  or  projecting,  because 
with  such  a  conformation  the  inferior  palpebral  border  would  have  a  strong 
tendency  constantly  to  separate  the  lips  of  the  incision;  but  otherwise,  the 
advantages  which  have  been  attributed  to  it  have  been  deduced,  assuredly, 
much  more  from  theoretical  reasoning  than  from  practical  experience.     By 
cutting  at  less  than  half  a  line  from  the  circumference  of  the  cornea,  it  is 
difficult  to  avoid  the  iris  ;  and  we  should  have  cause  to  fear  that  the  opacity 
of  the  cicatrix  would  reach  too  near  the  centre  of  the  pupil.     A  step  which 
the  student  finds  most  difficult  to  execute  well,  is  tjie  striking  perpendicularly 
on  the  eye.     It  is,  however,  a  point  of  the  greatest  importance.     In  approach- 
ing too  near  to  the  transverse  line,  the  point  of  the  knife  becomes  almost 
always  engaged  between  the  different  laminae  of  the  cornea,  gets  more  or  less 
obliquely  through  its  thickness,  and  arrives  at  last  in  the  anterior  chamber, 
but  at  a  line  and  a  half  from  its  entrance  ;  giving,  in  fact,  a  very  little  open- 
ing, although  in  appearance  the  wound  is  very  large.     To  accomplish  the 
object  properly,  it  is  necessary  that  the  surgeon  should  never  lose  sight  of  tlie 
position  of  the  eye,  and  according  as  this  organ  is  more  or  less  turned  inwards 
must  his  instrument  be  more  or  less  inclined  towards  the  temple  or  towards 
the  face.     It  must  be  recollected,  at  the  same  time,  that  the  cornea  is  the 
segment  of  a  smaller  sphere  than  the  sclerotica,  which  occasions  the  perpen- 
dicular at  the  point  of  puncture  to  be  a  little  less  inclined  towards  the  median 
line.     As  the  knife  is  entering  the  anterior  chamber,  the  cutting  edge  must 
be  kept  as  exactly  downwards  as  possible,  in  order  to  escape  the  ciliary  circle 
and  iris  behind,  or  making  a  cicatrix  too  near  the  centre,  if  it  were  inclined 
forwards.     At  the  moment  the  point  is  about  to  pass  the  side  next  the  carun- 
cula  lachrymalis,  if  it  be  not  directed  a  little  anteriorly,  it  will  carry  itself 
towards  the  sclerotica  and  dig  into  the  cornea.    When  the  operator  com- 
mences pushing  his  knife,  he  must  continue  it  without  ceasing,  making  no 
retrograde  movement  until  he  has  completely  traversed  the  front  of  the  eye. 
The  gradual  increase  of  the  thickness  and  breadth  of  the  knife  permits  it  to 
.45 


S54  NEW    ELEMENTS   OF 

fill  the  incision  exactly,  so  that  the  aqueous  humor  cannot  escape  until  the 
incision  is  completed.  But  if  the  knife  be  drawn  backwards  in  the  least,  it 
necessarily  leaves  a  passage  for  the  immediate  escape  of  this  liquid.  Then, 
the  iris  floating  forwards,  and  the  anterior  tunics  of  the  eye  becoming  flaccid, 
the  incision  can  only  be  terminated  with  the  scissors,  unless  it  is  preferred  to 
postpone  the  operation  to  another  time.  The  rule  requires  that  at  least  one  half 
of  the  circle  of  the  cornea  sl^ould  be  detached.  A  smaller  flap  would  render 
the  escape  of  the  chrystalline  difficult,  especially  when  it  is  voluminous,  and 
would  require  pressure  that  might  be  followed  by  the  expulsion  of  the  vitreous 
humor.  Ware  extended  it  to  two-thirds  of  this  membrane,  but  although  in 
such  a  case  gangrene  of  the  flap,  dreaded  by  M.  Maunoir,  be  not  much  to  be 
feared,  yet  it  is  not  necessary  to  go  so  far. 

In  proscribing  without  distinction  all  instruments  for  holding  the  eye, 
surgeons  have  not  thought  it  the  less  necessary  to  prevent  all  movements  of 
the  eye  whilst  traversing  the  anterior  chamber.     When  it  turns  itself  obsti- 
nately towards  the  vault  of  the  orbit,  the  trefoil  of  Pamard  is  the  only  thing 
that  can  render  extraction  practicable.      If  it  be  towards  the  greater  angle 
that  it  conceals  itself,  in  case  the  will  of  the  patient  should  be  insufficient  to 
direct  it  out,  we  can  sometimes  accomplish  it  by  the  aid  of  the  flnger,  applied 
over  the  caruncula  lachrymalis.  The  eye  might  be  fixed  without  pain,  and  even 
without  danger,  between  the  middle  and  index  fingers  of  the  operator  and 
the  assistant,  if  the  operator  were  assured  of  the  cessation  of  all  pressure  after 
the  knife  has  traversed  the  cornea  from  side  to  side,  that  is,  just  before  the 
definite  completion  of  the  flap ;  but  it  is  so  easy  to  evacuate  the  eye  of  the 
living  subject,  that  without  great  practical  experience  it  would  be  imprudent 
to  adopt  this  practice.       Yet  I  see  no  risk  in  proceeding  thus  until  the  knife 
reaches  the  greater  angle.  Then  the  operator  is  master  of  the  organ.  Notliing 
prevents  the  completion  of  the  operation,  provided  the  blade  of  the  instru- 
ment be  not  displaced.    Instead  of  the  flexible  probe,  used  by  Pellier,  Siege- 
rist,  &c.,  the  surgeon,  when  the  ball  of  the  finger  is  insufficient  to  attain  the 
end,  may  use  the  nail  of  the  index,  or  even  of  the  little  finger,  in  the  follow- 
ing manner:  the  extremity  of  the  finger  is  placed  in  the  greater  angle,  so 
that  its  ball  shall  fall  perpendicularly  upon  the  internal  side  of  the  eye,  and 
its  back  forwards  and  towards  the  median  line.     As  soon  as  the  ceratotome 
presents  itself  on  the  side  towards  the  caruncula,  its  edge  is  placed  at  a  right 
angle  upon  the  free  edge  of  the  nail,  as  if  to  support  it;  then  while  it  is  car- 
ried from  the  external  to  the  internal  angle,  the  nail  fixes  the  cornea,  making 
a  slight  effort  as  if  to  glide  out  towards  the  heel  of  the  instrument,  until  the 
incision  is  completed.  By  means  of  this  manoeuvre,  well  understood  and  well 
executed,  a  neat  and  regular  division  may  be  effected.     The  eye  is  neither 
compressed  nor  dragged,  and  the  wounding  of  the  neighboring  parts  can 
always  be  avoided.    If  badly  executed,  it  would  be  more  prejudicial  than 
useful ;  and  the  projection  of  the  superior  maxillary  bone,  or  of  the  brow, 
makes  it  difficult  in  most  subjects.   Unless  the  nail  and  the  knife  glide  firmly 
upon  each  other,  the  cornea  will  not  fail  to  be  caught  between  them,  whicli 
would  completely  frustrate  the  aim  of  the  contrivance.   A  thin  slender  finger, 
armed  with  a  nail  somewhat  long,  is  best  adapted  to  this  purpose.  In  a  word, 
it  is  necessary  that  the  cutting  edge  of  the  knife  should  continue  upon  the 
border  of  the  nail  "vvithout  quitting  it  for  an  instant,  without  touching  the 


OPERATIVE    SURGERY.  355 

ball  of  the  finger,  and  without  allowing  the  inferior  half  circle  of  the  cornea 
to  advance  towards  the  root  of  the  nose. 

Notwithstanding  all  these  precautions,  the  iris  will  sometimes  present  itself 
under  the  edge  of  the  knife.  Gentle  friction  on  the  eye  tiirough  the  upper 
lid  often  causes  it  to  retire,  either  because  by  this  means  we  solicit  its  con- 
traction, or,  as  appears  more  probable,  because  the  pressure  which  is  thus 
exercised  upon  the  cornea  gives  it  its  natural  position,  by  forcing  the  liquid 
before  the  caratotome  to  pass  from  the  anterior  to  the  posterior  chamber ;  or, 
perhaps,  because  we  straighten  the  fold  by  flattening  the  vitreous  membrane. 
At  all  events,  we  never  succeed  better  than  when  we  apply  the  naked  finger 
on  the  latter,  and  compress  it  gentl}'.  The  worst  that  can  result  from  this,  is 
an  unnatural  perforation  of  the  iris — a  second  pupil ;  and  this  happened  to 
Wenzel,  Roux,  and  Forlenze.  Authors  give  us  a  number  of  examples.  It 
has  happened  to  me  several  times,  and  I  have  not  been  able  to  perceive  that 
the  restoration  of  sight  has  been  rendered  manifestly  less  complete.  I  think 
it  less  dangerous  than  to  withdraw  the  knife  for  the  purpose  of  completing 
the  incision  with  the  scissors,  and  that  prudence  permits  us  to  neglect  it 
whenever  it  is  necessary,  in  order  to  avoid  it,  to  expose  the  eye  to  fatiguing 
manoeuvres. 

The  elasticity  of  the  sclerotica,  perhaps  also  tlie  action  of  the  straight  mus- 
cles, is  often  sufficient  to  displace  the  lens,  which  presents  itself  spontane- 
ously at  the  incision  immediately  on  withdrawing  the  knife,  or  soon  after.  It 
is  from  this  fact  that  many  practitioners  have  formed  the  idea  of  opening  the 
capsule  at  first,  and  leaving  the  expulsion  of  the  cataract  until  after  having 
carried  the  operation  to  the  same  point  on  the  other  eye. 

B.  Bell,  and  after  him  Jung,  for  fear  of  breaking  up  the  chrystalline,  have 
proposed  to  scrape  the  capsule,  instead  of  incising  it.     It  is  a  practice  essen- 
tially vicious,  which  only  the  great  skill  of  the  able  oculist  of  Germany  has 
been  able  to  spread.    Pellier,  Siegerist,  and  especially  Wenzel,  have  thought 
it  would  be  better  to  open  this  membrane  with  the  ceratotome  whilst  travers- 
ing the  anterior  chamber,  than  after  the  completion  of  the  incision.     It  was 
easy  for  Wenzel  to  reach  the  anterior  leaf  of  the  capsule  with  admirable 
promptitude,  by  inclining  the  point  of  the  knife  a  little  backwards  at  the 
moment  it  passed  before  the  iris.   For  less  experienced  operators,  it  would  be 
a  mere  feat  of  dexterity,  an  imprudence  not  without  danger.      It  is  a  useless 
complication  of  the  operation  to  raise,  as  some  wish,  the  flap  of  the  cornea 
with  a  spatula,  whilst  another  instrument  is  directed  towards  the  pupil.  We 
rarely  use  the  cataract  knife  for  this  incision,  because  it  is  too  large,  and 
because  it  wounds  the  iris  very  easily.     The  needle  of  Hey,  the  little  myrtle- 
leaf  of  Morenheim,  the  lance-shaped  needle  of  Beer,  would  have  more  advan- 
tages, would  be  more  easy  to  introduce,  and  to  use  afterwards.      But  these 
are  particular  instruments  which  can  be  well  neglected,  and  replaced  by  the 
ordinary  crooked  needle,  or  the  serpette  of  M.  Boyer,  which,  because  of  its 
convex  and  round  edge,  is  better  suited  than  the  others  to  open  the  incision 
and  tear  the  envelope  of  the  chrystalline.  The  kystitome,  either  of  La  Faye 
or  of  M.  Bancal,  enclosed  in  a  sheath  until  after  its  arrival  in  the  pupil,  is  less 
likely,  it  must  be  confessed,  than  any  of  the  others  to  wound  the  iris.     The 
principal  objections  to  it  are,  that  it  is  not  indispensable,  and  that  it  can  serve 
no  other  purpose  than  this  one. 


356  NEW   ELEMENTS   OF 

The  lens  escapes  without  difficulty  by  a  puncture  in  the  centre,  or  a  semi- 
lunar incision  of  the  lower  edge  of  the  capsule,  as  well  as  by  the  numerous 
vertical  and  transverse  divisions  which  Beer  was  in  the  habit  of  making  upon 
it,  because  it  tears  what  resists  it ;  but  after  it  has  left  the  capsule  the  shreds 
of  the  opening  approach  or  fall  towards  the  visual  axis,  and  can,  by  becom- 
ing opaque,  produce  a  second  cataract.  On  the  contrary,  by  making  the 
semilunar  incision  above,  as  I  have  advised,  the  tearing  of  the  capsule  must 
be  from  above  downwards,  so  that  the  resulting  fragments  will  hang  below  the 
pupil.  Finding  it  sometimes  very  difficult  to  effect  the  destruction  of  the 
capsule.  Beer  undertook  to  remove  it  entirely  either  with  a  crotchet,  in  the 
cases  of  capsular  cataract,  or  a  small  forceps  for  the  encysted,  or  with  the 
lancet  needle  for  those  of  the  capsulo-lenticular  kind.  He  began  by  sinking 
the  flat  point  of  this  last  instrument  into  the  centre  of  tlie  lens,  to  which  he 
gave  some  slight  quick  movements  of  elevation  and  depression,  as  if  to  destroy 
its  adhesions ;  he  then  turned  it  on  its  axis  to  the  extent  of  a  fourth  of  a  circle, 
in  such  a  manner  as  to  place  one  of  its  sides  above  and  the  other  below ;  then 
gave  it  some  slight  transverse  movements;  turned  it  again  circularly,  and 
after  having  thus  completely  broken  up  its  organic  attachments,  withdrew  it 
by  jirks  and  forced  it  through  the  pupil.  Although  Beer  affirms  that  he  has 
many  times  followed  this  course  with  success,  it  has  found,  and  must  continue 
to  find,  but  very  few  advocates.  In  fact,  who  does  not  see  that  the  remedy 
is  worse  than  the  disease ;  that  we  should  succeed  better  by  opening  the  cap- 
sule largely  than  by  detaching  it  en  masse,  and  that  by  those  repeated  move- 
ments, the  lens  will  most  frequently  burst  it  and  leave  it  behind ;  an  occurrence 
the  more  probable  as  the  posterior  leaf  of  the  capsule  is  not  susceptible  of 
separation  from  the  vitreous  humor. 

As  to  the  rest,  it  is  rare  for  this  inner  half  of  the  chrystalline  envelope  to  be 
opaque.  And  this  is  fortunate;  for  unless  the  opacity  were  very  limited,  it 
would  be  probably  without  remedy.  Even  then,  I  know  not  how  far  it 
will  be  permitted  to  follow  the  counsel  of  Morenheim  and  Beer  to  isolate 
the  opaque  spot,  and  attempt  to  extract  it  with  a  crotchet.  Some  have 
thought,  when  the  cataract  is  milky,  of  giving  vent  to  the  altered  fluid  ;  others, 
when  it  was  membranous,  of  destroying  the  capsule  only,  in  order  to  save  the 
lens  in  situ  with  its  natural  transparency;  as  if  in  the  liquid  cataract  all  the 
lenticular  apparatus  was  not  diseased  at  the  same  time,  or  as  if  the  lens  could 
maintain  its  properties  in  a  normal  state  when  its  capsule  had  been  opened. 
Whether  diseased  or  not,  it  should  be  taken  away  in  all  cases,  if  nothing  else 
prevents.  In  producing  dilatation  of  the  pupil  by  external  means,  the  prepa- 
rations of  Belladonna  render  the  escape  of  the  vitreous  humor  very  easy,  and 
may  thus  become  more  or  less  dangerous.  If  we  reject  them,  the  pupil 
remains  sometimes  so  contracted  as  to  hinder  the  expulsion  of  the  lens.  In 
order  to  obviate  these  two  inconveniences,  Bischoff  and  others  have  advised  us 
to  open  the  cornea,  then  the  capsule,  and  then  turn  the  back  of  the  patient  to 
the  light,  when  the  cataract  will  itself  make  its  escape.  By  this  means  the 
pupil,  which  is  strongly  contracted  in  the  first  part  of  the  operation,  dilates 
itself  without  danger  towards  the  conclusion.  If  it  were  expedient,  we  might 
defer  medicinal  applications  until  after  opening  the  eye.  But  we  should,  before 
resorting  to  active  measures,  make  the  patient  move  the  eye  about,  upwards, 
inwards,  and  outwards ;  because  such  movements  frequently  cause  the  escape 


OPERATIVE    SURGERY.  557 

of  the  opaque  body.  If  from  any  cause  the  vitreous  humor  should  escape, 
the  eye-lids  must  be  instantly  closed  and  the  head  turned  backwards.  This 
accident,  whith  entirely  destroys  the  eye  where  the  hyaloid  membrane 
escapes,  is  much  less  dangerous  than  was  for  a  long  time  thought,  in  the  con- 
trary case.  It  may  even  be  remarked,  that  the  loss  of  a  certain  quantity  of 
the  vitreous  humor  ralher  increases  than  diminishes  the  chances  of  a  success- 
ful operation.  The  escape  of  the  fourth,  or  even  the  half  of  this  liquid,  must 
not  make  us  despair  of  success.  There  is  no  evidence  of  its  being  formed 
anew;  but  the  aqueous  humor,  more  abundantly  secreted,  takes  its  place,  and 
the  functions  of  the  eye  are  scarcely  perceived  to  suflfer. 

h.  Process  of  Guerin  and  Dumont. — Witli  the  view  of  reducing  the  opera- 
tion to  its  most  simple  expression,  Guerin,  and  almost  at  the  same  time  Du- 
mont, a  cruizing  captain  of  Normandy,  invented  an  instrument  which  should, 
by  a  very  ingenious  mechanism,  hold  the  eye-lids  apart,  fix  firmly  the  globe  of. 
the  eye,  and  complete  at  a  single  stroke  the  incision  of  the  cornea."  The. 
first  of  these  instruments,  terminated  by  a  sort  of  ring  at  a  right  angle  with 
the  handle,  concave  behind  and  moulded  exactly  to  fit  the  front  of  the  eye, 
enclosing  a  blade  of  the  form  of  a  fleam,  w^iich  is  thrown  into  motion  by  a 
spring  and  escaping  the  instant  it  is  loosened,  opens  at  once  the  half  of  the 
circle  of  the  cornea,  either  from  below  upwards,  or  the  reverse.  The  ring 
and  the  handle  of  the  second  are  in  the  same  line.  Its  blade,  offering  some 
analogy  to  the  pharyngotome,  is  made  to  act  from  the  lesser  towards  the 
greater  angle  of  the  eye  moving  horizontally ;  different  from  the  other, which  falls 
upon  tlie  eye  like  the  edge  of  a  guillotine.  The  instrument  of  Guerin,  of  which 
perhaps  the  idea  was  given  by  the  fleam  of  Van  Wy,  has  been  a  long  time 
neglected  in  France,  and  M.  Eckold  is  the  only  one  to  my  knowledge  who, 
after  improving  it,  has  endeavored  to  introduce  it  in  Germany.  Although 
more  convenient  and  less  dangerous,  that  of  Dumont  has  not  been  better 
received.  If  those  machines  of  which  the  ancients  were  so  prodigal,  if  every 
species  of  blind  agency  is  banished  with  so  much  care  from  the  practice  of 
other  operations  by  modern  surgeons,  how  much  more  reason  is  there  for 
removing  them  from  the  eye — an  organ  so  delicate  and  so  easy  to  destroy ! 
The  jar  which  is  necessarily  produced  by  touching  a  mechanical  spring,  the 
fear  of  wounding  some  part  which  it  is  important  to  avoid,  of  making  an  opening 
too  large  or  too  small,  of  cutting  too  near  or  too  far  from  the  sclerotica,  have 
particularly  alarmed  practitioners.  It  would  be  unjust,  however,  to  accord 
no  merit  to  such  conceptions,  or  to  call  them  at  once  absurd  as  some  have 
done,  without  the  means  of  judging  of  their  utility.  Many  physicians  can 
attest,  with  M.  Hedelhoffer,  that  Petit,  of  Lyons,  very  often  and  very  suc- 
cessfully used  the  instrument  of  Dumont.  Modified  by  the  nephew  of  the 
inventor,  it  has  even  succeeded  sixty-two  times  in  seventy-one  operations,  if 
all  that  has  been  recently  reported  to  the  academy  be  true. 

C.  Superior  Ceratotomy. — When  the  inferior  semi-circumference  of  the 
cornea  is  opaque,  or  altered  in  any  other  manner,  its  division  is  sometimes 
quite  difficult.  The  incision  will  also  be  ill-disposed  to  cicatrize.  Even 
when  healthy  this  membrane  may  be  very  small,  so  that  it  is  necessary  to 
raise  more  than  half  to  obtain  a  sufficient  opening.  In  such  cases  Wenzel 
advises  the  incision  of  the  superior  semicircle,  and  is  said  to  have  succeeded 
in  this  way  upon  the  duke  of  Bedford .  Richter  gives  the  same  advice,  and  B.  Bell 


358  NEW   ELEMENTS   OF 

formally  proposed  it  even  for  ordinary  cases.  According  to  him,  the  escape 
of  the  vitreous  humor  is  less  to  be  feared,  the  cicatrix  of  the  cornea  is  formed 
more  quickly,  and  is  less  visible  and  less  injurious  to  the  sight  than  by  the 
ordinary  process.  M.  Wagner  published  in  Germany,  that  Mr.  Alexander,  of 
London,  has  not  hesitated  to  put  the  idea  of  Wenzel  to  the  proof,  and  Mr. 
Wilmot,  cited  by  M.  Eccard,  asserts  that  Messrs.  Lawrence,  Green,  and 
Tyrell  have  often  practised  it.  In  France  M.  Dupuytren  has  thought  proper 
to  try  it ;  but  no  person  before  M.  Jaeger,  successor  to  Beer,  of  Vienna,  had 
collected  a  sufficient  number  of  facts  from  the  living  subject  to  found  a  general 
method.  With  the  superior  incision,  besides  the  advantages  pointed  out 
by  Wenzel  and  Bell,  there  is  nothing  to  fear  from  the  rubbing  of  the  borders 
of  the  lids  nor  the  eye-lashes.  M.  Jaeger  says  the  tears  flow  more  freely,  and 
occasion  less  irritation  to  the  incision,  which  also  less  frequently  suppurates, 
and  procidentia  of  the  iris  must  be  rare.  A  preliminary  difficulty  attracted  his 
attention,  which  is  the  tendency  of  the  eye  to  roll  inwards  or  to  turn  under 
the  upper  lid.  Here  he  believes  that  he  has  triumphed  over  all  obstacles,  by 
inventing  a  particular  ceratotome  formed  of  two  blades,  the  one  narrower  than 
the  other,  applied  face  to  face  in  such  a  way  as  to  resemble  the  knife  of  Beer 
or  Richter,  when  closed.  By  pressing  upon  a  button  at  the  side,  the  smaller 
blade  is  made  to  glide  upon  the  larger  as  in  opening  a  sheath-handle  penknife. 

The  patient  and  assistant  should  be  placed  as  in.  the  ordinary  method. 
The  operator  holds  the  double  ceratotome  as  a  pen,  turning  the  edge  upwards 
and  pushing  it  across  the  anterior  chamber  parallel  to  its  transverse  axis ; 
conforming  in  other  respects  to  the  precepts  above  mentioned.  This  done,  he 
gives  the  eye  its  natural  position,  or  even  inclines  it  a  little  downwards  if 
necessary,  and  fixes  it  with  the  larger  blade  of  the  knife,  whilst  the  other 
blade,  set  in  motion  by  the  thumb  of  the  same  hand,  produces  the  incision 
of  the  cornea,' by  sliding  from  its  point  towards  its  heel. 
1  Since  in  the  space  of  six  months  M.  Jaeger  has  practised  extraction  of 
the  cataract  sixty  times  with  success,  by  means  of  his  double  ceratotome,  it 
would  be  improper  to  assert  that  the  instrument  is  absolutely  bad  ;  a  priori, 
however,  we  can  hardly  see  its  advantages.  If  it  is  true  that  we  can  fix  the 
eye  firmly  with  the  stationary  blade,  whilst  its  other  piece  divides  the  supe- 
rior segment  of  the  cornea,  it  must  on  the  other  hand  traverse  the  tissues 
with  the  more  difficulty.  Superior  ceratotomy,  besides,  can  be  very  well 
performed  with  the  ordinary  knife ;  and  M.  Gr^fe,  who  has  used  it  with 
success  seventeen  times  out  of  eighteen,  and  among  others  upon  tlie  Duke 
of  Cumberland,  believes  it  preferable  to  the  double  ceratotome.  As  to  the 
operation  itself,  of  all  the  advantages  which  have  been  accorded  it,  there 
are  very  few  that  are  real.  It  renders  less  probable  the  wounding  of  the 
iris,  the  escape  of  the  vitreous  humor,  and  perhaps  the  separation  of  the 
lips  of  the  incision  by  the  edges  of  the  eye-lids ;  but  the  operation  in 
all  its  steps  is  certainly  more  difficult,  and  less  sure  than  in  the  inferior  ope- 
ration.* 

Dressing. — After  extraction  the  dressing  and  consecutive  treatment  differ 
very  little  from  that  recommended  after  depression.  But  it  is  not,  perhaps, 
useless  to  present  some  object,  not  too  brilliant,  to  see  if  the  patient  distin- 

'  *  This  is  a  method  of  exception,  not  of  choice,  applicable  only  to  the  cases  indicated  by 
Wenzel ;  supposing,  at  the  same  time,  that  it  is  not  better  to  resort  to  the  needle. — TV. 


OPERATIVE    SURGERY.  359 

guishes  it,  before  covering  up  the  eyes.  It  is  not  to  satisfy  mere  curiosity  that 
this  precaution  is  indicated,  but  because  such  proof  will  give  us  renewed 
assurance,  when  not  perfectly  satisfied  that  there  does  not  remain  in  the  eye 
any  opaque  substance  of  sufficient  importance  to  demand  extraction.  Re- 
pose, absence  of  all  movement  of  the  eye,  and  of  the  superior  extremity  of 
the  body,  is  of  absolute  necessity.  Although  the  head  should  be  but  very 
slightly  elevated,  I  see  no  reason  which  requires  us  to  place  it  lower  than  the 
feet,  as  done  by  M.  Forlenze.  The  regimen  must  be  more  severe,  longer 
continued,  the  first  dressing  a  little  longer  delayed,  and  the  eye  less  early 
exposed  to  the  light  than  after  depression. 

C.  Comparative  Examination  of  the  Two  Methods. 

Depression,  which  was  the  only  method  in  use  until  the  middle  of  the  last  cen- 
tury, because  no  other  was  known,  fell  into  such  disuse,  at  least  in  France, 
after  the  publication  of  the  works  of  Daviel,  that,  in  spite  of  the  efforts  of  Pott 
to  revive  it,  it  was  scarcely  practised  at  the  commencement  of  the  present 
century.  The  modifications  it  underwent  from  Scarpa  so  far  restored  it  to 
notice,  that  at  present  it  is  on  an  eq[uality  with  extraction,  if  not  above  it. 
Hence  the  question,  which  of  these  two  methods  is  the  better,  already  so 
much  debated  and  still  undecided,  presents  itself  to  us  every  day.  Even 
if  it  be  not  incapable  of  decision,  it  must  at  least  be  confessed  that  the  ele- 
ments concerned  in  it  are  difficult  to  weigh.  What  are  we  to  conclude  from 
such  a  method  possessing  a  greater  number  of  partisans  of  merit  than  such 
another  ?  from  Scarpa,  Hey,  Dubois,  Dupuytren,  Richter,  and  Beclard,  Lis- 
firanc,  Lusardi,  Langenbeck,  having  obtained  greater  success  by  depression 
tlian  by  extraction;  while  with  Wenzel,  Ware,  Richter,  Beer,  Demours, 
Boyer,  Roux,  Forlenze,  Pamard,  it  is  the  reverse  ?  When  an  operator,  even 
the  most  skillful  and  conscientious,  makes  choice  of  one  method,  his  practice, 
his  predilection,  always  biasses  him  more  or  less,  and  renders  him  an  im- 
proper judge  of  other  methods.  Nor  are  the  results  announced  by  different 
men!  equally  qualified,  decisive  arguments.  The  success  which  depression 
procured  to  M.  Dupu^i:ren  does  not  prove  that  this  operator  w^ould  have 
been  less  successful,  if  in  the  beginning  he  had  attached  himself  with  the 
same  zeal  to  the  improvement  and  propagation  of  extraction.  To  show  the 
fallacy  of  this  kind  of  proof,  suppose  that  twenty  of  the  ablest  surgeons  of 
Europe  should  operate  only  by  extraction,  whilst  twenty  others,  taken  at 
hazard,  should  always  have  recourse  to  depression :  because  the  practice  of 
the  first  shows  a  greater  proportion  of  success,  does  it  follow  necessarily, 
and  from  that  alone,  that  extraction  is  preferable  to  depression  ? 

Let  us  see  if,  after  having  reviewed  the  advantages  and  disadvantages  of 
both,  we  arrive  at  any  thing  more  satisfactory.  Extraction  permits  us  to  take 
away,  without  the  possibility  of  its  returning  the  obstacle  to  vision.  It  is  less 
painful,  and  rarely  followed  by  internal  inflammation ;  it  exposes  neither  the 
nerves  nor  the  vessels  to  being  wounded,  and  leaves  untouched  all  the  interior 
of  the  eye,  the  retina,  the  choroid  coat,  the  ciliary  circle,  &c.  But  in  prac- 
tising it  we  may  wound  and  deform  the  pupil,  or  alloAv  the  vitreous  humor  to 
escape.  If  the  incision  should  not  heal  by  the  first  intention,  it  ulcerates; 
soon  brings  on  procidentia  of  the  iris ;  sometimes  atrophy  of  the  globe  of  the 


S60 


NEW   ELEMENTS    OF 


e^e,  or  at  least  an  extensive  opacity  of  the  cornea ;  the  sequelae  of  the  opera- 
tion are  tedious ;  it  is  rare  that  the  ophthalmia  which  follows  it  terminates 
before  the  fifteenth  or  twentieth  day ;  in  fine,  it  cannot  be  used  on  all  subjects, 
nor  at  all  ages. 

Depression  merely  displaces  the  opaque  body,  and  leaves  it  in  the  eye  to 
continue  there  a  permanent  cause  of  irritation,  liable  to  reascend;  it  is  fre- 
quently followed  by  a  secondary  membranous  cataract,  iritis,  deep-seated  pain, 
and  general  nervous  symptoms.  The  needle  traverses  delicate  tissues,  wounds 
of  necessity  the  choroid  coat,  the  retina,  the  vitreous  humor,  and  sometimes 
also  the  iris  and  the  ciliary  body.  But  on  the  other  hand  it  cannot  give  issue 
to  the  vitreous  humor,  does  not  expose  the  cornea  to  opacity  or  ulceration, 
the  iris  to  procidentia  or  excision,  nor  the  eye  to  immediate  destruction.  The 
day  after  the  operation  the  puncture  is  closed,  and  the  sclerotica,  which  most 
frequently  is  scarcely  inflamed  at  all,  resumes,  in  about  eight  or  ten  days,  its 
natural  aspect ;  in  fine,  if  necessary,  it  can  be  performed  in  all  cases,  and 
repeated  once  or  oftener  on  the  same  organ  without  running  any  great  risk 
of  injury  to  the  patient. 

According  to  this  enumeration,  it  would  at  the  first  glance  seem  that  de- 
pression must  be  superior  to  extraction.     But  a  profound  examination  does 
not  permit  us  to  draw  a  conclusion  so  clear  and  positive.     The  puncture  of 
the  sclerotica,  choroid,  retina,  and  vitreous  body,  does  not  produce  much  more 
pain  than  the  incision  of  the  cornea;  at  least,  when  performed  as  I  have  indi- 
cated.    The  wounding  of  the  nerves,  vessels,  and  ciliary  body,  is  easily  pre- 
vented, and  generally  unimportant.     When  the  capsule  of  the  lens  is  properly 
torn,  we  cannot  see  why  secondary  cataract  should  be  more  common  after 
depression  than  after  extraction.    If  the  lens  be  well  engaged  in  the  vitreous 
humor,  it  is  difficult  for  it  either  to  rise  again  or  to  hurt  the  retina.     With 
address  we  can  easily  preserve  the  iris,  which  the  needle  never  wounds  so 
severely  as  the  ceratotome.     But  it  is  erroneous  to  say  that  this  method  is 
more  simple  and  easy  than  the  other.     It  is  not  so  easy  as  may  be  imagined, 
to  pass  an  instrument  between  the  uvea  and  the  cataract;  to  engage  it  between 
the  lens  and  its  envelope ;  to  make  a  suitable  opening  in  the  capsule  to  prevent 
the  opaque  body  from  turning  either  upwards  or  downwards,  if  the  needle  be 
pressed  ever  so  little  in  either  direction  more  than  in  the  other,  or  if  the  lens 
should  have  contracted  adhesions  to  any  of  the  neighboring  parts ;  in  fine,  it 
is  often  only  after  repeated  attempts  that  we  can  succeed  in  getting  it  down, 
and  fixing  it  in  the  bottom  of  the  eye.  The  greatest  address  is  then  necessary  to 
practise  depression  with  every  chance  of  success.     If  it  be  generally  preferred 
by  inexperienced  men,  it  is  much  less  because  of  its  apparent  simplicity  than 
because  it  does  not  expose  their  deficiency  so  readily  as  extraction.     Again, 
the  irritation  which  it  produces  augments  the  secretion  of  the  humors,  pro- 
ducing a  feeling  of  distention  in  the  eye  which  does  not  take  place  after  the 
other  operation.    Acute  or  chronic  iritis,  contracting  or  entirely  obliterating 
the  pupil,  may  also  often  be  a  consequence  of  this  process.     The  laceration 
of  the  vitreous  body,  although  without  immediate  danger,  may  not  be  always 
exempt  from  inconvenience.     The  lens,  which  does  indeed  sometimes  disap- 
pear by  absorption  or  dissolution,  more  frequently  retains  its  form  and  volume 
for  some  years  or  for  life ;  whatever  the  moderns  may  say  of  it,  after  Pott, 
Scarpa,  and  Dablin,  who  in  1722  proved  its  absorption,  and  concluded  that  it 


OPERATIVE    J5URGERY.  S6l 

constantly  disappears  after  depression.  Beer  has  seen  it  rise  again  at  the  end 
of  twenty-six  years.  Of  twelve  patients  operated  on  by  depression,  whose 
eyes  I  have  had  an  opportunity  of  examining  in  the  hospital  after  death,  one, 
two,  two  and  a  half,  and  four  years  after  the  operation,  it  had  scarcely  dimi- 
nished one  fifth  in  the  only  subject  in  which  there  was  any  sensible  alteration. 
In  others  it  had  formed,  through  the  intervention  of  some  laminae  of  the  hya- 
loid membrane,  adhesions  to  the  retina  and  choroid  coat,  itself  presenting  a 
sort  of  knob  or  cicatrix  about  three  lines  long.  M.  Campaignac,  who  has  made 
many  researches,  especiully  on  this  point  of  practice,  also  says,  after  numerous 
observations,  that  the  lens  is  far  from  disappearing  so  quickly  or  so  constantly 
as  is  generally  believed  after  depression.  This  is  an  inconvenience,  it  must 
be  confessed ;  and  an  inconvenience  that  no  argument  can  destroy,  and  which 
will  always  render  the  operation  by  depression  less  complete  than  that  by 
extraction.  Keratonyxis,  which  Dr.  Wedermeyer  rejected  after  having  tried 
it  fifty-three  times,  will  succeed  no  better;  and,  whatever  M.  Schindler,  who 
defends  it,  may  say,  it  would  be  a  poor  way  of  securing  supporters,  to  pene- 
trate as  he  does  at  the  centre  of  the  cornea,  instead  of  the  lowest  point. 
Escaping,  or  left  in  the  anterior  chamber,  either  whole  or  in  small  fragments, 
the  lens  is  far  from  dissolving  as  promptly  as  some  ai«Jiors  pretend.  Observ- 
ations made  by  M.  Plichon,  at  La  Salpetriere,  prove  that  it  often  act%  as  a 
foreign  body,  and  if  not  soon  removed  exposes  the  eye  to  serious  dangers. 
Another  defect,  still  more  important,  is  the  following :  the  iris  may  remain 
movable,  and  the  pupil  clear,  and  the  whole  organ  bear  the  appearance  of  per- 
fect integrity,  yet  the  vision  may  b^.  totally  destroyed.  I  have  seen,  at  the 
central  bureau,  four  persons  who  had  been  operated  upon  at  Paris,  blind  from 
this  cause.  A  man,  aged  sixty-two  years,  on  whom  I  operated  in  1829  at  the 
hospital  of  St.  Antoine,  has  recently  asked  my  advice.  At  first  sight  any  one 
would  affirm  that  his  vision  was  perfectly  good.  The  pupil  is  of  a  beautiful 
black ;  round,  regular,  movable ;  neither  dilated  nor  contracted  too  much,  and 
yet  his  blindness  is  complete.  What  has  so  often  imposed  upon  the  partisans 
of  depression  is,  that  the  patients  seem  so  often  to  recover  their  sight  after  a 
certain  time,  and  keep  it,  in  fact,  during  a  month  or  two,  but  afterwards  find 
it  gradually  growing  weaker,  until  in  less  than  a  year  it  is  entirely  gone.  If 
the  operation,  repeated  seven  times  in  one  case,  six  times  in  another,  and  thir- 
teen times  on  each  eye  in  a  third,  have  enabled  Dr.  Hey  to  cure  his  patients, 
it  does  not  make  it  the  less  true  that  these  secondary  attempts  are  most  fre- 
quently unsuccessful.  The  truth  is,  however,  that  the  consequences  are  com- 
monly trifling.  After  depression  there  almost  always  remain,  or  are  formed, 
some  particles,  more  or  less  opaque,  before  the  vitreous  humor.  Experience 
proves  that  after  extraction  this  accident  is  much  more  rare. 

As  to  extraction,  it  is  evident  that  the  section  of  the  cornea  is  much  more 
delicate  than  the  perforation  of  the  sclerotica ;  that  in  spite  of  every  precau- 
tion the  vitreous  humor  may  escape,  the  iris  be  extensively  wounded  by  the 
knife,  or  ruptured  or  torn  by  the  lens ;  yet  if  the  operation  is  well  done  and 
the  patient  in  good  condition,  two  accidents  only,  the  escape  of  the  vitreous 
humor  and  the  consecutive  opacity  of  the  cornea,  can  render  it  dangerous : 
while,  all  other  things  being  equal,  it  gives  a  result  immediate  and  definitive, 
and  more  satisfactory  than  that  of  depression.  But  it  must  be  said  that  the 
escape  of  the  lens  endangers  two  other  accidents.  Although  largely  dilated 
46 


30g  NEW    ELEMENTS   OF 

by  the  belladonna,  the  pupil  almost  always  contracts  enough  to  oppose  some 
resistance  to  tlie  opaque  body,  which  then  tends  to  tear  up  the  iris  from  below 
80  as  to  escape,  if  the  pressure  on  the  eye  be  not  conducted  with  extreme 
caution.  This  pressure,  brought  suddenly  upon  the,  cornea  bj  an  unexpected 
movement  of  the  patient,  may,  if  it  occur  at  the  moment  the  edge  of  the  cata- 
ract presents  itself  at  the  flap,  push  it  up  over  the  vitreous  humor ;  leaving 
us  in  doubt  whether  it  has  really  escaped  or  is  yet  in  the  eye,  as  once  hap- 
pened to  me.  Procidentia  of  the  iris,  which  is  more  frequently  a  consequence 
of  the  operation  in  old  persons,  because  of  the  slowness  of  the  cornea  to  cica- 
trize in  them,  is  treated  by  mechanical  means  or  belladonna  if  there  be  no 
adhesion,  but  with  the  nitrate  of  silver  if  there  be  ;  and  is  not  more  difficult 
to  cure  in  these  than  in  other  circumstances.  When  an  operator  desires  to 
leave  no  opaque  particle  in  the  eye,  there  is  no  objection  to  throwing  in  one  or 
two  injections  of  lukewarm  water  through  the  incision  with  AnePs  little 
syringe.  Perhaps  it  would  be  even  advantageous  to  imitate  M.  Forlenze,  and 
adopt  this  method  generally.  In  a  word,  if  the  dangers  of  extraction  are  more 
serious  and  apparent,  those  of  depression  are  more  numerous  and  real.  Ope- 
rators of  equal  skill  avoid  more  easily  those  of  the  first  than  those  of  the 
second ;  and  if  the  employment  of  the  needle  fails  less  frequently  to  procure 
gome  benefit  to  the  patient,  the  method  of  Davicl  furnishes  in  compensation 
a  greater  amount  of  complete  cures.  I  conclude,  then,  that  when  circum- 
stances occur  which  render  it  indifferent  which  of  the  two  may  be  used, 
extraction  should  be  preferred ;  but  in  other  cases  sometimes  one  may  be 
adopted,  and  sometimes  the  other. 

Depression  appears  preferable,  for  example,  upon  infants  and  intractable 
subjects,  whentlie  eyes  are  small  and  sunken;  when  the  cornea  presents  spots 
of  opacity,  is  small  or  flattened ;  when  the  eye-lids  or  the  conjunctiva  has  been 
a  long  time  diseased  ;  when  there  is  cause  to  apprehend  active  inflammation 
of  the  appendages  of  the  eye ;  when  the  cataract  is  completely  fluid ;  when 
the  pupil  is  contracted,  or  the  iris  adheres  to  the  cornea ;  when  the  eye  is  very 
prominent  or  very  irritable.  Extraction,  on  the  contrary,  offers  greater  advan- 
tages with  old  persons,  and  even  adults,  if  the  anterior  chamber  be  large;  the 
lens  very  soft  or  very  hard ;  the  cataract  membraVious  or  adherent ;  the  eye  per- 
fectly healthy,  not  very  sensitive,  and  susceptible  of  being  pierced  without 
difficulty.  I  should  add,  in  concluding  these  remarks,  that  any  surgeon 
would  sin  against  humanity  if  he  should  practise  the  operation  for  the  cataract 
before  he  had  exercised  himself  at  first  a  long  time  upon  the  dead  body,  an(][ 
afterwards  upon  living  animals.  Yet  it  must  be  stated  that  this  kind  of  expe- 
riments are  far  from  giving  an  accurate  idea  of  what  really  exists  in  the  living 
subject ;  and  that  extraction  alone  can  be  simulated  in  a  way  at  all  sa^tis- 
factory. 

Surgeons  have  long  felt  the  want  ^f  a  means  of  producing  artificial  cata- 
ract, to  give  the  means  of  preparatory  practice  upon  animals  and  dead  sub- 
jects, and  leave  the  eye  at  the  same  time  all  the  mobility  which  renders  it  so 
difficult  to  be  fixed  at  the  moment  of  operation  upon  the  living.  Troja,  in 
Italy,  and  M.  Bretonneau,  in  France,  have  made  some  attempts  to  render  the 
lens  opaque  by  the  aid  of  acids.  M.  Leroy  thought  it  could  be  better  accom- 
plished by  means  of  electricity ;  but  no  person  before  M.  Neuner,  of  Darm- 
stft-iit,  made  it  a  particular  object  of  study.    The  liquid  he  used  with  greatest 


OPERATIVE  SURGERV.  S6S 

success  was  a  solution  of  six  grains  of  corrosive  sublimate  in  one  gros  of  pure 
alcohol.  A  small  glass  syringe  garnished  with  platina,  terminated  by  a  very 
fine  pipe,  and  traversed  by  an  extremely  fine  stylet  that  passes  through  both 
extremities,  is  used  for  the  purpose  of  introducing  to  the  lens  from  behind  a 
few  drops  of  this  solution,  which  soon  causes  that  body  to  change  its  color. 

Among  the  machines  invented  to  represent  on  the  eyes  of  the  dead  subject 
the  principal  difficulties  met  witl\  on  the  living,  the  ophthalmophantome  of  M. 
Sachs  is  certainly  the  most  ingenious :  composed  of  a  stand,  a  mask,  and  a 
porte-oeuil,  of  w^hich  I  cannot  here  give  a  description.  It  appears  to  me  too 
complicated  ever  to  come  into  general  use. 

After  one  of  the  chief  refractive  agents  of  the  eye  has  been  either  removed 
or  displaced,  I  need  not  say  that  almost  every  individual  operated  on  for  cata- 
ract should  wear  such  convex  glasses  as  are  used  by  near  sighted  persons. 
With  children,  those  who  have  been  blind  from  birth,  and  all  subjects,  in  fine, 
who  for  the  first  time  are  beginning  the  cultivation  of  their  sight,  it  is  well  to 
add  to  the  precautions  generally  used  a  very  simple  resource  employed  with 
success  by  M.  Dupuytren,  which  consists  in  fixing  the  hands  behind  the  back, 
so  that  being  deprived  of  these  assistants  they  are  forced  to  make  greater  exer- 
tions with  their  eyes  in  directing  themselves  towards  external  objects. 

§  4.  Artificial  PupiL 

Two  very  different  states  may  require  the  establishment  of  an  artificial 
pupil :  opacity  in  the  cornea,  or  the  contraction  or  obliteration  of  the  natural 
pupil.  In  the  first  case,  whether  the  obstacle  to  vision  may  have  been  the  result 
of  simple  ophthalmia,  ulcer,  wound,  or  any  other  lesion,  is  of  little  im- 
portance. Provided  the  internal  parts  of  the  eye  be  unaffected,  and  there 
remains  a  transparent  portion  of  the  cornea,  the  formation  of  an  artificial  pupil 
may  be  tried.  In  the  second,  whatever  be  the  cause  or  degree  of  the  disease ; 
whether  it  be  simple  or  complicated  with  adhesions,  the  operation  is  practica- 
ble if  the  retina  have  not  lost  its  faculty  of  perceiving  luminous  rays,  and  the 
anterior  chamber  preserves  its  transparency.  If  this  last  condition  be  want- 
ing, it  is  useless  to  make  a  new  pupil  for  the  transmission  of  light,  for  the 
impression  will  not  be  felt.  Acute  and  chronic  inflammations  of  the  internal 
tunics,  as  well  as  every  kind  of  alteration,  the  course  of  which  has  not  been 
definitively  arrested,  are  contra-indications,  which,  although  less  absolute,  are 
yet  sufficient,  with  some  exceptions,  to  arrest  a  circumspect  surgeon.  Almost 
all  authors  advise  not  to  attempt  it  when  there  is  only  one  eye  affected,  or 
even  otherwise  when  the  patient  is  able  to  conduct  himself  without  a  guide. 
As  the  operation  is  itself  sometimes  followed  by  accidents  capable  of  deeply 
affecting  the  vision,  it  appears  but  little  conformable  to  the  laws  of  humanity 
to  expose  the  sufferer  to  the  loss  of  the  little  that  yet  remains,  when  the  chances 
of  amelioration  are  so  precarious. 

A.  Methods  of  Operating. 

Every  process  invented  for  forming  a  new  pupil  may  be  reduced  to  three 
methods.    The  first,  iridiotomy  or  Qoretomia,  consists  in  incising  the  iris ;  the 


S64  NEW  ELEMENTS  OF 

second,  iridectomia  or  corectomia^  in  excising  a  piece  of  this  membrane ;  and 
the  third,  iridodialysis  or  coredialysis,  in  detaching  its  circumference  at  some 
point. 

1.  Coretomia  or  the  Method  hy  Incision. — No  one  before  Cheselden  had 
spoken  of  tliis  process.  Since  his  time  it  has  attracted  the  attention  of  Wool- 
house,  Mauchart,  Sharp,  Sprasgel,  Meiners,  and  Rathleau,  who  have  proposed 
it  in  case  of  a  persistence  of  the  pupillary  membrane;  of  Odhelius,  Guerin, 
Janin,  Wenzel,  and  of  Messrs.  Maunoir,  Adams,  &c.,  who  have  subjected  it 
to  several  modifications.  The  patient,  operator,  and  assistants  must  be  placed 
ajs  in  the  operation  for  cataract. 

a.  Process  of  Cheselden. — With  a  small  knife  in  the  form  of  a  scalpel, 
cutting  on  one  side  only,  Cheselden  penetrated  through  the  sclerotica,  as  in 
couching,  as  far  as  the  uvea,  and  passed  the  point  of  the  instrument  into  the 
anterior  chamber.  Then  directing  it  inwards  and  backwards  according  to 
some,  or  according  to  others  from  the  internal  angle  to  the  external,  and 
from  behind  forwards,  he  completed  a  transverse  incision  from  two  to  three 
lines  long  in  the  centre  of  tlie  iris.  A  pupil  of  an  elliptical  form,  similar  to 
that  of  some  quadrupeds,  was  the  result  of  this  delicate  operation,  which  suc- 
ceeded well  and  forcibly  attracted  the  attention  of  the  learned. 

b.  Process  of  Sharp.— In  practising  coretomia  Sharp  claims  to  have  done 
nothing  more  than  to  imitate  Cheselden.  A  little  scalpel  slightly  convex  on 
the  back,  of  which  he  gives  a  figure,  is  at  first  carried  horizontally,  the  edge 
turned  backwards,  into  the  posterior  chamber  between  the  circle  and  the  root 
of  the  ciliary  processes.  It  is  then  enough  to  incline  the  point  more  or  less 
anteriorly,  and  give  it  a  slight  push  to  penetrate  into  the  anterior  chamber.  It 
remains  to  cut  the  iris  either  on  a  level  with  or  below,  or  which  is  better,  above 
the  natural  pupil.  The  opening  produced  by  this  operation,  which  continues 
for  some  time,  never  fails  to  contract,  and  at  last  even  to  become  entirely 
closed.  Even  Sharp  appeared  to  have  little  confidence  in  Cheselden's  method. 
Mauchart  deserves  to  be  mentioned  here,  only  because  he  was  the  first  to  sug- 
gest the  idea  of  passing  the  instrument  through  the  cornea  or  anterior  chamber 
in  forming  the  pupil.  He  objects,  besides,  to  giving  the  artificial  opening  too 
great  an  extent,  because,  as  he  remarks,  this  kind  of  a  pupil  can  neither  dilate 
nor  contract  spontaneously  like  the  natural  one.  Henkel  also  preferred  to 
penetrate  through  the  anterior  chamber.  Huermann,  who  is  of  the  same 
opinion,  advises  us  to  use  an  ordinary  lancet  instead  of  needles  or  the  knife 
of  Cheselden,  to  cut  the  iris  and  cornea. 

c.  Process  of  Odhelius. — After  having  pierced  the  cornea  as  for  the  extrac- 
tion of  cataract,  Odhelius  cut  the  iris  from  the  centre  to  the  circumference 
in  a  subject  whose  cornea  was  opaque  opposite  the  pupil,  which  was  also 
contracted.  By  this  means  he  obtained  a  triangular  opening — the  base 
being  the  remains  of  the  primitive  pupil,  and  thus  completely  restored  the 
sight. 

d.  Process  of  Janin. — Having  frequently  tried  Cheselden's  method  without 
success,  Janin  thought  to  succeed  better  by  giving  a  vertical  direction  to  the 
incision.  The  transverse  one  soon  and  almost  necessarily  closes  itself,  he 
said,  because  the  radiating  fibres  of  the  membrane  are  only  separated,  whilst 
they  are  really  cut  by  a  perpendicular  incision  made  a  little  to  the  inside 
of  the  natural  pupil.    It  was  an  accident  that  led  him  to  this  modificatioo. 


OPERATIVE    SURGERY.  365 

It  happened  to  him  as  to  many  others,  to  cut  the  iris  in  performing  the 
operation  for  extraction ;  making  thus  against  his  will  an  artificial  pupil  at 
the  side  or  rather  below  the  natural  one.  Seeing  that  this  opening  made  by 
chance  did  not  close,  whilst  those  which  he  had  made  by  design  were  always 
obliterated,  he  endeavored  to  profit  by  his  mishap,  and  set  himself  to  mature 
the  process  which  chance  had  pointed  out.  Instead  of  scissors,  Kortum 
advises  us  to  cut  the  iris  vertidlally  with  the  same  ceratotome  which  is  used  in 
dividing  the  cornea.  But  in  spite  of  the  experiments  of  Weissemborn  and  the 
observations  of  Pellier,  which  tend  to  confirm  its  advantages,  the  method  of 
Janin  was  soon  abandoned  by  practitioners.  It  was  not  long  before  it  was 
found  that  a  pupil  so  formed  does  not  remain  much  longer  than  that  formed 
by  any  other  method.  Like  Pellier,  Huermann,  and  Henkel,  Janin  penetrated 
through  the  anterior  chamber. 

e.  Process  of  Guerin, — To  obtain  the  advantages  of  both,  Guerin  proposed 
to  combine  the  methods  of  Cheselden  and  Janin ;  that  is,  to  make  a  crucial 
incision  instead  of  one  simply  vertical  or  transverse.  But  on  the  one  hand 
the  operation  is  then  more  difficult,  and  on  the  other  it  is  not  rare  to  see  the 
four  flaps  approximate  so  as  to  prevent  the  light  from  reaching  the  bottom  of 
the  eye  ;  so  that  the  practice  has  not  much  to  recommend  it.  When  vision  is 
prevented  by  leucoma,  Pellier  enlarged  the  natural  pupil,  instead  of  cutting 
out  a  new  one.  For  this  purpose  he  opened  the  cornea  as  if  for  extraction, 
passed  a  small  grooved  probe  into  the  posterior  chamber  of  the  eye,  which 
served  to  direct  a  pair  of  small  scissors,  and  then  divided  the  iris  outwards, 
inwards,  or  upwards,  from  the  pupil  to  the  ciliary  ligament. 

/.  Process  of  Maunoir. — Although  the  result  of  the  individual  researches  of 
its  author,  the  method  invented  by  Maunoir  seems  to  be  but  an  improvement 
of  that  of  Pellier.  This  surgeon,  by  means  of  a  ceratotome  or  lancet,  made  an 
opening  from  two  to  three  lines  long  in  the  inferior  and  exterior  part  of  the 
cornea,  through  which  he  introduced  a  pair  of  very  small  scissors  bent  at  an 
angle  near  the  handles,  one  of  the  blades  of  which  terminated  in  a  head ; 
opens  them  in  the  anterior  chamber,  and  passes  one  blade  through  the  iris 
into  the  posterior  chamber,  so  that  the  other  with  the  button  remains  behind 
the  cornea ;  thus  seizing  the  membrane,  he  incises  it  first  inwards,  then  out- 
wards and  upwards  so  as  to  form  a  triangular  flap,  the  adherent  base  of 
which  is  towards  the  circumference  and  the  free  summit  towards  the  centre 
of  the  eye.  The  scissors -needle,  invented  by  M.  Montain  for  the  purpose  of 
avoiding  the  previous  division  of  the  cornea,  although  ingenious,  offers  no 
improvement  sufficiently  useful  to  merit  the  preference  claimed  for  them  by 
the  inventor.  By  the  double  incision  the  circular  fibres  which  M.  Maunoir 
admits  in  the  iris  are  twice  cut,  while  its  radiating  fibres  remain  untouched ; 
these  by  their  contraction  tend  to  dilate  the  new  pupil,  the  reverse  of  which 
takes  place  in  Cheselden's  operation.  The  ideas  of  the  surgeon  of  Geneva 
have  received  the  sanction  of  the  celebrated  Scarpa,  who  in  defence  of  them 
renounced  his  own  method.  This  method  has  also  found  partisans  in  Ger- 
many ;  but  in  France  and  England  it  is  generally  neglected.  Above  all,  it  is 
evident  that  if  it  be  desirable  to  attempt  coretomia  in  this  manner — of  which 
M.  Carron  declares  himself  the  ardertt  defender  in  an  unpublished  work 
which  I  have  before  me — it  may  be  advantageously  modified  by  using,  as  I 
have  several  times  done,  an  ordinary  ceratotome  for  cutting  the  triangular 


166 


KKW    ELEMENTS    Of 


flap  of  the  iris ;  doing  by  design  what  is  so  often  done  by  accident  in  the 
operation  for  the  extraction  of  the  cataract :  what  Wenzel  appears  to  have 
advised,  and  what  Odhelius  performed. 

g.  Process  of  Mr,  Mams. — Lately  Sir  William  Adams  has  revived  the 
method  of  Cheselden,  with  this  difference,  that  instead  of  a  straight  knife 
like  Sharp's,  he  employs  a  small  scalpel,  convex  on  its  edge ;  that  he  breaks 
up  the  lens  if  it  be  opaque,  and  tries  before  quitting  the  eye  to  engage  some  of 
the  pieces  in  the  transverse  incision  of  the  iris,  to  pnevent  its  closing.  M.  Roux 
used  this  method  several  times  whilst  I  was  his  assistant,  and  in  every  case 
the  new  pupil  finally  disappeared.  Besides,  it  appears  not  to  have  received 
much  confidence  in  the  author's  own  country  ;  for  it  scarcely  appears  to  have 
been  tried  by  other  surgeons.  I  have  not  myself  been  more  happy  in  two 
attempts  which  I  have  made. 

Coretomy  was  still  further  modified  by  Jurine,  Langenbeck,  Weller, 
Faure,  Wardrop,  who  carried  a  needle  into  the  posterior  chamber;  penetrated 
the  iris  from  behind  into  the  anterior  chamber ;  then  passing  again  in  the  oppo- 
site direction  through  this  membrane  in  the  internal  angle  of  the  eye,  returned 
the  point  of  the  instrument  into  the  posterior  chamber ;  then  united  the  two 
little  wounds  by  means  of  one  of  the  edges  of  the  instrument  rather  than  the 
point,  detaching  one  of  the  extremities  of  the  flap  which  they  had  circum- 
scribed. But  it  has  found  numerous  antagonists  recently  amcmg  the  oculists 
of  Germany.  They  object  to  it,  that  in  passing  the  needle  through  the  iris, 
either  from  the  anterior  or  the  posterior  chamber,  a  lesion  of  some  of  the 
apparatus  of  the  lens  is  almost  inevitable,  becoming  one  of  the  most  ordinary 
causes  of  cataract  and  rarely  followed  by  permanent  success;  that  it  is 
difficult  of  application  when  there  is  an  opacity  of  the  cornea,  or  if  there 
exist  adhesions  or  even  simple  synechia  of  the  iris.  Although  all  those 
objections  have  some  foundation,  they  are  not  of  a  nature  to  make  us 
reject  the  operation  entirely.  I  have  thought  too  of  modifying  it  still 
farther. 

h.  Process  of  the  Author. — I  use  a  knife  a  little  longer  and  narrower  than 
Wenzel 's,  cutting  on  both  edges  as  far  as  four  lines  from  the  point,  and  dull 
or  rounding  from  thence  on  the  back  to  the  handle;  an  instrument  of  which 
the  lancet  called  the  serpenfs  tongue  will  give  a  very  good  idea.  Held  as  a 
pen,  it  is  pushed  like  any  other  ceratotome  through  the  cornea  from  the  tem- 
poral side  of  the  orbit  a  little  obliquely  backwards.  When  it  has  reached  the 
anterior  chamber,  the  point  is  to  be  passed  with  great  care  through  the  iris 
into  the  posterior  chamber,  so  that  it  may  be  easily  returned  through  the 
same  membrane  at  another  point  into  the  anterior  chamber,  leaving  an  inter- 
val of  two  or  three  lines.  Then  continuing  to  push  it  on  until  it  pierces 
the  cornea  a  second  time,  it  is  easy  to  divide  the  kind  of  bridge  that  covers 
its  anterior  face,  and  only  to  detach  completely  one  extremity  of  the  flap, 
after  having  reduced  the  other  to  as  small  a  pedicle  as  may  be  desired.  A 
division  can  thus  be  obtained  equivalent  to  a  loss  of  substance.  The  small 
flap  that  is  made  will  not  fail  to  contract  upon  itself,  and  eventually  must  be  lost 
in  the  aqueous  humor.  When  the  manoeuvre  is  well  executed,  it  is  even 
possible  in  most  cases  to  excise  the  piece  entirely.  In  fact,  if  the  instrument 
acts  equally  upon  the  adherent  sides  of  the  flap  at  the  moment  the  section 
of  cue  side  is  performed,  it  is  sufficient  to  advance  the  ceratotome  a  little,  and 


OPERATIVE    SURGERY.  S67 

incliae  its  edge  towards  the  cornea  in  order  to  detacn  the  other,  and  convert 
coretomy  into  corectomy. 

2.  Coredialysis. — To  Scarpa  is  due  the  introduction  of  this  method.  Manj 
authors,  however,  had  spoken  of  it  before  him.  Sharp,  for  example,  remarks 
in  speaking  of  coretomy,  that  when  pressed  bj  the  instrument  the  iris  is 
often  detached  from  its  insertion  instead  of  divided.  In  a  patient  treated 
for  cataract  by  Wenzel,  the  lens  escaped  through  such  an  accidental  opening. 
The  natural  pupil  afterwards  almost  entirely  disappeared,  but  the  patient 
continued  to  see  through  the  abnormal  opening.  If  Assalini  may  be  believed, 
Buzzi,  of  Milan,  who  practised  coredialysis  as  early  as  1788,  passed  the 
needle  through  the  posterior  chamber  into  the  iris  at  a  line  from  the  oblite- 
rated pupil,  and  by  well  managed  tractions  detached  this  membrane  from  the 
ciliary  circle.  A.  Schmidt,  who  published  a  good  memoir  on  the  subject  in 
1803,  is  said  to  have  used  it  in  1802,  and  to  have  conceived  the  idea  of  it  in  1792. 

a.  Process  of  Scarpa. — When  his  needle  has  reached  the  interior  of  the  eye, 
the  same  as  for  depression,  Scarpa  turns  the  concavity  forwards,  passes  it 
behind  the  internal  and  superior  part  of  the  uvea,  and  presses  the  point 
through  the  iris  into  the  anterior  chamber ;  then  using  it  as  a  crotchet, with  a 
kind  of  see-saw  motion,  downwards,  forwards,  and  outwards,  until  it  detaches 
the  greater  circumference  of  this  membrane  for  about  two  or  three  lines,  so  as 
to  produce  an  opening  a  little  larger  than  the  natural  pupil. 

b.  Process  of  T,  Couleon. — Tache  Couleon  among  the  earliest,  Flajani, 
Himley,  Beer  especially,  and  Buchorn,  advise  that  the  needle,  either  straight 
or  curved  in  any  manner,  be  passed  through  the  cornea,  and  not  the  sclerotica, 
as  done  by  Scarpa.  According  to  them,  it  is  as  possible  in  this  manner  to 
make  the  new  pupil  on  the  outside  as  on  the  inside,  besides  giving  the  operator 
a  better  opportunity  of  seeing  what  he  does,  and  making  the  puncture  of  the 
eye  less  dangerous. 

c.  Process  of  Assalini. — After  having  made  an  incision  at  the  external  angle 
of  the  cornea,  Assalini  introduced  into  the  anterior  chamber  a  fine  curved 
forceps,  with  which  he  seized  the  iris  at  a  little  distance  from  its  ciliary  bor- 
der and  detached  it,  as  in  Scarpa's  method.  This  forceps  appeared  useless  to 
Bonzel,  who  replaced  them  by  a  very  small  crotchet  used  in  the  same  manner. 
Dzondi  employs  a  kind  of  forceps,  one  of  the  branches  of  which  is  grooved  on 
the  internal  face  to  receive  the  other  when  the  instrument  is  closed.  He 
asserts  that  there  is  no  risk  of  tearing  the  iris  with  this  instrument,  and  that 
it  is  easier  to  effect  the  detachment  with  it  than  with  any  other. 

The  strongest  and  best  founded  objection  to  coredialysis  is,  that  the 
detached  border  of  the  iris  resumes  after  a  little  while  its  natural  position, 
and  that  after  a  certain  time  the  new  pupil  is  always  closed. 

d.  Process  of  M,  Langenbeck. — To  obviate  this  inconvenience,  M.  Langen- 
beck,  after  seizing  the  iris  by  means  of  a  little  crotchet  protected  by  a  sheath, 
and  drawing  it  gently  towards  him,  engages  it  in  the  wound  of  the  cornea, 
which  should  be  very  small,  and  fixes  it  there  as  if  to  produce  myocephalon, 
and  then  disengages  his  instrument  with  the  utmost  caution.  The  adhesions 
which  soon  form  in  this  kind  of  hernia  prevent  the  pupil  thus  made  from 
contracting,  and  give  the  operation  every  necessary  security. 

e.  Reisinger,  who  professes  the  same  idea,  objects  to  the  sheathed  crotchet 
of  M.  Langenbeck,  and  uses  a  simple  ocular  forceps,  the  point  of  which  is 


368  NEW  ELEMENTS  OF 

curved  in  a  hook  on  one  side.  This  forceps  is  introduced  flat  and  closed 
into  the  anterior  chamber ;  then,  with  the  concavity  turned  awaj,  it  is  opened 
one  or  two  lines,  and  closed  again  after  having  been  sunk  into  the  iris.  This 
membrane,  being  thus  pinched  or  grappled,  is  detached  and  drawn  out,  so  as 
to  produce  an  artificial  procidentia.  The  coreoncion,  so  much  boasted  of  bj 
M.  Grasfe,  is  employed  in  the  same  manner  as  the  crotchet  of  M.  Langenbeck, 
and  differs  little  from  it  otherwise  than  by  a  small  ceratotome  which  it  has  at 
one  of  its  extremities. 

/.  Process  of  M.  Lusardi. — Very  recently  M.  Lusardi  has  proposed  to 
reduce  coredialysis  to  its  greatest  simplicity,  by  inventing  a  crotchet-needle 
which  is  sufficient  alone  to  perform  the  whole  operation.  This  instrument 
when  closed  has  the  form  of  Scarpa's  needle,  or  rather  of  a  very  small  hook- 
knife.  Its  two  shanks  are  so  disposed,  that  by  drawing  the  shortest  a  little 
back — that  which  corresponds  to  the  concavity — there  results  an  opening  which 
transforms  it  into  a  real  forceps.  It  is  introduced  through  the  cornea  as  if  for 
ceratonyxis,  then  passed  by  the  anterior  chamber,  if  that  be  free ;  if  not,  by 
the  posterior  chamber,  after  having  penetrated  the  iris  at  the  ciliary  circle. 
Arrived  there,  the  surgeon  applies  the  back  against  the  greater  circumference 
of  the  ocular  diaphragm,  which  he  endeavors  to  detach  by  swaying  the  instru- 
ment; then  opens  the  needle  and  allows  it  to  spring,  and  the  membrane  is 
caugiit.  There  is  then  nothing  to  do  but  to  draw  it  towards  the  opening  in 
the  cornea,  with  such  precautions  as  are  necessary  to  produce  a  new  pupil  of 
proper  dimensions.  With  this  instrument,  which  had  already  been  described 
in  Italy  by  Donegana  and  Baratta,  M.  Lusardi  thinks  there  is  no  risk  of 
injuring  the  capsule  of  the  lens — which  is  not  proved — and  that  he  can 
establish  an  artificial  pupil  upon  any  point  of  the  ciliary  circumference,  which 
is  more  correct;  but  the  ordinary  needle  offers  nearly  the  same  resources;  and 
the  most  important  advantage  whicn  I  can  see  in  this  serpette  is,  that  it 
enables  us  to  excise  a  part  of  the  iris ;  to  have  recourse  to  corectomia  at  once, 
if  there  be  any  cause  to  fear  that  coredialysis  may  be  insufficient.  I  shall  not 
speak  here  of  the  method  of  Assalini,  who,  to  remove  the  new  pupil  as  far  as 
possible  from  the  lens,  advises  us  to  destroy  a  part  of  the  circle  and  of  the 
ciliary  processes  at  the  same  time  that  we  detach  the  great  circle  of  the  iris ; 
it  is  too  directly  contrary  to  the  end  proposed  for  any  surgeon  ever  to  have 
recourse  to  it. 

g.  The  Method  of  Donegana  does  not  deserve  the  same  proscription. 
Seeing  that  after  coredialysis,  according  to  Scarpa's  method,  the  new  pupil 
almost  always  ultimately  closes,  this  oculist  has  proposed,  to  prevent  that 
inconvenience,  to  unite  the  method  by  incision  to  that  by  detachment.  Con- 
sequently he  incises  the  iris  parallel  to  its  radiating  fibres  from  the  greater 
towards  the  smaller  circumference  for  about  two  lines,  after  having  detached 
it  from  the  sclerotica.  For  this  purpose  we  may  penetrate  through  either 
chamber,  and  use  an  ordinary  needle,  or  an  instrument  with  a  blade  a  little 
thinner,  almost  straight,  and  very  sharp.  Unfortunately  it  is  not  as  easy, 
however,  as  one  would  suppose,  to  cut  the  iris  after  detaching  it  in  the  interior 
of  the  eye.  It  folds  under  the  knife,  and  tears  or  separates  from  the  neigh- 
boring parts  much  easier  than  it  di\  ides.  However,  this  is  an  improvement 
that  may  be  of  some  assistance,  and  which  it  would  be  advantageous  to  attempt 
when  we  wish  to  practise  this  operation  according  to  Scarpa's  principles. 


OPERATIVE    SURGEKY.  369 

3.  Coredomia.—a.  rre»ze/ appears  to  have  been  the  inventor  of  eorectomia. 
Yet  it  cannot  be  denied  that  Guerin  had  practised  it  before  him,  who,  as  re- 
marked b}^  Sprengel,  sometimes  excised  the  point  of  the  flap  of  his  crucial 
incision.  Sabatier,  who  adopted  the  practice  of  Wenzel,  has  given  us  the 
most  satisfactory  idea  of  it.  The  first  steps  are  the  same  as  for  extraction. 
Whilst  crossing  the  eye  the  knife  is  made  to  form  a  flap  in  the  iris  similar  to 
that  of  the  cornea.  A  pair  of  small  scissors  introduced  into  the  anterior 
chamber  is  then  used  to  separate  it  at  the  base,  seizing  it  at  the  same  time  at 
the  point  with  a  pair  of  small  forceps,  if  necessary.  An  opening  is  thus  obtained 
by  removal  of  substance  that  offers  every  chance  of  success. 

b.  Process  ofM.  Demours. — M.  Demours  thought  proper  to  pursue  a  method 
somewhat  different  in  case  of  the  existence  of  leucoma.  He  made  an 
incision  into  the  anterior  chamber,  which  comprehended  at  the  same  time  both 
cornea  and  iris ;  then  with  two  cuts  of  a  pair  of  scissors  he  circumscribed 
and  took  away  a  flap  from  the  latter  about  as  large  as  a  leaf  of  sorrel.  The 
difference  between  these  two  methods  is  but  trifling.  If  the  first  offer  some 
advantages  by  permitting  us  to  stop  at  coretomy  when  that  is  deemed  sufticient, 
the  second  exposes  less  to  the  danger  of  evacuating  the  eye.  To  one  or  the 
other  may  be  ascribed  the  principal  processes  extolled  by  the  oculists  of  the 
present  day. 

c.  Process  of  T.  Couleon  and  Dr.  Gibson. — Like  Wenzel  Dr.  Gibson 
opens  the  cornea  at  first  as  largely  as  if  for  extraction  of  a  cataract,  but 
does  not  touch  the  iris.  He  then  forces  this  membrane  through  the  incision 
by  means  of  gentle  pressure  upon  the  globe  of  the  eye,  and  with  a  pair  of 
scissors  excises  a  disc  of  suitable  dimensions.  M.  Forlenze  does  not  hesitate 
to  open  the  cornea  for  two-thirds  of  its  circumference,  so  as  to  seize  the  iris 
with  a  forceps  or  a  crotchet,  and  remove  a  flap,  like  M.  Demours.  In  a  thesis 
defended  in  1803,  M.  Morault  ascribes  a  similar  method  to  T.  Couleon. 

d.  Beer  asserts  that  an  opening  of  two  lines  in  length  in  the  cornea  is  suf- 
ficient for  the  iris. to  become  spontaneously  engaged,  and  that  then  we  may 
excise  the  part  that  attempts  to  escape.  If  this  do  not  happen,  he  draws  the 
membrane  tow^ards  him  by  means  of  a  hook. 

e.  Process  of  M.  Walther. — For  the  purpose  no  doubt  of  reconciling  the 
principles  of  Gibson  with  those  of  Beer,  M.  Walther  opens  the  cornea  for 
about  three  lines,  draws  the  iris  outwards  with  a  crotchet,  and  excises  a  flap  of 
suitable  size  with  a  pair  of  small  scissors.  By  an  opening  nearly  similar, 
M.  Lallemand,  of  Montpelier,  has  been  able  to  seize  the  membrane  with 
the  small  crotchet  forceps,  draw  it  towards  him,  and  excise  a  considerable 
piece,  thus  forming  an  elliptical  pupil  similar  to  that  of  the  cat,  vertical, 
and  two  lines  broad  and  six  long.  The  success  was  so  complete,  says  the 
author,  that  the  patient  is  able  to  follow  the  army  of  Spain  as  overseer  of  an 
infirmary. 

The  forceps -needle  of  Wagner  and  Dzondi,  the  raphiankistron  of  Emden, 
the  irianklstron  of  Schlagintweit,  and  the  method  of  Himley,  do  not,  differ 
enough  from  those  above  mentioned  to  justify  me  in  detaining  the  reader  with 
them.  I  will  say  the  same  of  the  method  of  Autenrieth,  which  consists  in 
destroying  a  portion  of  the  sclerotica,  of*the  ciliary  processes,  and  cirule ;  in 
taking  away,  in  short,  a  disc  from  the  oculai-  shell,  behind  the  cornea,  taking 
the  simple  precaution  to  close  the  opening  with  the  conjunctiva,  which  is  to 
47 


370  NEW  ELEMENTS  OF 

be  previously  separated.      The  best  that  can  be  done  for  such  an  idea  is 
not  to  speak  of  it.  ^ 

/.  Process  of  Dr.  Fhysick. — After  having'  cut  tlie  cornea  and  iris  in  con- 
formity with  the  precepts  of  Wenzel,  Dr.  Physick  introduces  into  the  anterior 
chamber  forceps  terminated  by  plates,  somewhat  similar  to  our  chin^ney- 
pincers.  The  inner  face  of  these  plates  presents  at  their  circumference  a 
cutting  edge,  forming  a  pair  of  scissors  of  a  peculiar  kind,  with  which  it  is 
easy  to  seize  and  remove  a  flap  of  the  iris  after  a  stroke  of  the  ceratotome. 

B.  Relative  Value  of  the  Various  Methods . 

These  various  methods  show  at  least  the  ceaseless  efforts  of  practitioners 
to  improve  one  of  the  most  delicate  operations  in  ocular  surgery.  Unhappily 
there  are  obstacles  and  difficulties  often  met  with  here  which  the  greatest  ad- 
dress, the  most  consummate  ingenuity  cannot  surmount.  Considered  in  an 
/  abstract  point  of  view,  there  is  no  doubt  that  corectomiais  superior  to  the  other 
two  methods.  Yet  in  practice,  as  the  instrument  used  must  cross  the  anterior 
chamber,  it  is  almost  impossible  to  have  recourse  to  it  when  the  iris  adheres 
to  the  cornea,  or  when  the  latter  membrane  is  opaque  for  a  considerable  extent. 
Coretomia  presents  nearly  the  same  inconveniences,without  all  its  advantages  ; 
and  besides,  experience  proves  that  the  opening  it  produces  rarely  persists 
more  than  a  few  weeks.  To  coredialysis  then  must  be  accorded  the  prefer- 
ence. It  is  the  same  in  case  of  adherent  membranous  cataract,  or  an  opacity 
of  any  kind  before  or  behind  the  iris  which  cannot  be  destroyed ;  observing 
that  we  are  forced  to  carry  the  pupil  towards  the  circumference  of  the  iris. 
Only  coretomia  and  coredialysis  permit  us  to  operate  by  scltroticonyxis.  Yet 
as  they  can  be  as  well  performed  by  keratonyxis,  we  should  prefer  the  former 
only  in  cases  of  very  distinct  synechia  anterior,  because  it  renders  a  lesion  of 
the  lens  almost  inevitable.  Should  any  one  desire  to  perform  coretomia 
without  trying  the  process  which  I  have  contrived,  I  would  recommend  to 
him  that  of  M.  Maunoir,  or  that  of  Wenzel,  which  is  still  better.  For  co- 
rectomia  we  may  use  indifferently  the  method  of  Demours,  Forlenze,  Gibson, 
Beer,  or  Walther;  although  the  best  of  all  in  my  opinion  would  be  that  of 
Physick  (as  I  have  modified  it),  if  it  were  possible  to  get  an  instrument  small 
enough  and  finely  finished,  which  I  have  not  yet  been  able  to  do.  When  it 
has  been  decided  to  perform  coredialysis,  the  simple  crotchet  of  Bonzel  will 
answer  all  the  purposes  of  the  more  complicated  instruments  of  Beer,  Rei- 
singer,  &c. ;  but  I  doubt  whether  it  be  as  easy  as  it  seems  to  be  admitted  by 
these  authors,  to  fix  in  the  opening  of  the  cornea  the  portion  of  the  iris  which  has 
been  with  more  or  less  difficulty  drawn  out.  If  the  accident  which  we  hope  to 
remedy  by  forming  an  artificial  pupil  be  manifestly  the  consequence  of  an  ope- 
ration for  cataract,  there  is  then  much  less  inconvenience  than  in  other  cases  in 
passing  the  instrument  by  the  posterior  chamber.  But  then  at  the  same  time 
the  eye  is  too  much  altered  to  permit  very  great  hopes  of  success.  It  is  evidently 
unnecessary  to  open  the  anterior  chamber  as  largely  as  advised  by  Wenzel, 
Forlenze,  and  Gibson.  If  the  lens  and  its  capsule  be  healthy,  it  is  otherwise. 
Yet  if  there  be  any  suspicion  of  opacity  in  these  parts,  it  is  better  to  extract 
them..  Perhaps  we  should  even  make  it  a  rule  to  extract  them  whether  opacity 
had  coipmenced  or  not.     By  this  means  we  would  escape  the  unpleasant  sight 


OPERATIVE    SURGERY.  371 

of  a  consecutive  cataract  making  its  appearance  to  destroy  the  chances  of  suc- 
cess of  the  primary  operation,  as  happened  to  me  in  a  man  aged  thirty  years. 
With  this  view  the  opening  of  the  cornea  could  not  be  too  large,  since  we 
operate  for  cataract  and  artificial  pupil  at  the  same  time.  When  there  are 
opaque  spots  on  the  eye,  and  when  keratonyxis  cannot  be  performed,  the  case 
becomes  very  embarrassing.  If  the  incision  be  upon  the  healthy  front  of  the 
cornea,  the  cicatrix  resulting  from  it  and  the  inflammation  which  follows  it,  too 
often  destroy  the  little  transparency  that  the  primary  disease  had  left.  The 
leucomatose  portion,  on  the  contrary,  we  have  cause  to  fear  will  suppurate 
and  cause  the  loss  of  the  eye.  Yet  many  practitioners,  and  among  them 
Fause  and  Lusardi,  have  remarked  that  the  section  of  a  cornea  thus  opaque 
is  not  so  dangerous  as  it  is  generally  thought  to  be ;  and  they  go  even  so 
far  as  to  say  it  agglutinates  more  rapidly  than  when  it  is  not  thus  diseased. 
This  is  easy  to  be  conceived ;  for  such  tissues  being  less  sensible,  less  excit- 
able, nearer  the  state  of  vegetative  life,  must  inflame  more  moderately  than  if 
in  a  perfectly  normal  state.  If  then  the  cornea  be  opaque  to  a  great  extent, 
we  must  husband  carefully  that  part  which  yet  remains  good,  and  penetrate 
through  the  altered  portion.  In  the  opposite  case,  when  the  transparency  is 
affected  only  in  a  small  and  very  circumscribed  spot,  it  is  better  to  cut  the 
sound  tissue.  To  be  prepared  for  every  exigency,  every  variety  of  form 
under  which  the  disease  may  present  itself,  it  is  well  to  become  familiarized 
with  the  various  methods  I  have  detailed,  each  of  which  may  at  times  offer 
peculiar  advantaj2:es.  I  will  add,  however,  that  the  method  by  excision  is  the 
only  one  which  offei's  ultimately  any  real  chances  of  success.  All  the  methods 
by  incision,  either  simple  or  complicated,  as  well  as  that  by  detachment,  are 
decidedly  bad,  and  shoujd  be  adopted  only  by  way  of  exception.  I  have  per- 
formed this  operation  according  to  the  precepts  of  Scarpa,  W^enzel,  and 
Maunoir ;  and  although  the  artificial  pupil  has  remained  large  enough  for  some 
time,  it  has  always  ultimately  reduced  itself  to  almost  nothing.  I  have 
recently  practised  upon  a  young  girl  the  method  of  Odhelius,  and  although  the 
opening  appeared  at  first  very  large,  it  has  already  begun  to  contract.  These 
facts  and  the  wounds  of  this  same  membrane  during  the  operation  for  cataract, 
have  satisfied  me  that  the  various  methods  based  upon  the  supposed  muscular 
nature  of  the  iris  are  built  upon  a  false  foundation.  Instead  of  retracting 
itself  towards  the  root,  the  flap  of  the  iris  which  I  made  in  1829,  at  St. 
Antoine,  on  a  man  sixty  years  of  age,  on  the  contrary,  approximated  little  by 
little  towards  the  point  from  which  it  had  been  separated.  The  same  thing 
happened  to  me  in  1831,  at  La  Pitie. 

After  the  operation  the  patient  must  be  subjected  to  the  same  regimen  and 
the  same  precautions  as  if  he  had  been  treated  for  cataract.  Yet  the  con- 
sequences are  rarely  as  serious.  After  keratonyxis  and  even  scleroticonyxis, 
they  are  often  reduced  to  the  slightest  inflammatory  symptoms.  If  the 
patient  has  not  completely  or  for  a  long  time  lost  the  habit  of  perceiving 
light,  we  can  frequently  dispense  with  confinement  to  bed,  and  be  content 
with  making  him  wear  a  bandage  of  black  taffeta  for  some  days.  The  lady 
operated  on  by  Wardrop,  returned  in  a  carriage  immediately  after  without 
any  bad  result.  An  ungovernable  subject,  upon  whom  I  could  impose  no 
rules  of  conduct,  got  up  the  same  night  of  the  operation,  would  not  submit  to 
any  retrenchment  in  his  aliment  or  change  in  his  habits  after  the  expiration 


S72  NEW   ELEMENTS   OF 

of  the  next  day,  and  this  without  being  affected  with  the  least  inflammation. 
Of  seven  others  upon  whom  I  operated,  none  suffered  from  inflammatory 
symptoms.  But  when  we  have  performed  keratotomy ;  when  we  have  opened 
the  cornea  extensively,  like  Wenzel,  &c.;  when  we  have  thought  it  neces- 
sary to  extract  the  lens  or  its  appendages ;  and  when  tlie  natural  pupil  has 
been  completely  closed  for  a  long  time,  it  would  be  very  imprudent  not  to 
enforce  exactly  the  same  regimen  as  after  an  operation  for  cataract.  In  all 
these  cases  the  most  intense  ophthalmia  may  be  easily  induced. 


§  5. — Puncture — Incision. 

Puncture  of  the  eye  was  formerly  employed  in  onyx,  or  effusion  of  pus 
between  the  lamellae  of  the  cornea ;  in  hypopyon,  or  abscess  of  the  anterior 
chamber ;  empyesis,  or  abscess  of  the  posterior  chamber ;  hydrophthalmia ; 
buphthalmia :  and  in  all  cases,  in  fine,  where  the  eye  was  the  seat  of  an  exces- 
sive accumulation  either  of  its  ownnatural  humors,  or  of  any  abnormal  liquid. 

1.  Onyx. — When  the  small  purulent  spots  which  sometimes  form  in  the 
thickness  of  the  cornea  have  been  vainly  combated  by  antiphlogistics,  emol- 
lients, discutients,  &c.,  nothing  appears  more  rational  than  to  open  them. 
The  operation  is,  however,  so  simple,  that  it  is  scarcely  worth  describing. 
The  surgeon,  depressing  the  lower  lid  whilst  the  assistant  elevates  the  other, 
seizes,  with  the  right  hand  for  the  left  eye  and  the  left  hand  for  the  right  eye, 
an  ordinary  lancet,  bare  or  enveloped  with  a  ribbon  nearly  to  the  point,  and 
divides  the  layers  of  the  cornea  which  separate  the  onyx  from  the  exterior 
with  all  necessary  caution,  repeating  the  puncture  as  often  as  the  separate 
abscesses  in  the  front  of  the  eye  may  require  it.  A  cataract  needle  will  do 
as  well  as  a  lancet,  and  any  pointed  cutting  instrument  will  serve.  Unless 
the  transparency  of  the  cornea  be  utterly  destroyed,  the  instrument  should 
be  carried  as  far  from  the  centre  of  the  organ  as  the  disease  will  admit,  and 
penetrate  rather  obliquely  than  by  a  perpendicular  incision.  Some  surgeons 
disapprove  of  either  puncture  or  incision  in  these  cases.  It  aggravates,  they 
say,  or  reproduces  the  inflammation,  leaves  indelible  cicatrices,  and  may 
produce  other  serious  injuries  to  the  eye.  Besides,  the  matter  forming  the  onyx, 
almost  always  adherent  to  the  lamellae,  is  rarely  so  fluid  that  it  will  escape 
from  a  simple  incision.  Finally,  this  pus  disappears  of  itself  when  the 
ophthalmia  which  produced  it  is  entirely  removed.  Although  adopting  some 
of  these  reasons,  I  think  the  operation  useful  when  the  pus  is  gathered  into  a 
true  sac,  in  a  fluid  or  concrete  mass  large  enough  to  take  away  all  hope  of 
its  disappearance  without  surgical  aid.  The  facts  which  science  possesses, 
and  the  late  labors  of  M.  Gierl  in  particular,  seem  to  me  to  show  that  the 
puncture  of  the  eye  offers  us  then  some  undeniable  advantages,  and  that  the 
moderns  have  exaggerated  its  possible  bad  results. 

2.  Hydrophthalmia. — The  puncture  of  the  eye  for  hydrophthalmia,  whether 
attended  or  not  by  the  liquefaction  of  the  vitreous  humor  or  the  extravasation 
of  blood  or  pus,  is  a  means  of  relief  not  so  often  resorted  to  at  the  present 
time.  It  would  be  imprudent,  doubtless,  to  commence  the  treatment  by  it; 
but  when  general  therapeutic  means  and  topical  applications  have  been  tried 
without  success,  and  the  distension  of  the  eye  continues,  I  can  see  nothing 
more  rational  than  paracentesis  of  the  eye.    By  removing  the  compression  of 


OPERATIVE    SURGERY-.  S7S 

tlie  retina,  the  iris,  the  ciliary  circle,  processes,  vessels,  and  nerves,  it  calmg 
the  most  violent  pains,  and  appears  to  me  capable  of  preventing  most  serious 
consequences  and  becoming  a  most  important  palliative,  if  not  curative  means. 
Though  used  in  Japan  and  China  for  some  centuries,  and  practised  by 
Tuberville  and  Woolhouse,  this  remedy  does  not  appear  to  have  been  formally 
proposed  by  any  one  for  hydrophthalmia,  before  Yalentini,  Nuck,  and  Mau- 
chart.  Woolhouse  advised  the  puncture  of  the  sclerotica,  and  Nuck  of  the 
centre  of  the  cornea.  'Puncturing,  properly  so  called,  is  now  generally 
abandoned.  It  is  in  almost  every  case  advantageously  superseded  by  inci- 
sion. Some  prefer  to  open  the  anterior,  others,  M.  Basedow  for  example,  the 
posterior  chamber.  Bidloe  opened  the  inferior  part  of  the  cornea  with  a 
hawk-billed  lancet.  Meckren  used  a  large  triangular  needle  made  for 
the  purpose.  At  the  present  time  a  cataract-ceratotome  is  most  usually 
employed.  Saint  Yves  divided  the  cornea  transversely.  Louis  dislikes  too 
large  an  opening.  Heister  advises  the  incision  of  the  sclerotica.  Others  are 
for  puncturing  first,  and  extending  the  opening  with  scissors  or  some  other 
instrument.  But  amongst  the  whole  the  choice  truly  lies  between  Bidloe's, 
or  rather  Galen's  method,  and  that  of  Maitre-Jean  and  Heister.  None  of 
the  others  accomplish  the  purpose  so  well,  and  most  are  more  complicated  or 
much  more  dangerous.  The  incision  of  the  sclerotica  either  outwards  or 
downwards,  or  parallel  to  the  fibres  of  this  membrane,  reduces  itself  in  effect 
to  a  trifling  puncture,  and  would  be  preferable  if  the  aqueous  humor  could 
always  escape  thereby.  But  unhappilj  this  is  not  the  case.  Even  in  simple 
hydrophthalmia  it  is  evidently  necessary  in  dividing  the  sclerotica,  to  do  the 
same  with  at  least  two  lines  of  the  ciliary  circle,  which  must  make  this  ope- 
ration more  dangerous  than  the  division  of  the  cornea.  It  is  only  then  when 
the  disease  affects  the  vitreous  body — differing  from  simple  hydrophthalmia — 
that  Heister's  method  offers  any  advantages;  yet  even  in  that  case  it  is  of  little 
importance  which  be  pursued,  as  the  eye  is  in  most  cases  utterly  lost. 

Operation. — Having  disposed  the  patient  and  assistants  as  if  for  the  extrac- 
tion of  a  cataract,  opened  the  lids,  and  fixed  the  eye,  the  surgeon,  with  the 
point  of  a  lancet,  bistoury,  or  ceratotome,  held  as  a  pen,  makes  an  incision  of 
two  or  three  lines  through  the  inferior  or  external  part  of  the  cornea,  as  far 
from  the  pupil  as  possible  without  wounding  the  iris.  The  aqueous  humor 
soon  escapes ;  there  is  no  nec3ssity  for  pressure.  A  very  manifest  relief  is 
generally  the  immediate  consequence.  As  there  may  be  some  hope  of  saving 
the  eye,  nothing  should  be  done  to  prevent  the  cicatrization  of  the  wound.  It 
should  be  dressed  as  an  operation  for  cataract,  and  the  puncture  renewed 
after  some  days  (according  to  M.  Basedow,  who  reports  four  instances  of 
success),  if  a  new  accumulation  of  fluid  seems  to  require  it.  No  one  would 
now  advise  us  to  imitate  Nuck  and  some  of  the  surgeons  of  the  last  century, 
in  putting  a  plate  of  lead  between  the  lids  in  order  to  press  the  eye  back- 
wards and  make  it  gradually  retire  into  the  orbit.  Such  a  practice,  in  itself 
unworthy  of  discussion,  could  only  have  been  adopted  by  those  who  confound 
exophthalmia,  buphthalmia,  and  proptosis  with  true  hydrophthalmia. 

If  some  point  of  the  tunics  of  the  eye  be  more  manifestly  altered,  promi- 
nent, or  thinner  than  the  others,  it  sliould  certainly  be  preferred  to  the  point 
above  indicated  for  the  paracentesis.  When  in  buphthalmia  the  projection 
of  the  eye  depends  upon  dropsy,  upon  a  forced  dilatation  of  the  sclerotica,  it  i& 


S74 


NEW    ELEMENTS  OF 


still  hjdrophthalmia,  and  indicates  the  same  operation  as  above.  On  the  con- 
trary, it  will  be  of  no  use,  and  will  only  aggravate  the  condition  of  the  patient 
when  the  disease  is  caused  by  the  development  of  some  humor,  or  by  tho 
existence  of  some  organic  lesion  of  the  orbit. 

3.  Hypopyon. — Galen  seems  to  have  been  the  first  to  propose  paracentesis 
for  hypopyon.  Yet  he  did  not  have  recourse  to  it  until  after  having  vainly 
tried  succussion,  so  much  extolled  by  Justus,  and  which  Heister  and  Mauchart 
since  have  not  disdained  to  try.  According  to  this  author,  the  inferior  part 
of  the  cornea  is  to  be  opened  a  little  anterior  to  its  union  with  the  sclerotica,  and 
the  pus  soon  flows  fordi.  Aetius  advises  the  use  of  aneedle  at  some  point  of 
the  membrane  that  is  uninflamed.  G.  de  Chauliac,  Benedetti,  Pare,  and 
Dionis  have  followed  the  direction  of  Galen  with  success ;  and  in  spite  of  the 
efforts  of  Nuck,  Woolhouse,  and  many  others,  who,  like  the  Arabians, 
advised  us  to  be  content  with  a  puncture  to  give  air  to  the  matter;  who  even 
go  so  far  as  to  recommend  leaving  a  canula  in  the  place,  which  may  be  used 
for  making  injections  into  the  eye,  modern  operators  are  satisfied  with  a 
clean  and  simple  incision,  when  they  have  decided  to  treat  hypopyon  by 
paracentesis.  This  would  be  in  fact  the  best  method  in  such  cases,  if  any 
operation  be  necessary,  or  if  we  are  to  believe  M.  Gierl  on  this  subject.  But 
the  great  masters  of  the  present  time  unite  in  condemning  all  species  of  sur- 
gical interference;  saying,  with  reason,  that  the  small  quantity  of  pus  which 
forms  hypopyon  will  disappear  quite  soon  of  itself  when  the  ophthalmia  is 
reduced ;  that  a  way  to  augment  the  secretion  and  produce  opacity  of  the 
cornea,  is  to  open  the  anterior  chamber  with  an  instrument  of  any  kind;  that 
the  chronic  purulent  deposites — the  only  ones  perhaps  that  paracentesis 
does  not  aggravate — are  formed  of  a  matter  too  firmly  adherent  either  to  the 
iris  or  the  cornea  to  be  made  to  escape  by  an  incision  of  some  lines  in  extent; 
that  we  should  trust  to  general  treatment  and  collyria  to  arrest  such  disease 
while  it  is  yet  within  the  bounds  of  true  hypopyon,  while  there  are  yet  hopes 
of  preserving  the  function  of  vision.  For  these  reasons  I  think,  with  Boyer, 
Richerand,  and  Dupuytren,  that  the  puncture  of  the  eye  is  but  rarely  appli- 
cable to  abscess  of  the  anterior  chamber,  unless  we  employ  it,  like  Lehoc,  to 
renew  the  aqueous  humor  as  well  as  to  evacuate  the  purulent  matter. 

4.  Empyesis. — In  abscess  of  the  posterior  chamber,  that  is,  in  empyesis  or 
empyema  of  the  eye,  it  would  seem  at  first  sight  that  all  must  agree  upon  the 
necessity  of  having  recourse  to  paracentesis.  But  this  would  be  a  mistake. 
Many  have  advised  it.  Almost  all  the  surgeons  of  the  last  century  practised 
it  frequently.  Yet  it  is  in  fact  a  feeble  resource.  By  this  means  we  can 
only  imperfectly  evacuate  the  morbid  collection.  As  it  is  soon  reproduced, 
the  evil  is  hardly  removed  for  a  few  moments.  The  eye  once  in  that  condi- 
tion is  lost  without  resource.  Incision  is  of  no  greater  advantage.  It  is  neces- 
sary to  excise  a  portion  sufficiently  large  to  empty  the  eye  and  determine 
atrophy  of  that  organ.  The  seton  used  in  China  and  Japan,  extolled  by 
Woolhouse,  and  lately  again  brought  forward  by  Mr.  Ford,  &c.,  is  a  barbarous 
means  unworthy  of  criticism.  It  can  scarcely  be  conceived  how  it  could 
enter  the  mind  of  any  man  to  traverse  the  anterior  or  posterior  chamber  from 
the  external  to  the  internal  angle,  with  a  needle  drawing  after  it  a  cord  which 
is  to  be  tied  by  its  two  ends  in  front  of  the  eye,  to  cause  the  escape  or  the  dis- 
sipation of  the  empyema.  The  dangers  and  uselessness  of  such  a  proceeding 
are  too  evident  to  need  pointing  out. 


OPERATIVE    SURGERY.  375 

§  6.  Recision. 

Staphyloma  of  the  cornea,  empyema,  hypopyon,  and  iiydrophthalmia,  are 
almost  the  only  diseases  requiring  excision  of  the  anterior  portion  of  the  eye, 
or  for  which  it  can  be  reasonably  tried. 

Its  object  is  to  empty  the  organ,  to  produce  atrophy,  and  thereby  transform 
it  into  a  simple  stump  capable  of  supporting  an  artificial  eye.  It  is  the  last 
resort,  only  permitted  in  a  hopeless  case  to  remedy  a  most  serious  disease  or 
a  shocking  deformity,  and  only  when  it  is  demonstrated  that  sight  can 
neither  be  preserved  nor  restored.  In  hypopyon,  empyesis,  and  hydrophthalmia, 
it  is  to  be  resorted  to  only  after  trial  of  incision  or  puncture,  and  when  these 
have  proved  insufficient.  The  most  ancient  authors  used  it  in  procidentia 
oculi.  Galen  speaks  of  it  as  a  common  method.  Aetius  recommends  it  to 
be  combined  with  ligature ;  and  that  before  removing  the  staphyloma  two 
ligatures  should  be  passed  through  it.  The  ligature  may  be  circular,  crucial, 
or  transverse,  like  that  of  Paul  of  Egina,  and  others ;  the  taxis  and  compres- 
sion of  Manget,  and  the  crucial  incision  of  Woolhouse,  are  none  of  them  now 
in  use.  The  surgeons  of  the  present  day,  when  they  wish  to  obtain  a  perfect 
cure  of  staphyloma  of  the  cornea,  follow  the  advice  of  Pare  and  Louis,  that  is 
to  practice  a  clean  and  simple  incision. 

Operation. — For  whatever  disease  it  may  be,  if  we  object  to  taking  away  the 
whole  organ,  we  should  confine  ourselves  to  removing  the  summit.  Cancerous 
affections,  if  they  ever  admit  of  a  simple  recision,  form  the  only  exception  to 
this  rule.  By  carrying  the  plane  of  the  incision  through  the  posterior  cham- 
ber, as  some  oculists  have  done,  the  muscles  are  apt  to  draw  what  is  left  of  the 
sclerotica  and  optic  nerve  to  the  bottom  of  the  orbit,  leaving  us  without  a 
stump  after  recovery.  On  the  other  hand,  if  the  opening  be  too  small,  the 
morbid  or  natural  humors  only  partially  escape  ;  the  w^ound  soon  cicatrizes, 
and  leaves  a  depression  as  unsightly  perhaps  as  the  staphyloma  itself,  besides 
rendering  it  difficult  to  use  an  artificial  eye.  AVe  escape  these  two  extremes 
by  taking  the  whole  of  the  cornea,  and  nothing  more.  Then  we  are  sure  that 
the  vitreous  humor  will  escape  or  disappear,  and  that  no  new  accumulation 
producing  painful  distension  will  be  formed  in  the  posterior  chamber.  The 
iris  being  preserved,  it  is  evident  that  the  sclerotica  cannot  become  everted 
nor  sink  into  the  orbital  cavity;  and  that  after  cicatrization  the  muscles  can 
impress  upon  the  organ  the  most  of  its  natural  movements,  and  transmit  them 
to  the  artificial  eye.  The  crucial  incision  with  excision  of  the  four  flaps,  as 
recommended  by  Richter,  is  altogether  useless.  The  patient  being  suitably 
placed  and  supported,  the  inferior  half  of  the  cornea  is  to  be  divided  with 
Daviel's  instrument,  the  point  of  a  lancet,  a  bistoury,  or  ceratotome  of  any 
kind,  as  if  for  extraction  of  the  lens.  The  flap  is  then  seized  with  any  good 
forceps,  and  fully  detached  by  means  of  sharp  scissors  or  a  bistoury.  With  un- 
manageable subjects,  or  when  the  eye  is  difficult  to  fix,  a  hook  fastened  into 
the  middle  of  the  segment  renders  the  excision  more  sure  and  prompt.  This 
process  is  more  simple  tlian  that  of  Terras,  who  passed  a  ligature  through  the 
tumor  in  order  to  cut  it  off  more  easily  and  permit  us  to  remove  as  rapidly 
as  possible,  and  with  a  single  stroke  of  a  bistoury,  the  whole  of  the  cornea  or 
staphyloma ;  beginning  eitlier  above  or  below.  The  ring  and  blade  of  M.  De- 
mours  is  not  more  convenient  and  deserves  no  preference. 


376  NEW  ELEMENTS  OF 

The  consequences  of  this  operation  are  commoijly  active  inflammation  of  all 
the  parts  within  the  orbit,  fever,  headache,  and  sometimes  even  same  symp- 
toms of  a  much  higher  grade.  In  general,  however,  after  about  ton  or  fifteen 
days,  the  swelling  begins  to  decrease ;  the  suppuration,  at  first  very  abundant, 
does  not  last  long,  and  towards  the  enil  of  a  month,  a  little  sooner  or  a  little 
later,  it  is  possible  to  put  in  the  artificial  eye.  As  this  is  not  an  operation  with- 
out danger,  those  who  desire  it  to  be  performed  for  simple  deformity  should 
be  informed  of  its  nature ;  nor  should  it  be  performed  in  such  cases  except  at 
their  solicitation.  But  on  the  contrary,  when  the.  disease  is  dangerous  of  itself, 
such  as  empyema,  hydrophthalmia,  &c.,  there  is  no  room  for  hesitation ;  every 
fear  must  disappear  in  the  presence  of  such  affections. 

§  7.  Extirpation, 

Although  extirpation  of  the  eye  was  not  clearly  described  until  towards 
the  close  of  the  last  century,  there  is  every  reason  to  believe  that  the  older 
surgeons  had  frequent  recourse  to  it:  thus  J.  Lange,  who  wrote  in  1555, 
boasts  of  having  preserved  an  eye  which  surgeons  wished  to  extirpate.  A 
little  later,  in  1583,  M.Donat  attempted  to  demonstrate  its  inutility,  and  main- 
tained that  compression,  aided  by  proper  internal  remedies,  almost  always 
triumphed  over  such  affections  as  seemed  to  require  it;  which  proves  at  least 
that  it  had  been  long  known  to  practitioners.  Bartisch,  who  published  his 
book  in  1583,  has  not  then  the  merit  of  its  invention,  but  only  of  calling 
attention  to  it  and  rendering  the  operation  more  easy.  Some  authors,  Covil- 
lard,  Lamswerde,  and  Spigel  for  example,  pretend  to  have  cured  without  an 
operation  subjects  whose  eyes  had  been  violently  forced  from  the  orbit  and 
hung  upon  the  cheek.  Maitre-Jean  long  since  showed  the  impossibility  of 
such  an  occurrence  according  to  the  letter ;  but  Louis  has  well  remarked,  that 
disrobing  these  assertions  of  their  hyperbole,  some  proof  in  their  favor  is 
found  in  the  fact  that  the  optic  nerve  and  the  surrounding  muscles  can  bear 
considerable  elongation  without  requiring  the  extirpation  of  the  eye.  Besides, 
there  are  numerous  examples  of  this  elongation  produced  in  a  gradual  manner 
by  some  cases  of  exostosis,  by  tumors  of  all  kinds  in  the  orbit,  nasal  fossae,  and 
maxillary  sinuses.  But  if  the  ej'^e  really  hangs  out  from  the  orbit  in  conse- 
quence of  some  traumatic  lesion,  instead  of  seeking  to  replace  it  we  should 
completely  separate  and  remove  it  at  once.  In  such  cases  there  is  no  method 
to  describe.  A  single  cut  with  the  scissors  or  bistoury  is  sometimes  sufficient; 
in  others  the  surgeon  must  necessarily  vary  the  process  to  suit  the  accident.  On 
the  contrary,  when  the  eye  has  been  forced  from  the  orbit  by  degrees,  either 
entirely  or  partially,  and  whether  it  be  itself  disorganized  or  not,  it  may  be 
wrong  to  extirpate  it.  It  is  not  to  it  that  we  must  apply  our  surgical  means. 
It  is  the  business  of  the  surgeon  to  destroy  the  original  cause  if  he  can,  and 
then  the  displaced  organ  will  soon  return  to  its  natural  position.  It  was  thus 
that  St.  Yves  triumphed  over  a  dangerous  exophthalmia,  by  determining  the 
resolution  of  a  scirrhus  formed  in  the  depths  of  the  orbit.  It  was  by  this  means 
that  the  surgeon  Brossaut,  of  whom  Louis  speaks,  saw  the  sight  of  an  eye 
restored  and  the  eye  returned  into  its  cavity,  after  the  oxostosis  of  the  ethmoid 
bone,  which  had  forced  it  out,  had  been  destroyed  ;  by  this  course  Guerin,  of 
Bordeaux,  and  M.  Dupuytren,  have  arrived  at  the  same  result,  removing  or 


J 


OPERATIVE    SURGERY.  377 

emptying  the  various  cysts  or  tumors  of  which  the  parts  about  the  eye  are  so 
often  the  seat.  Its  extirpation  then  is  not  necessary  for  buphthalmia,  for 
hydrophthalmia,  empyesis,  or  staphyloma.  Only  cancerous  affections  admit 
of  a  resort  to  it.  And  it  yet  remains  to  be  decided  after  the  existence  of  these 
is  proved,  whether  the  operation  is  to  be  attempted.  Those  who  think 
affirmatively,  with  Desault,  &c.,  found  their  opinion  upon  tlie  fact  that  the 
disease  is  observed  on  infants  and  young  persons  much  more  frequently  than 
upon  adults,  and  that  at  that  age  it  is  much  more  likely  to  be  reproduced  than 
after  puberty.  Their  opponents  adduce  the  researches  of  Wardrop,  which  go 
to  prove  ihaitfungus  hematodes — a  mixture  of  the  encephaloid,  erectile  colloide, 
and  melaric  tissues,  or  one  of  them  alone,  almost  always  constitute  the  disease. 
And  as  there  is  nothing  which  reproduces  itself  either  in  the  same  or  some 
other  place  with  more  obstinacy  than  this  kind  of  abnormal  tissue,  they 
maintain  that  the  operation  gives  useless  pain,  and  that  nothing  should  be  tried 
but  simple  palliatives.  That  which  reason  and  analogy  has  taught  them  to 
expect,  experience  has  but  too  fully  verified.  Whatever  some  authors  may 
say,  the  labors  of  the  ancients  as  well  as  those  of  the  moderns,  prove  that 
extirpation  of  the  cancerous  eye  does  not  render  it  less  liable  to  return  than 
the  removal  of  a  similar  disease  from  any  other  part.  I  would  not  conclude 
however  that  it  is  right  to  remain  inactive.  So  far  from  it,  that  I  think  the 
operation  should  be  urged  before  the  viscera  have  had  time  to  become  invaded 
by  the  morbific  germs;  as  soon  as  the  disease  is  no  longer  doubtful,  and  when 
it  appears  possible  to  remove  it  completely.  All  this,  however,  enters  into 
the  general  question,  whether  or  not  it  be  proper  to  operate. 

Operation. — 1.  Process  of  Bartisch. — The  extirpation  of  the  eye,  which  is 
much  more  frightful  than  difficult,  more  alarming  for  its  consequences  than 
fraught  with  immediate  dangers  or  delicate  of  execution,  may  be  performed 
in  various  ways.  We  find  no  details  upon  this  subject  in  authors  before  Bar  - 
tisch,  who  dug  out  the  diseased  part  with  a  kind  of  cutting  spoon.  Although 
no  person  at  this  day  could  recommend  so  coarse  an  instrument,  yet  it  is  not 
true,  as  was  once  said,  that  it  is  apt  to  injure  the  bone  and  render  the  ope- 
ration much  more  difficult  than  witii  any  other  knife.  Its  dimensions  do  not 
permit  it  to  reach  the  bottom  of  the  orbit,  but  I  cannot  perceive  that  it  is 
often  necessary  to  go  so  deep.  To  be  just,  it  should  be  discarded  merely  as 
useless  or  not  very  convenient. 

2.  F,  de  Hilden,  who  had  occasion  to  extirpate  the  eye,  in  1596,  conceived 
the  idea  of  embracing  tlie  projecting  part  at  first  in  a  kind  of  purse  with  a 
draw-string.  Detaching  the  tumor  from  the  lids  and  neighboring  parts  with 
a  bistoury,  he  used  for  dividing  the  muscles  and  optic  nerve  a  sort  of  two- 
edged  scalpel,  curved  sideways,  broad,  short,  and  blunt  at  its  point,  or 
terminated  with  a  button.  We  see  in  these  proceedings  the  beginnings  of  a 
more  enlightened  surgery  ;  and  the  operator  spoken  of  by  Bartholin  was  truly 
unpardonable  in  not  profiting  by  them  fifty  years  afterwards,  nor  recoiling  at 
the  thought  of  seizing  the  eye  with  pincers.  Although  more  ingenious,  Hilden's 
instrument  has  yet  submitted  to  the  fate  of  Bartisch's.  While  Job  a  Meck- 
ren  succeeded  with  the  spoon  of  tJie  oculist  of  Dresden,  and  Muys  and 
Leclerc  with  tlie  knife  of  Hilden,  Lavauguyon  maintained  that  a  good  lancet 
fixed  upon  a  handle  was  always  sufficient,  and  might  be  substituted  for  them 
both.  Saint  Yves  used  only  a  thread  to  fix  the  diseased  mass  and  one  cutting 
48 


378  NEW  ELEMENTS  Of 

instrument,  which  he  does  not  describe,  for  the  whole  operation.  The 
observations  of  Bidloe  make  no  mention  of  any  particular  knife,  except  along 
bistoury  bent  at  an  angle  near  the  handle,  and  which  is  much  extolled  by  V, 
1).  Maas. 

3.  Heister  has  shown  us  that  a  hook  or  forceps,  and  an  ordinary  bistoury, 
with  which  Hoin,  of  Dijon,  was  contented  in  1737,  are  sufficient  for  this 
operation. 

4.  Such  was  the  state  of  things  when  Louis  undertook  to  fix  the  principles 
for  extirpation  of  the  eye.  According  to  him,  when  the  tumor  is  retained 
by  nothing  but  the  straight  muscles  and  the  optic  nerve,  we  should  use  a  pair 
of  scissors  curved  sideways ;  these  are  to  be  carried  to  the  bottom  of  the  orbit 
to  divide  the  musculo-nervous  attachment,  and  serve  as  a  spoon  or  scoop  to 
remove  the  whole  mass. 

Desaulty  who  in  the  earlier  years  of  his  practice  adopted  the  method  of 
Louis,  afterwards  abandoned  the  scissors  as  useless,  and  held  to  the  simple  bis- 
toury only,  with  which  he  could  effect  more  than  with  the  curved  one  of  B.  BelL 
Sabatier,  Messrs.  Boyer,  Richerand,  Dupuytren,  and  all  the  operators  of  the 
present  time,  conform  to  the  advice  of  Louis  or  Desault  almost  indifferently. 
With  the  bistoury  there  is  no  necessity  of  changing  the  instrument  from 
beginning  to  end  of  the  operation.  The  division  of  the  soft  parts  is  neater. 
It  is  sufficient  to  draw  the  eye  in  one  direction  whilst  cutting  in  the  other  to 
reach  easily  the  posterior  part  of  the  eye.  One  must  be  very  unfortunate  or 
unskillful  to  carry  the  point  of  the  instrument  into  the  optic  foramen,  the  max- 
illary or  spheroidal  fissures.  It  is  therefore  here,  as  we  have  already  so 
often  seen,  a  matter  of  choice  or  of  circumstance,  and  not  of  necessity. 

First  Stage. — The  patient  might  be  seated  on  a  chair,  but  it  is  much  better 
to  operate  upon  him  in  bed,  taking  care  to  have  the  head  well  elevated.  The 
surgeon  places  himself  on  the  same  side  with  the  affected  eye,  and  conducts 
himself  in  different  ways,  according  as  the  neighboring  parts  are  or  are  not 
invaded  by  the  cancer.  If  they  are,  he  is  to  conform  to  the  precept  of  Guerin, 
making  two  semilunar  incisions,  which  enable  him  to  circumscribe  the  base 
of  tlie  orbit  and  detach  the  lids  so  as  to  remove  them  with  the  rest  of  the 
disease.  But  if  otherwise,  he  must  exert  himself  to  preserve  the  appendage* 
of  the  eye.  If  they  have  contracted  adhesion  without  suffering  any  real 
degeneration,  he  must  dissect  each  lid  away  and  turn  it  outwards.  When 
the  globe  is  thus  freed  from  them,  it  is  sufficient  to  extend  the  external  pal- 
pebral angle  about  an  inch  towards  the  temple  with  a  stroke  of  the  bistoury, 
as  appears  to  have  been  first  advised  by  Acrel,  and  not  by  Desault.  Throughout 
the  whole  our  assistant  holds  the  head  of  the  patient  so  as  to  follow  and  favor 
the  movements  of  the  operator.  The  latter  fixes  the  projecting  part  of  the 
tumor  with  his  hand  if  he  can,  as  Desault  did ;  or  uses  a  hook  with  a  single 
or  double  crotchet,  hooked  forceps,  such  as  Museux's,  or  the  purse  of  Hilden, 
or  better  still,  as  prescribed  by  St.  Yves,  a  strong  ligature  passed  by  means  of 
a  needle  through  the  degenerated  mass. 

Second  iS/a^e.— Holding  the  bistoury  in  the  right  hand  like  a  pen,  the  ope- 
rator carries  the  point  of  it  to  the  greater  angle,  sinks  in,  grazing  the  ethmoid 
bone,  to  the  neighborhood  of  the  optic  foramen,  and  then  passes  it  flatwise  over 
the  whole  inferior  semi-circumference  of  the  orbit,  separating  the  attachments 
of  tlie  lesser  oblique  muscle,  the  oculo -palpebral  fold  of  the  conjunctiva,  and 


OPERATIVE    SURGERY.  S79 

some  cellulo-adipose  filaments;  then  commencing  again  at  the  internal  or 
nasal  extremity  of  the  wound,  with  the  edge  of  the  instrument  upwards,  divides 
the  greater  oblique  muscle,  and  endeavors  to  remove  with  the  same  stroke  the 
lachrymal  gland ;  when,  having  traversed  the  roof  of  the  orbit,  he  approaches 
the  temple  and  is  about  to  unite  the  two  incisions  at  tlieir  outer  extremity. 

Third  Stage. — Thenceforth  the  eye  is  held  in  its  cavity  only  by  the  four 
straight  muscles  and  the  optic  nerve,  forming  a  pedicle.  If  the  scissors  be 
preferred  for  dividing  this,  the  operator  glides  them  on  the  internal  rather  than 
the  external  side,  with  their  concavity  towards  the  glohe,  as  deeply  as  possible, 
and  witli  one  cut  separates  the  cancer.  If  any  attachments  still  retain  it,  they 
are  rapidly  divided  in  the  same  way,  whilst  suitable  tractions  are  applied 
with  the  other  hand.  When  the  surgeon  prefers  the  bistoury  to  the  scissors, 
he  should  also  select  the  inner  side  for  its  passage.  On  this  side,  the  orbitary 
walls  being  nearly  straight,  it  is  easy,  by  inclining  the  point  of  the  instrument 
outwards,  to  cross  and  cut  the  pedicle.  But  I  must  state,  that  with  the  bis- 
toury as  well  as  with  the  scissors  it  is  not  much  more  difficult  to  accomplish 
the  end  by  following  the  temporal  wall  of  the  orbit.  This  was  the  route  that 
Desault  generally  took,  saying  it  was  the  shortest  and  most  convenient.  A 
motive  more  worthy  of  attention  is,  that  by  this  we  are  more  sure  of  escaping 
the  maxillary  and  sphenoidal  fissures.  Whether  the  lachrymal  gland  be  can- 
cerous or  not,  it  is  necessary,  if  it  have  not  been  removed  before,  to  seize  it 
immediately  after  the  operation  by  a  hook  or  forceps  and  dissect  it  out.  The 
secretion  of  tears  being  no  longer  needed  would  only  be  injurious.  The 
surgeon  then  assures  himself,  by  passing  the  finger  into  the  orbit,  of  the  state 
of  the  remaining  parts ;  and  if  there  be  any  unsound  he  should  remove  or 
destroy  them  either  with  the  bistoury,  the  scissors,  or  the  scraper. 

Dressing. — No  large  artery  should  have  been  wounded.  Those  that  are 
divided  come  from  the  ophthalmic.  The  ligature  is  not  necessary  even  when 
they  bleed  freely.  Pledgets  of  lint,  clean  or  powdered  with  rosin,  applied 
with  more  or  less  pressure,  are  sufficient  to  arrest  it.  The  sponge  proposed 
by  some  operators  in  place  of  this  substance,  would  have  the  inconvenience  of 
pressing  the  tissues  too  much  by  swelling  in  the  midst  of  a  solid  cavity.  The 
little  bag  filled  with  some  emollient  cataplasm,  as  recommended  by  Mr.  Tra- 
vers,  who  insists  upon  refraining  from  the  slightest  pressure,  does  not  appear  to 
be  of  any  real  advantage.  At  the  end  of  four  or  five  days  suppuration  is  esta- 
blished. The  lint  is  then  easily  removed.  Nothing  prevents  us,  if  it  is  thought 
proper,  from  rendering  the  removal  of  the  first  dressings  still  more  simple  by 
covering  the  hollow  of  the  wound  with  a  piece  of  fine  linen  cut  in  holes  and 
covered  with  cerate,  which  serves  as  a  sack  for  the  lint,  and  which,  when  the 
lids  have  been  removed,  is  easily  turned  over  upon  the  periphery  of  the  orbit. 
A  soft  pledget  large  enough  to  support  the  deeper  dressings,  a  pretty  long 
compress  laid  obliquely,  and  the  monocular  bandage  complete  the  dressing, 
which  any  surgeon  may  modify  to  meet  circumstances.  After  the  first 
removal,  which  may  take  place  from  the  third  to  the  sixth  day,  the  dressing 
has  no  further  peculiarity.  The  wound,  after  being  washed  with  warm  water 
and  softly  dried,  must  be  dressed  every  time  with  a  little  dry  lint.  The  lids 
slightly  raised  and  protected  by  small  fillets  smeared  with  cerate,  are  covered 
again  by  a  soft  pledget  and  a  compress.    The  whole  is  kept  in  place  by  a 


S80  NEW   ELEMENTS   OP 

monocular  or  some  other  appropriate  bandage.  The  cure  is  commonly  com- 
pleted between  the  third  and  tenth  week. 

Remarks. — Although  the  preservation  of  the  eye-lids  renders  the  deformity 
less  shocking,  it  is  better  to  sacrifice  them  than  to  leave  the  least  vestige  of 
the  disease.  The  incision  of  their  external  angle  renders  the  rest  of  the  ope- 
ration easier,  and  produces  no  particular  ill  effect.  A  single  stitch  or  a  strip 
of  adhesive  plaster,  will  secure  reunion.  If  the  operation  is  commenced  by 
the  superior  incision,  the  blood  must  somewhat  embarrass  the  operator  in 
cutting  below.  When  the  eye  only  is  affected  it  is  not  necessary  to  carry 
the  instrument  more  than  an  inch  deep.  But  it  is  necessary  to  go  to  the  apex 
of  the  orbit  when  morbid  adhesions  have  been  formed  between  the  soft  parts 
and  the  bone.  Then  the  spoon  of  Bartisch,  the  knife  of  Hilden,  and  the  bis- 
toury of  Bidloe  will  expose  us  to  fractures,  which  it  is  always  best  to  avoid. 
At  this  point,  too,  any  sharp  instrument  used  without  great  caution  may  pene- 
trate through  the  frontal  bone  into  the  brain,  especially  if  to  reach  the  levator 
muscle  or  the  lachrymal  gland  we  elevate  the  point  too  much;  enter  the 
maxillary  sinus  and  divide  the  infra-orbital  nerve  or  vessels,  if  we  carry  it 
too  far  in  the  opposite  direction ;  penetrate  into  the  nasal  within ;  the  zygo- 
matic or  pterygo-maxillary  fossa  behind  and  without,  and  reach  the  second 
branch  of  the  trigeminus  nerve,  or  the  internal  maxillary  artery ;  or  into  the 
cranium  again  by  the  sphenoidal  hole,  and  touch  the  middle  lobe  of  the  brain. 
Yet  if  the  bistoury  should  not  scrape  the  bone  it  will  not  be  sure  to  remove  the 
whole  of  tlie  cancer,  but  may  require  a  subsequent  excision.  The  lachrymal 
gland  particularly,  being  almost  entirely  hid  behind  the  external  orbital  process, 
is  not  easily  removed  with  the  eye.  The  scraper  of  Bichat,  or  a  chemical 
caustic,  will  be  less  dangerous  than  the  actual  cautery,  if  either  of  them  be 
indispensable  for  the  removal  of  the  soft  parts ;  at  least  in  the  roof  of  the 
orbit.  In  fact,  the  proximity  of  the  brain  would  render  the  use  of  the  actual 
cautery  Y^ry  dangerous.  Although  it  be  the  common  practice  to  use  the  same 
hand  for  both  incisions,  it  would  seem  more  convenient  on  the  right  eye  for 
example,  to  use  the  right  hand  for  the  lower,  and  the  left  for  the  upper 
incision,  unless  the  latter  be  carried  from  the  temple  towards  the  nose.  The 
levator  palpebrae  muscle  should  be  cut;  because,  if  left  it  tends  continually  to 
draw  the  upper  lid  inwards  after  the  cure,  thereby  augmenting  the  necessary 
deformity.  I  had  almost  forgotten  to  say  that  M.  Dupuytren  begins  witli  the 
superior  incision,  and  finishes  by  detaching  the  organ  from  the  apex  towards 
the  base  of  the  orbit. 

Artificial  Eyes. — Nothing  would  be  more  desirable  certainly  than  to  be 
able  to  use  an  enamel  eye,  when  the  disease  enables  us  to  retain  the  lids  in 
their  integrity  ;  but  we  should  not  flatter  ourselves  too  much  with  such  hopes. 
The  orbit,  like  all  natural  cavities,  once  emptied  contracts  upon  itself;  its 
walls  approach  each  other  from  the  bottom  towards  the  exterior ;  the  circum- 
ference lessens,  so  that  after  a  certain  time  the  vault  becomes  completely 
effaced  with  this  coarctation  and  the  deposition  of  fibro-cartilaginous  matter. 
Obliged  to  follow,  the  eye-lids  contract  adhesions  by  their  posterior  face,  are 
deformed,  and  become  most  frequently  incapable  of  applying  themselves  to 
the  artificial  organ  which  we  would  place  behind  them.  Consequently, 
whether  the  lids  be  removed  or  not,  we  must  expect  to  be  forced,  if  the  patient 


OPERATIVE    SURGERY.  SSt 

desires  to  hide  his  mutilation,  to  use  spectacles,  skillfully  furnished  with  a. 
colored  plate  of  metal  to  be  fixed  over  the  obliterated  cavity.  In  former  times 
they  bestowed  more  pains  upon  them  than  we  do.  They  had  two  kinds  of 
artificial  eyes :  one  like  ours,  to  be  placed  behind  the  lids ;  the  other,  used 
from  the  time  of  Pare,  who  is  said  to  have  been  the  first  to  speak  of  it,  a  kind 
of  convex  plate,  on  which  the  anterior  part  of  the  eye  and  its  appendages 
were  painted,  and  which  was  held  in  place  by  means  of  a  spring.  Formerly 
the  first  were  made  of  gold  or  silver ;  now  enamel  is  justly  preferred.  Upon 
this  must  be  represented  the  cornea,  iris,  pupil,  sclerotica,  and  the  vessels.  In 
order  to  apply  it,  take  it  by  the  extremities  of  its  greater  diameter  between 
the  thumb  and  first  finger,  and  carry  it  to  the  edge  of  the  superior  lid,  jvhich 
is  gently  raised  with  the  other  hand.  It  enters  then  as  it  were  of  itself,  when 
the  lower  lid  is  depressed.  In  order  to  remove  it  at  night  on  going  to  bed,  the 
patient  slips  under  it  the  head  of  a  pin,  draws  down  the  inferior  lid,  and  pulls 
it  forwards.  It  should  be  deposited  in  a  glass  of  water  for  the  night,  and  be 
cleansed  and  dried  carefully  every  morning  before  being  replaced.  I  need  not 
say  that  its  dimensions  should  be  adapted  to  the  orbit  of  the  particular  indi- 
vidual, and  that  it  is  better  to  renew  it  whenever  it  begins  to  change.  When 
the  enamel  is  good,  and  the  two  posterior  thirds  of  the  natural  eye  remain  to 
constitute  a  stump,  the  resemblance  is  sometimes  so  striking  that  it  produces 
a  complete  illusion.  In  the  other  case,  as  there  is  nothing  to  move  it,  it 
remains  permanently  fixed  in  the  centre  of  the  eye,  and  unhappily  it  does 
not  prevent  us  from  distinguishing  those  who  are  obliged  to  use  them. 


SECTION  III. 

The  Mouth. 
Jrt.  1.— 7%e  Lips 

§  1.  Hare-lip, 

The  labial  fissure  known  by  the  name  of  hare-lip,  is  either  acquired  or 
congenital.  When  it  occurs  after  birth,  it  is  observed  as  frequently  on  one 
lip  as  on  the  other;  but  the  second  variety  has  scarcely  been  seen  except  upon 
the  upper.  The  case  of  Nicati,  who  professes  to  have  met  with  it  on  the 
lower  lip,  is  certainly  an  exception.  Since  Louis  interested  himself  in  prov- 
ing that  the  hare-lip  is  not  attended  with  any  loss  of  substance,  Blumenbach, 
Tenon,  Beclard,  Meckel,  &c.,  have  attempted  to  explain  its  formation  by 
certain  laws  of  organization,  considering  its  several  grades  as  a  cessation  of 
development.  At  first,  according  to  some,  three  portions  compose  the  upper 
lip,  a  middle  and  two  lateral.  There  might  even  be  four  according  to  others, 
who  make  the  middle  portion  originally  divided  into  two  parts.  In  this 
hypothesis  one  of  the  embryo  fissures  of  the  lip  is  supposed  to  remain  in  the 
case  of  simple  hare-lip;  and  the  proof  they  say  is,  that  it  is  almost  constantly- 
found  on  the  median  line.  When  the  two  lateral  portions  remain  isolated  from 
the  middle  portion,  the  hare-lip  is  neces^^sarily  double.  If  the  authors  of  some 
observations  already  ancient,  and  more  recently  Moscati,  are  not  mistaken ; 
if  they  have  really  seen  the  leporine  fissure  in  an  exact  line  with  the  septum 


582  NEW   ELEMENTS   OF 

of  the  nose,  this  may  be  explained  by  admitting  the  non-union  of  the  two 
portions  of  the  middle  lobe  of  the  lip.  Lastly,  as  to  the  lower  lip,  a  con- 
genital hare-lip  will  always  occupy  the  median  line,  because  in  its  origin 
there  are  never  more  than  two  portions.  Numerous  researches  upon  embryos 
and  foetuses  of  every  age,  induce  me  to  believe  that  these  inaccurate  ideas  are 
the  result  of  erroneous  observations  or  gratuitous  suppositions.  The  lips  are 
no  more  composed  of  two,  three,  or  four  pieces,  at  three,  four,  six,  or  eight 
weeks  than  at  three  or  four  months.  From  the  moment  they  begin  to  appear 
they  seem  as  entire  as  the  buccal  opening  which  they  exactly  bound.  The 
contrary  only  occurs  accidentally.  The  hare-lip,  like  most  other  monstrosi- 
ties, ought  in  my  opinion  to  be  referred  to  disease  much  more  frequently^  than 
to  a  defect  of  natural  development. 

CHEILORAPHY. 

A.  Simple  Hare-lip, 

a.  History, — Although  the  hare-lip  is  one  of  the  most  common  deformities 
of  infancy,  it  scarcely  occupied  the  attention  of  the  ancients.  Celsus  is  the 
j&rst  who  mentions  it,  and  he  rather  confusedly.  The  Arabians  scarcely 
notice  it,  and  it  is  clear  that  until  the  times  of  Franco  and  Pare  its  treatment 
did  not  attract  all  the  attention  that  it  deserved.  At  present,  on  the  contrary, 
it  forms  a  part  of  practice  to  which  nothing  further  seems  wanting.  For  its 
cure  three  indications  are  to  be  fulfilled.  The  edges  are  to  be  made  raw,  its 
two  sides  are  to  be  brought  evenly  together,  and  the  two  lips  of  the  division 
are  to  be  kept  in  perfect  contact  until  they  have  become  agglutinated. 

1st.  It  was  with  hot  iron,  that  Abul-Kasem,  as  well  as  Ludovic,  produced 
the  state  of  rawness  in  the  hare-lip.  The  butter  of  antimony  or  some  other 
caustic  was  preferred  by  Thevenin.  Chopart,  yielding  in  this  to  the  advice 
of  Louis,  expected  to  succeed  better  by  applying  two  vesicatory  strips  to  the 
edges  of  the  fissure.  Such  means  only  deserved  and  actually  met  with  but 
incomplete  success.  They  have  been  justly  abandoned.  ExcisioUy  which 
has  been  in  use  from  the  time  of  Celsus  and  Rhazes  (this,  however,  did  not 
prevent  Fabricius  ab  Aquapendente  from  confining  himself  to  simple  scarifica' 
tions),  is  the  only  method  admitted  at  the  present  day.  In  performing  it, 
D.  Scacchi  and  Dionis  used  common  scissors;  Henkel,  button -pointed  ones. 
But  M.  A.  Severin  and  Acrel  gave  exclusive  preference  to  the  bistoury, 
which  Louis  and  Percy  have  strongly  endeavored  to  bring  into  general  use; 
while  Roonhuysen,  Le  Dran,  and  B.  Bell,  had  recourse  indifferently  to  either 
of  these  two  instruments.  The  advocates  of  the  bistoury  contend  that  it 
produces  less  pain,  and  makes  a  wound  much  neater  and  less  inclined  to  sup- 
purate ;  that  the  scissors  cut  more  by  pressure  than  actual  incision ;  that  they 
bruise  the  tissues  and  produce  a  wound  of  two  oblique  planes  like  a  double 
roof,  by  no  means  favorable,  from  its  shape,  to  immediate  union.  Experience 
has  a  thousand  times  demonstrated  the  futility  of  these  objections.  To  be 
assured  on  this  point,  Bell  operated  on  one  side  with  the  scissors  and  on  the 
other  with  the  bistoury,  without  explaining  his  intention.  The  patient  was  at 
first  embarrassed,  in  deciding,  but  at  last  declared  that  the  pain  was  greater 
in  the  part  where  the  bistoury  had  been  employed.  The  scissors  have  an 
advantage,  in  requiring  no  support,  in  being  more  easily  managed,  and  in 


OPERATIVE   StTRGERY.  583 

cutting  off  at  one  stroke  all  that  is  to  be  taken  away.  Desault,  who  has 
strongly ;  advocated  them,  recommends  them  to  be  made  of  considerable 
thickness  and  much  hollowed  in  the  blades.  Those  which  are  now  pre- 
ferred bear  the  name  of  M.  Dubois,  and  are  constructed  on  this  principle. 
For  the  purpose  of  giving  greater  advantage  to  the  power  which  moves  them, 
the  handles  are  made  comparatively  long;  the  blades  are  short  and  solid, 
and  thus  cut  with  great  neatness  and  all  desirable  precision.  This  is  the 
only  instrument  used  in  France. 

Nevertheless,  it  would  be  wrong  to  conclude  that  the  bistoury  is  not  suf- 
ficient. Louis  has  afforded  proof  enough  to  the  contrary,  and  many  practi- 
tioners of  Germany  and  England  are  still  in  the  constant  habit  of  employing 
it.  The  manner  of  using  it,  has  singularly  varied.  At  the  instance  of 
Guillemeau,  Le  Dran  commenced  by  inserting  its  point,  from  the  mouth 
towards  the  skin,  through  the  lip  a  little  above  the  summit  of  the  division ; 
he  then  cut  perpendicularly  from  above  downwards,  or  from  behind  forwards 
as  far  as  the  labial  border;  and  did  the  same  on  the  opposite  side.  B.  Bell 
reversed  this  process.  Placing  himself  behind  his  patient's  head,  he  began 
his  incision  at  the  free  edge  of  the  lip,  carrying  it  upwards  and  backwards 
to  a  point  above  the  abnormal  fissure,  holding  his  bistoury  as  a  pen.  Enaux, 
after  destroying  the  adhesion  between  the  alveolar  arch  and  the  lip,  passed 
behind  the  lip  a  plate  of  cork  to  give  support  to  the  action  of  the  bistoury.  A 
fold  of  paper,  a  common  playing-card,  or  a  thin  piece  of  white  wood,  will 
very  well  supply  the  place  of  the  bit  of  cork  of  Enaux.  The  forceps  or 
pincers,  whether  of  metal  like  those  of  J.  Fabricius,  or  of  wood  like  those 
used  by  M.  A.  Severin,  which  serve  to  fix  the  lip  while  the  section  is  being 
made,  and  which  by  the  greater  breadth  of  their  posterior  branch  were  able 
to  supply  the  place  of  the  pasteboard  required  in  the  use  of  the  bistoury,  and 
the  intention  of  which  was  also  to  aid  in  the  approximation  of  the  two  cut 
borders  and  prevent  hemorrhage,  have  long  since  been  rejected  from  prac- 
tice. Heister,  B.  Bell,  and  0.  Acrel,  are,  I  believe,  the  latest  autliors  who 
have  thought  proper  to  recommend  them.  ^ 

2d.  After  the  borders  are  made  raw,  the  hare-lip  is  found  retTtK^ed  to  the  state 
of  a  simple  wound,  and  its  union  is  to  be  immediately  attempted  by  the  aid  of 
appropriate  bandages  or  the  suture,  or  by  combining  both  these  means.  Franco, 
who  was  satisfied  with  the  plasters  of  Andre  de  Lacroix  fixed  upon  the  cheeks 
ind  narrow  ribands  crossed  beneath  the  nose  constituting  what  he  termed  the 
dry  suture,  and  then  a  retaining  bandange ;  F.  Sylvius,  who,  according  to  Muys, 
succeeded  with  adhesive  strips  alone,  supported  also  by  a  bandage;  Purman 
and  G.  W.  Wedel,  who  it  is  said  were  not  less  successful;  have  found  in 
Pibrac,  but  particularly  in  Louis,  an  ardent  defender.  According  to  this  au- 
thor, the  bloody  suture  is  not  only  useless  but  even  injurious.  Useless,  inas- 
much as  the  hare-lip  being  unattended  with  any  loss  of  substance,  must  always 
be  susceptible  of  approximation  by  the  uniting  bandage  of  rectilinear  wounds; 
injurious,  for  its  presence  is  a  permanent  cause  of  irritation,  which  cannot 
fail  to  excite  muscular  retraction.  In  accordance  with  this  principle,  Louis 
employed  a  single  point  of  interrupted  suture,  and  a  simple  bandage  to  complete 
the  union.  The  ideas  of  Pibrac,  who  wished  in  some  measure  to  proscribe  the 
suture  from  surgery,  seemed  to  find  here  a  just  application.  To  produce  a 
complete  coaptation  Valentine  invented  a  clasp,  a  kind  of  double  flat  forceps, 
capable  of  embracing  the  two  sides  of  the  wound  without  destroying  their 


384  NEW    ELEMENTS    OF 

parallelism,  and  of  being  approximated  at  pleasure  by  means  of  a  transverse 
piece  and  a  screw.  To  prevent  the  contusion  and  the  unequal  compression  which 
the  instrument  of  Valentine  was  apt  to  produce,  Enaux  proposed  a  bandage, 
the  model  of  which  is  still  preserved  in  the  museum  of  the  Faculty  of  Paris, 
and  which  being  applied  over  the  nape  of  the  neck,  the  vertex,  and  beneath 
the  lower  jaw,  by  as  many  segments  of  circles,  presents  two  cushions  which 
are  to  push  forward  the  parts  when  applied  to  the  cheeks,  and  may  be  united 
by  passing  a  strip  in  front  of  the  wound  from  one  to  the  other.  Evers  rejected 
all  these  means,  and  confined  himself  to  emplastic  strips,  crossed  beneath  the 
nose  in  the  form  of  St.  Andrew's  cross;  and  M.  Dudan  has  since  invented 
with  the  same  view  a  new  clasp,  founded  on  the  same  principle  with  that  of 
Valentine.  No  doubt  the  hare-lip  is  sometimes  cured  in  this  manner;  but^ 
it  is  also  certain  that  more  frequently  the  union  is  bad  and  incomplete ;  thafw 
there  often  remains  a  groove  of  more  or  less  depth  either  in  front  or  behind  ; 
and  a  gap  is  left  quite  open  below,  almost  as  disagreeable  as  the  original  disease : 
while  the  bloody  suture,  properly  performed,  avoids  all  these  disadvantages. 
On  this  account  it  is  almost  exclusively  practised  in  our  day,  and  bandages 
are  no  longer  advised  but  as  auxiliaries. 

Celsus,  who  sewed  the  hare-lip,  does  not  give  details  enough  to  let  us  un- 
derstand what  was  the  kind  of  suture  employed  in  his  time.  It  is  probable 
from  what  is  said  of  it  by  Albucasis,  that  the  Arabians  used  the  gloverh  su- 
ture. Others,  Heuermann,  Ollenroth,  and  W.  Dros,  for  example,  have  advised 
the  interrupted  suture,  which  was  also  preferred  by  Lassus,  in  order  to 
avoid  leaving  inflexible  bodies  in  the  wound.  There  is  none,  even  to  the  quilted 
suture,  which  has  not  had  fts  partisans,  although  the  twisted  suture  has  almost 
always  maintained  the  preference.  Ambrose  Pare,  the  first  author  who  de- 
scribes it  in  precise  terms,  performed  it  by  means  of  needles  furnished  with 
eyes,  which  he  carried  through  the  wound  from  one  side  to  the  other,  and  then 
fixed  by  turns  of  thread,  passed  in  the  form  of  the  figure  8,  over  the  two  ex- 
tremities. Fabricius  ab  Aquapendente  used  flexible  needles,  the  extremities 
of  which  he  bent  forwards  after  their  insertion.  Those  of  Roonhuysen  were 
angular  or  triangular,  like  those  of  Pare ;  he  wound  them  with  silken  thread, 
and  cut  off  their  points  with  nippers.  Dionis  used  them  of  steel,  and  curved. 
Instead  of  taking  off  their  points,  like  Roonhuysen  and  Dionis,  La  Charriere 
merely  placed  a  small  compress  between  their  extremities  and  the  skin.  For 
the  purpose  of  introducing  them  without  trouble,  notwithstanding  their  fine- 
ness, Heister  made  use  of  a  porte-aiguille;  and  J.  L.  Petit,  who  used  them 
stronger,  and  furnished  the  two  extremities  of  each  with  a  head,  caused  them 
to  be  made  of  silver,  which  he  introduced  by  means  of  an  instrument  resem- 
bling a  larding-pin.  Le  Dran  employed  gold  pins,  so  that  they  might  be  at  the  * 
same  time  solid  and  strong  and  not  liable  to  be  oxydized  ;  their  points  were 
flattened  and  they  were  furnished  with  a  head  in  order  to  dispense  with  the 
porte-aiguille.  If  gold  and  silver  have  the  advantage  of  not  rusting,  they 
have  the  disadvantage  when  used  in  cutting  instruments  of  not  passing  through 
the  tissue  witli  facility.  For  this  reason  Sharp  soldered  to  his  silver  needle 
a  lance-shaped  point  of  steel.  Wedel  contends  that  common  needles  will 
serve,  and  should  be  wound  afterwards  with  a  hempen  thread.  Without  so 
much  preparation,  de  la  Faye  asserts  that  copper  pins  stout  and  long,  in  a 
word,  German  pins,  are  better  than  all  others.  As  their  points  might  wound 
the  patient,  Mursinna  recommends  that  they  should  be  guarded  afterwards 


OPERATIVE    SURGERY.  385 

v/ith  small  pieces  of  quill.  Le  Dran  found  it  more  convenient  to  use  small 
balls  of  wax.  Arneniann  employed  hollow  pins  from  which  the  head  and  point 
could  be  removed  at  pleasure.  Desault's,  which  are  of  silver  with  steel 
points,  diminish  in  size  from  their  cutting  extremity  to  that  which  is  to  support 
the  action  of  the  finger,  in  order  that  they  may  be  extracted  without  repassing 
them  by  the  same  way  that  they  entered,  and  without  again  drawing  the  blades 
through  the  flesh.  It  is  this  kind  that,  in  France  at  least,  has  united  almost 
every  suffrage.  Indeed  we  see  no  reason  to  object  to  them ;  except  that  good 
common  pins,  such  as  are  to  be  found  everywhere,  will  answer  the  purpose 
equally  well,  if,  before  inserting  them,  care  be  taken  to  grind  them  so  as  to 
flatten  the  point  by  rubbing  them  on  a  tile  or  stone  vase,  or  any  other  piece 
of  stone. 

As  to  the  semilunar  incisions  with  their  concavity  anteriorly,  which  Celsus 
performed  on  the  interior  of  the  cheek,  and  which  Guillemeau,  Thevenin,  and 
Manget  performed  on  the  exterior ;  the  dissection  of  the  posterior  face  of  the 
lip,  which  J.  Fabricius  and  D.  Scacchi  have  pointed  out  as  favoring  the 
approximation  of  the  borders  of  the  hare-lip ;  they  should  be  no  longer  men- 
tioned in  simple  cases,  unless  to  show  their  absurdity  and  barbarity.  It  is 
not  so,  however,  with  the  idea  of  preparing  the  parts  beforehand  for  approxi- 
mation. Instead  of  the  forceps  of  Fabricius,  &c.,  V.  D.  Haar,  and  after  him 
Arnemann,  and  Knackstedt  of  St.  Petersburg,  have  proposed  a  bandage,  which 
being  worn  for  a  week  or  two  is  capable  of  bringing  towards  the  median  line 
those  points  the  ultimate  contact  of  which  is  to  be  effected.  It  is  rare, 
nevertheless,  that  the  moderns  feel  obliged  to  follow  this  indication,  knowing 
that  the  common  uniting  bandage  will  attain  exactly  the  same  end.  Unless 
the  separation  be  extrenie,  the  immediate  coaptation  of  the  sides  of  the  wound 
presents  in  general  but  very  few  difficulties. 

Apprehensive  that,  notwithstanding  the  suture,  the  parts  might  afterwards 
retract,  surgeons  of  diff*erent  times  have  labored  to  find  means  to  obviate 
this  inconvenience.  Hence  the  load  of  apparatus  with  which  the  science  is 
overburdened,  and  the  association  of  the  dry  suture  or  bandages  with  the  bloody 
suture.  On  this  point  Dionis  seems  to  have  set  the  example.  He  placed  an 
adhesive  plaster  upon  his  twisted  needles  and  supported  the  whole  by  a  four- 
tailed  bandage.  By  means  of  a  circle  of  steel  which  passed  round  the  head, 
and  graduated  compresses  which  he  fixed  upon  the  cheeks.  La  Charriere 
considered  success  infallible.  As  substitutes  for  his  bandages  as  it  was  after- 
wards modified  by  Quesnay,  Heister,  Henkel,  Koenig,  Stuckelberger,  Eck- 
holdt,  &c.,  Enaux,  Valentine,  and  Beind  constructed  those  which  bear  their 
names,  but  which  have  entirely  yielded  to  the  bandages  of  Louis  and 
Desault.  Without  being  indispensable,  the  retaining  bandage,  such  as  is 
generally  used  among  practitioners  of  the  present  day,  has  the  undoubted 
advantage  of  protecting  and  aiding  tlie  action  of  the  needles,  and  of  render- 
ing disunion  of  the  parts  much  more  difficult  in  unmanageable  subjects. 
When  we  dispense  with  it,  like  the  ancients,  or,  like  Le  Dran,  limit  ourselves 
to  the  use  of  a  strip  of  adhesive  plaster,  extending  from  one  temple  to  the 
other,  and  running  beneath  the  nose  in  the  way  that  English  practitioners, 
vidth  Beclard,  &c.,  still  prefer,  its  inutility  is  its  only  fault ;  for  how  it  can  be 
injurious  does  not  appear. 

b.  Operative  Process.— The  following  is  the  mode  of  performing  this  ope- 
49  "  "      " 


♦       '«# 


386  NEW  ELEMENTS  OF 

ration :  The  apparatus  consists  of  a  hook ;  a  pair  of  dressing  or  dissecting 
forceps ;  a  pair  of  hare-lip  scissors ;  three,  four,  or  six  prepared  needles ;  a* 
single  waxed  thread  two  or  three  feet  long ;  another  thread  of  three  or  four 
strands  and  twice  as  long  as  the  first ;  small  rolls  of  diachylon  or  linen  to 
place  on  the  extremities  of  the  needles;  a  small  pledget  of  lint  spread  with 
cerate ;  two  compresses  a  little  longer  than  broad,  and  folded  six  or  eight 
times,  to  be  applied  to  the  cheeks ;  a  double-headed  roller  an  inch  wide,  and 
long  enough  to  make  four  or  five  turns  of  the  head ;  a  sling  or  four-tailed 
bandage;  adhesive  strips  in  case  the  bandage  is  not  to  be  employed;  and  a 
playing  card  and  a  straight  bistoury  if  the  scissors  are  not  to  be  used. 

First  Step, — The  patient  being  placed  on  a  chair  in  a  good  light,  has  his 
head  held  firmly  by  an  assistant  in  such  a  manner  as  to  enable  him  at  the 
same  time  to  compress  the  external  maxillary  arteries  beneath  and  in  front  of 
the  masseters,  to  push  forward  the  cheeks  towards  the  median  line,  and  hold 
the  lip,  if  necessary,  while  the  operator  makes  his  incision.  A  second 
assistant  is  charged  with  handing  the  several  parts  of  the  apparatus  as  they 
may  be  required.  Seated  or  standing  before  the  patient,  the  surgeon  passes 
a  thread  through  the  left  inferior  angle  of  the  division,  as  advised  by  Koenig, 
unless  he  prefer  inserting  a  pin  or  holding  it  with  a  hook,  as  practised  by  M. 
Roux,  or  merely  to  use  the  pincers  or  the  fore-finger  and  thumb  of  the  left  hand 
to  fix  it.  The  scissors,  held  in  the  other  hand,  are  then  carried  two  or  three 
lines  higher  than  the  superior  angle  of  the  fissure,  separating  all  the  rounded 
portion  at  a  single  stroke  if  possible,  and  encroaching  even  a  little  on  the 
sound  parts  so  as  to  make  a  wound  fresh,  straight,  regular,  and  perpendi- 
cular. On  the  other  side  he  stretches  the  lip  itself,  by  seizing  and  drawing  it 
with  the  thumb  and  fore-finger  placed  without  the  border  to  be  excised.  The 
scissors,  guided  as  before,  are  to  be  raised  with  their  point  as  high  as  the 
superior  extremity  of  the  first  wound,  and  even  a  little  higher,  in  order  that 
the  two  little  strips  which  are  to  be  insulated,  and  which  by  their  union 
represent  an  inverted  V,  may  be  immediately  freed  from  all  adhesion  up  to 
their  nasal  angle.  Nevertheless,  if  at  this  point  a  pedicle  should  remain, 
all  endeavor  should  be  made  to  leave  it  of  the  least  possible  .thickness,  and 
with  a  third  stroke  to  cut  it  as  high  as  possible ;  otherwise  this  part  of  the 
wound  being  too  round,  will  only  with  difficulty  admit  of  exact  coaptation. 

Second  Step, — ^To  make  the  suture,  the  operator  again  takes  hold  of  the 
right  angle  of  the  division  with  the  fore-finger  and  thumb  of  the  left  hand, 
and  with  the  right  carries  the  point  of  the  first  needle  to  a  point  on  the  skin 
half  a  line  above  the  red  border  of  the  lip,  and  three  lines  outwards  from  the 
raw  edge ;  he  then  enters  it  a  little  obliquely  from  below  upwards,  from  be- 
fore backwards,  and  from  the  skin  towards  the  mouth,  so  that  passing  through 
the  tissues  it  may  come  out  at  the  union  of  the  anterior  two-thirds  with  the 
posterior  third  of  the  bloody  part ;  then  changing  its  direction,  he  pushes  it 
through  the  other  lip  from  behind  forwards,  and  from  within  outwards,  so  that 
its  entrance  and  its  exit  may  be  on  as  exact  a  level  as  possible,  and  that  in 
its  whole  course  it  may  describe  a  slight  curve,  the  convexity  of  which  will 
look  a  little  backwards  and  upwards.  Its  two  extremities  are  then  included 
within  a  noose  of  the  single  thread  prepared  for  this  purpose,  which  allows 
the  assistant  in  charge  to  stretch  properly  the  whole  extent  of  the  lip  while 
the  surgeon  fixes  the  second  needle.    This,  which  is  usually  the  last,  is  to  be 


OPERATIVE    SURGERY.-  38? 

inserted  at  an  equal  distance  between  the  first  and  the  superior  angle  of  the 
hare-lip.  It  is  not  necessary,  as  with  the  first,  to  make  it  describe  a  curve, 
nor  to  carry  it  separately  through  the  two  parts  of  the  division.  It  is  pushed 
through  transversely  with  the  right  hand,  while  the  fingers  of  the  left  pre- 
serve the  two  edges  of  the  wound  in  exact  coaptation ;  always  taking  care 
to  enter  it  and  bring  it  out  of  the  skin  at  about  three  lines  from  the  solution 
of  continuity.  It  is  embraced  immediately  after  with  the  middle  portion  of 
the  doubled  thread,  the  operator  using  both  hands.  The  two  ends  of  the 
thread  are  then  carried  round  in  turns,  crossed  in  the  form  of  the  figure  8  ; 
afterwards  brought  back,  forming  an  X,  beneath  the  inferior  needle,  which  is 
wound  in  the  same  manner ;  and  thus  in  succession  from  one  to  the  other, 
until  the  thread  is  exhausted  or  the  whole  of  the  wound  concealed  by  the 
figures  8  and  X  which  it  has  formed.  In  conclusion,  the  two  ends  are 
arranged  so  as  to  be  brought  under  the  head  or  point  of  the  superior  needle. 

TTiird  Step. — The  first  thread  being  no  longer  of  use  is  cut  by  the  surgeon, 
who  then  places  between  the  integuments  and  the  metallic  ends  little  pro- 
tecting rolls,  or  the  pledget  of  lint,  the  fillet  of  diachylon,  or  the  bandage  if 
he  mean  to  use  it.  In  this  case  he  applies  the  body  of  the  bandage  to  the 
M  iddle  of  the  forehead ;  carries  its  two  heads  below  the  occiput ;  crosses 
them  and  changes  hands ;  brings  them  back  above  the  ears  upon  the  square 
compresses  which  the  assistant  holds  upon  the  masseter  muscles ;  carries  them 
to  the.  sides  of  the  nose ;  makes  a  slit  in  one  of  the  heads  of  the  bandage  oppo- 
site the  wound,  through  which  to  pass  the  other  and  cross  them  more  easily; 
carries  them  behind  above  the  nape  of  the  neck,  crosses  them  again,  and 
finishes  by  circular  turns  round  the  head.  The  string,  or  four-tailed  bandage, 
which  is  to  fix  the  whole  is  first  applied  with  its  body  to  the  chin.  The  two 
inferior  ends  are  carried  up  in  front  of  the  ears,  over  the  genal  compresses 
as  far  as  the  vertex,  where  they  are  made  fast.  The  two  remaining  ends  are 
carried  horizontally  backwards,  crossed  at  the  occiput,  and  brought  forwards 
on  the  forehead. 

Subsequent  Treatment, — This  being  done,  the  patient  is  put  to  bed,  where 
he  must  rest  quiet,  without  speaking  or  attempting  the  least  motion  of  the 
jaws  for  three  or  four  days.  His  diet  must  consist  of  broth,  light  soups  very 
liquid,  or  some  kind  of  ptisan.  At  the  end  of  three  days,  if  all  goes  well, 
the  superior  needle  may  be  removed.  On  the  fourth  the  inferior  one  may 
also  be  taken  away.  The  coil  of  thread  adhering  to  the  skin  being  left  in 
place  a  day  or  two,  allows  the  cicatrix  to  become  more  and  more  consolidated. 
When  it  is  disengaged  from  the  front  of  the  lip,  it  may  be  supplied  by  an 
adhesive  strip  if  there  be  any  fear  that  the  union  is  not  sufficiently  firm. 
Towards  the  ninth  or  tenth  day  the  cure  is  generally  completed.  After  the 
fourth  day  there  is  no  objection  to  soups  a  little  more  substantial,  or  to  the 
patient's  rising  and  walking  about. 

c.  i?emarA;s.— Before  commencing  the  operation,  it  is  almost  always  necessary 
to  divide  the  fraenum  of  the  superior  lip,  which  however  is  not  attended  with 
the  least  difficulty.  It  cannot  be  dispensed  with  if  scissors  are  to  be  used, 
except  in  cases  in  which  the  fissure  is  of  little  deptli  and  situated  without  the 
median  line ;  nor  does  the  bistoury  admit  of  any  exception  on  this  point  unless 
we  dispense  with  the  card.  When  this  is  employed,  the  fraenum  is  divided 
and  the  card  is  placed  as  high  as  possible  between  the  maxillary  bone  and  the 


388  NEW   ELEMENTS  OF 

lip.  After  fixing  the  left  border  of  the  hare -lip  upon  the  card  bj  holding  it 
at  its  inferior  angle,  the  point  of  the  instrument,  which  is  held  as  a  pen,  is 
carried  to  the.part  where  the  incision  is  to  commence,  where  it  is  inserted  per- 
pendicularly, the  handle  gradually  depressed,  and  a  single  stroke  cuts  through 
the  whole  length  of  the  fleshy  border  contained  between  its  edge  and  the  card 
which  prevents  it  from  penetrating  the  mouth.  To  cut  off  the  other  border, 
the  surgeon  seizes  the  lip  beyond  the  line  of  division,  unless  he  can  use  his 
left  hand  sufficiently  to  perform  with  it  what  he  has  done  on  the  other  side 
with  the  right,  carrying  in  every  case  the  point  of  the  bistoury  to  the  supe- 
rior angle  of  the  first  wound,  and  terminating  the  incision  on  this  side  as  on 
the  other.  The  compress  which  Lavauguyon  placed  between  the  lip  and  the 
gum  to  prevent  adhesions  of  this  latter  ;  rejected  as  useless,  or  else  as  danger- 
ous by  Le  Dran,  proposed  again  by  Heuermann,  is  not  used  at  the  present 
day ;  nor  the  plate  of  lead  advised  by  Eckholdt  for  the  same  end.  Cases  in 
which  the  lip  has  been  detached  to  a  great  extent  from  the  maxillary  bone,  are 
the  only  ones  which  give  an  excuse  for  its  application. 

It  is  useless  to  apply  so  many  as  five  needles,  as  recommended  by  Roon- 
huysen ;  two  are  generally  sufficient ;  and  it  is  not  absolutely  necessary  that 
the  superior  one  should  be  at  the  superior  part  of  the  wound,  as  adv\ged  by 
Le  Dran.  De  la  Faye  and  Mursinna,  who  direct  to  commence  with  the  supe- 
rior, no  doubt  forgot  that  the  two  labial  extremities  of  the  division  are  thus  in 
danger  of  not  being  on  a  level.  De  la  Faye  himself  was  obliged  to  cut  off 
afterwards  the  unsightly  tubercle  which  resulted  from  this  mode  of  operation 
in  one  of  his  patients.  Without  conforming  entirely  to  the  principle  of  Le 
Dran ;  without  plunging  the  inferior  needle  in  the  vermilion  border  of  the  lip 
(a  rent  would  almost  inevitably  be  the  consequence),  yet  it  must  be  known, 
that  at  more  than  a  line  above,  union  might  well  prove  incomplete  and  a  little 
gap  be  left  below.  If  it  does  not  penetrate  near  the  buccal  surface  of  the 
organ,  agglutination  will  only  take  place  in  front ;  a  furrow  or  groove  of  more 
or  less  depth  will  remain  behind,  and  render  success  very  imperfect.  The 
bleeding  parts  not  being  in  contact,  nor  pressed  upon  equally  through  their 
whole  thickness,  may  sometimes  be  the  cause  of  hemorrhage.  On  the  other 
hand  it  is  easily  perceived  how  troublesome  it  would  be  to  pierce  each  half  of 
the  lip  entirely  through.  In  making  the  needle  describe  an  arch,  the  object 
is  to  depress  the  tissues  on  the  median  line  a  little  more  than  on  the  sides,  in 
order  to  reproduce  as  much  as  possible  the  tubercle,  the  little  projection  which 
there  naturally  exists.  Curved  or  flexible  needles  would  be  incapable  of 
fulfilling  this  indication. 

"  Although,  as  a  general  rule,  it  is  necessary  to  cut  off  rather  too  much  than 
too  little,  and  to  prolong  the  wound,  according  to  B.  Bell,  nearly  to  the  nose, 
yet  it  is  sufficient,  when  the  gap  is  of  little  depth,  to  take  away  all  the  red 
border  and  reduce  the  hare-lip  to  the  state  of  a  recent  wound  with  loss  of 
substance,  exactly  triangular,  and  with  edges  of  the  sartie  thickness  throughout. 
If  the  eifusion  of  blood  from  the  coronary  artery,  which  is  at  first  copious,  will 
not  yield  to  compression  of  the  facial  on  the  edge  of  the  jaw,  the  assistant  has 
but  to  compress  the  corresponding  half  of  the  lip  to  arrest  it.  The  ligature 
is  never  indispensable  here,  nor  the  cautery.  When  the  cut  edges  are  brought 
together  the  hemorrhage  ceases ;  a  defect  of  contact  in  some  point  or  others 
or  some  unforeseen  accident,  will  alone  permit  it  to  continue.    For  the  rest. 


OPERATIVE    SURGERY.  S89 

the  surgeon  would  be  blamable  not  to  have  an  eye  on  it  timing  the  first  few- 
hours  following  the  operation,  particularly  in  children.  Indeed,  instead  of 
being  rejected,  the  blood  is  swallowed  by  them  as  it  flows  imperceptibly  into 
the  mouth,  and  in  this  manner,  Platner  says  hemorrhage  remains  unperceived, 
and  may,  according  to  examples  cited  by  J.  L.  Petit  and  Bichat,  go  so  far  as 
to  produce  death.  Before  applying  the  bandage  it  is  well  to  cover  the  head 
with  a  cotton  cap,  so  fitted  as  not  to  be  easily  deranged ;  to  have  the  head  well 
combed,  and,  as  practised  by  Desault,  to  rub  in  a  little  mercurial  ointment  to 
prevent  tlie  necessity  of  scratching,  which  young  subjects  could  not  resist  if 
vermin  were  engendered  in  the  head.  The  two  compresses  which  are  placed 
in  front  of  the  ears,  have  the  triple  advantage  of  pushing  forward  the  tissues, 
of  rendering  the  bandage  more  supportable,  and  of  preventing  the  motion  of 
the  cheeks. 

Instead  of  slitting  one  of  the  tails  of  the  bandage  through  which  to  pass  the 
other  on  a  level  with  the  wound,  it  might  with  propriety  be  crossed  carefully 
beneath  the  nose.  The  important  point  is,  that  no  wrinkles  be  made,  and 
the  pressure  produced  be  equal  and  gentle.  Louis  cut  the  free  extremity  of 
his  bandage  into  three  strips  from  fifteen  to  eighteen  inches  in  length,  and  also 
made  three  slits  or  button-holes  nearly  two  feet  farther,  for  the  purpose  of 
producing  a  crossing  more  even  and  firm  over  the  solution  of  continuity. 
Desault,  on  the  contrary,  rolled  his  into  a  single  head  and  fixed  it  by  a 
circular  turn  around  the  head,  and  when  he  had  brought  it  as  far  as  the 
labial  angle  of  one  side  by  means  of  the  genal  compress,  he  drew  forcibly 
towards  him  all  the  soft  parts  of  the  opposite  side,  which  otherwise  would 
have  been  liable  to  be  forced  backwards  contrary  to  the  intention  of  the  operator. 
But,  notwithstanding  what  is  said  by  Bichat,  the  ordinary  bandage  avoids 
some  of  the  disadvantages  and  preserves  all  the  simplicity  of  Desault's. 

The  sling  (four-tailed  bandage)  generally  employed  is  a  very  useful 
auxiliary  in  some  cases.  By  opposing  the  separation  of  the  jaws,  it  favors 
the  action  of  the  suture.  When  it  is  recollected,  that  in  a  patient  of  Garen- 
geot  a  burst  of  laughter  sufliced  to  disunite  the  wound ;  that  a  lad  operated 
upon  by  De  la  Faye  met  with  the  same  accident,  because  some  tobacco  being 
rasped  near  caused  him  to  sneeze ;  it  may  well  be  permitted  to  employ  every 
means  of  preventing  motion  of  the  mouth.  By  not  withdrawing  the  needles 
until  the  expiration  of  five  or  six  days,  as  directed  by  Garengeot,  after  having 
taken  away  the  thread,  it  is  to  be  feared  that  the  part  may  be  transformed 
into  an  ulcer  and  the  final  cure  retarded.  If  they  are  withdrawn  the  next 
day  or  the  day  following,  as  Le  Dran  assures  us  he  has  done  without  disad- 
vantage, it  is  almost  certain  that  union  will  not  be  preserved.  Besides, 
as  there  has  not  yet  been  time  for  suppuration  to  be  excited  around  them, 
their  extraction  can  never  take  place  without  difficulty.  In  every  case, 
•when  we  are  ready  to  withdraw  them,  it  is  proper  to  anoint  with  butter,  oil, 
or  cerate,  the  end  which  is  to  pass  through  the  tissues,  that  is,  the  point  in 
needles  with  heads  and  in  others  the  blunt  extremity.  They  must  be  drawn 
gently  and  steadily,  turning  them  on  their  axis  when  they  resist,  and  always 
giving  support  with  the  fore-finger  of  one  hand  to  the  corresponding  side  of 
Sie  lip  while  the  attempt  is  made  to  withdraw  them.  A  little  lint  spread 
with  cerate,  and  lotions  of  vegeto-mineral  water  are  all  that  the  subsequent 
cure  of  the  punctures  require. 


i 


390  NEW   ELEMENTS   OF 

B.  Complicated  Hare-lip. — «.  In  the  double  hare-lip,  if  the  palatine 
vault  does  not  partake  of  the  deformity,  two  different  conditions  may  exist. 
Sometimes  the  two  fissures  are  separated  only  by  a  narrow  and  somewhat  pro- 
minent tubercle,  which  must  be  included  in  the  angle  of  union  of  the  two 
incisions  made  in  simple  hare-lip.  Sometimes,  on  the  contrary,  this  tubercle 
is  too  large  to  admit  of  its  being  destroyed  without  disadvantage.  Then, 
whether  it  descend  or  do  not  descend  to  a  level  with  the  border  of  the  lips,  it 
is  better  to  cut  off  the  two  sides  at  the  same  time  as  the  external  edges  of  the 
double  division  which  it  separates.  It  is  then  perforated  with  all  the  needles 
in  the  first  case ;  but  in  the  second  with  only  one  or  two  of  the  uppermost, 
so  as  to  fix  it  in  the  middle  of  the  suture.  This  method,  the  most  ancient  of 
all,  is  at  the  same  time  the  most  simple,  the  most  prompt,  and  the  most 
certain.  Yet  if  the  middle  portion  be  very  large  at  its  base,  we  may,  having 
first  caught  its  apex  with  one  needle,  carry  through  one  or  two  others  from 
each  side,  in  a  manner  still  followed  by  M.  Gensoul.  After  the  cure  the 
cicatrix  resembles  a  capital  Y,  and  represents  the  passage  of  the  naso-labial 
columns.  The  patient  scarcely  perceives  that  he  has  been  made  to  undergo 
two  operations  instead  of  one.  He  is  cured  in  as  short  a  time,  and  subse- 
quent inflammation  is  neither  greater  nor  less  than  what  occurs  in  simple 
hare-lip.  Consequently,  the  idea  held  out  by  Louis  or  Heister  of  not  operat- 
ing at  first  but  on  one  side  and  waiting  its  complete  cicatrization  before 
attempting  the  other,  although  followed  since  by  some  practitioners,  neither 
has  nor  ever  should  have  been  adopted. 

b.  The  deformity  however  is  sometimes  still  more  complex.  TTie  portion 
of  the  maxillary  bone  which  supports  the  middle  button,  forms  in  some  cases 
a  considerable  projection  forwards.  Thus  constituted,  whether  coexistent  or  . 
not  with  a  double  division  of  the  palatine  vault,  the  attention  must  be  directed 
to  it  before  passing  to  the  rest  of  the  operation.  Franco  at  first,  D.  Ludovic, 
and  afterwards  Chopart  and  several  of  the  mojderns,  have  proposed  to  remove 
it  after  separating  its  soft  parts  with  a  small  saw  or  bone-nippers,  or  a  gouge 
and  mallet.  Desault  having  remarked  that  this  excision  would  leave  a 
vacancy  behind  the  lip,  which  therefore  would  not  find  a  proper  point  of  sup- 
port; that  moreover  there  might  result  such  a  narrowing  of  the  superior  dental 
arch  as  in  the  end  would  bring  it  to  lock  within  the  inferior  dental  arch 
during  mastication,  of  which  he  gives  an  example ;  conceived  the  idea  of 
preserving  the  projection,  and  directed  his  efforts  to  force  it  back  by  applying 
for  two  or  three  weeks  moderate  pressure  on  the  anterior  face  of  the  tubercle 
which  it  supports.  This  mode  succeeded  with  him  perfectly  in  several  cases. 
Verdier  and  other  surgeons  have  since  obtained  from  it  similar  advantages. 
It  ought  consequently  to  be  adopted  in  simple  deviations  of  the  teeth  nearest 
the  median  line.  To  extract  them,  as  suggested  by  Gerard,  and  as  most 
modern  operators  recommend,  is  an  extreme  means,  to  which  recourse  should 
not  be  had  until  after  having  vainly  tried  to  restore  them  to  their  position  by 
pressure,  or  by  drawing  them  within  the  mouth  by  means  of  wires  fixed  to  the 
lateral  teeth.  To  conclude,  it  is  rare  with  judicious  precautions  and  a  little 
patience  that  we  do  not  succeed  in  removing  these  osseous  projections  in 
young  subjects  without  destruction  of  any  part.  Lassus  has  very  well 
remarked,  tliat  if  the  teeth  or  the  bone  which  contains  them  present  in  frotit 
no  asperities  or  sharp  angles,  the  operation  will  terminate  successfully.  Union 


OPERATIVE   SURGERY.  391 

having  once  taken  place,  the  pressure  of  the  lip  on  the  parts  will  be  sufficient 
in  the  course  of  time  to  give  them  their  proper  place  and  direction.  In  some 
cases  it  would  be  advantageous  to  follow  the  method  pursued  by  M.  Gensoul, 
in  the  case  of  a  young  female  in  whom  the  intermaxillary  projection,  sur- 
mounted by  the  incisor  teeth  had  become  almost  horizontal.  After  dissecting 
and  turning  back  towards  the  nose  the  flap  of  the  soft  parts,  and  having 
removed  the  four  incisors,  this  surgeon  seized  the  prominent  part  of  the  bone 
with  strong  nippers  as  for  the  purpose  of  breaking  it,  and  succeeded  in  giving 
it  a  perpendicular  direction;  he  depressed  in  the  same  manner  the  right 
canine  tooth;  made  raw  the  four  borders  of  the  double  hare-lip;  used  the 
twisted  suture,  and  supported  the  whole  by  a  bandage.  The  young  patient, 
thirteen  years  old,  was  perfectly  cured.  The  incisive  bone  became  consoli- 
dated, as  well  as  the  canine  tooth,  in  the  new  position  given  to  it ;  and  its  edge, 
which  was  on  a  level  with  the  molar  teeth,  was  sufficiently  solid  to  serve  as  a 
point  d'appui  to  the  inferior  incisors  during  mastication. 

c.  The  Simple  Fissure  of  the  Maxillary  Arch,  or  that  in  the  shape  of  Y,  tp 
remedy  which  the  old  surgeons  thought  nothing  should  be  attempted,  and 
which  therefore  prevented  them  from  conceiving  the  treatment  of  the  hare- 
lip with  which  it  is  complicated,  is  no  obstacle  to  the  success  of  the  operation ; 
and  in  this  regard,  unless  there  is  too  wide  a  separation,  does  not  require  any 
special  modification  of  the  process.  After  the  suture,  its  edges  gradually 
approximate,  and  finally  the  fissure  itself  sometimes  completely  disappears ; 
insomuch,  that  examples  are  already  found  in  Roonhuysen,  Sharp,  De  laFaye, 
Quaisnay,  Richter,  B.  Bell,  and  Lapeyronie.  In  the  case  observed  by  Gerard, 
this  fissure,  which  was  not  less  than  a  finger's  breadth,  was  clo|ed  at  the  end 
of  two  years.  Several  weeks  were  sufficient  in  a  patient  of  Desault;  and 
M.  Roux  mentions  a  child,  three  years  old,  in  whom  a  similar  separation 
scarcely  left  a  trace  at  the  end  of  the  fifth  month.  The  moderate  but  con- 
stant and  regular  pressure  which  the  lip,  whose  continuity  has  just  been 
established,  exerts  upon  the  external  surface  of  the  bone,  is  the  only  cause  of 
this  truly  remarkable  phenomenon.  Nevertheless,  if  it  is  slow  in  effecting 
it,  either  in  consequence  of  the  long  duration  of  the  disorder  or  from  the 
extent  of  the  fissure,  I  do  not  see  why  we  should  not  seek  to  favor  it  by 
compressing  bandages,  applied  either  below  the  malar  bone  upon  the  skin,  as 
advised  by  Jourdain  and  Levret,  and  opposed  by  Richter ;  or  immediately 
upon  the  alveolo -dental  arches,  as  I  myself  performed  in  1825,  at  the  recom- 
mendation of  M.  Roux ;  or  by  covering  the  whole  head  with  a  bandage  in  the 
manner  of  the  fillet  of  Dent,  or  the  tape  apparatus  of  Terras.  Indeed  there 
may  be  a  thousand  modes  of  accomplishing  it ;  but  the  object  once  indicated, 
every  one  marks  out  for  himself  the  course  he  will  follow  to  fulfill  it.  As  in 
these  various  cases  the  part  finds  posteriorly  but  a  very  uneven  support,  and 
as  an  artificial  plate  retained  beneath  its  posterior  surface  would  have  the 
serious  disadvantage  of  irritating  the  parts,  the  bandage  should  be  so  dis- 
posed as  not  to  exercise  a  too  powerful  pressure  in  front.  I  need  not  add 
that  the  needles  cannot  be  safely  withdrawn  until  the  fourth  or  fifth  day. 

C.  Age  proper  for  the  Operation. — A  final  question  remains  to  be  consi- 
dered :  is  it  prudent  to  operate  on  the  hare-Jip  during  the  first  months  of 
life,  or  is  it  not  much  better  to  wait  till  the  age  of  reason  ?  The  latter  opinion, 
supported  by  Dionis  and  the  greater  part,  of  the  surgeons  of  the  eighteenth 


592  jf    *^  NEW   ELEMENTS   OF 

century,  is  almost  exclusively  adopted  among  us  at  the  present  day.  The 
reason  advanced  is,  that  the  very  young  infant,  being  incapable  of  concur- 
ring in  the  precautions  demanded  by  the  operation,  cries,  agitates  itself,  and 
yields  to  all  the  energy  of  its  motions  the  moment  it  is  approached.  The 
mere  sight  of  the  surgeon  or  of  those  around  it  during  the  cheiloraphy,  is 
sufficient  to  excite  its  fears  and  render  it  unquiet.  The  slight  consistence 
of  the  tissues  and  their  liability  to  laceration,  are  causes  why  the  points  of 
the  suture  tear  out  upon  the  least  traction.  The  tongue,  accustomed  to  the 
habit  of  sucking,  comes  continually  between  the  lips,  and  in  some  measure 
prevents  union.  Strict  diet,  which  is  rigidly  enforced  for  some  days,  pro- 
duces sometimes,  according  to  Lassus,  so  rapid  an  emaciation,  that  at  the  end 
of  twenty-four  or  forty-eight  hours  the  cheeks  of  the  child  become  flaccid, 
and  every  part  of  the  suture  greatly  relaxed.  Besides,  it  is  scarcely  of 
importance  to  the  patient  whether  he  is  cured  a  little  sooner  or  later,  a& 
long  as  he  is  unable  to  talk.  After  the  first  three  or  four  years,  the  dif- 
ficulty he  meets  with  in  expressing  his  thoughts,  the  raillery  of  his  little 
play-fellows,  and  the  consciousness  of  his  own  infirmity,  naturally  create  in 
him  a  desire  to  be  freed  from  this  embarrassment.  At  this  period,  reasoning, 
entreaties,  and  threats  have  already  acquired  a  certain  empire  over  him. 
He  is  able  to  submit  to  the  diet,  and  the  density  of  the  tissues  is  much 
increased. 

To  these  views  Busch  of  Strasburg,  who,  with  Roonhuysen,  Sharp,  Le 
Dran,  and  Heister,  adopted  the  opposite  opinion,  replies,  that  we  may  prevent 
the  motion  and  cries  of  the  patient  by  not  permitting  it  to  sleep  for  several 
days  beforeVnd,  and  administering  to  it  a  preparation  of  opium  shortly  be- 
fore the  operation,  in  order  that  it  may  be  quiet  and  fall  asleep  immediately 
after ;  that  a  child  of  three,  six,  or  even  ten  years  of  age  is  often  more  difficult 
to  manage  than  an  infant  at  the  breast;  that  altogether  a  stranger  to  fear,  the 
latter  only  regards  pain  and  real  wants,  whereas  the  former  resists  the  idea  of 
the  least  suffering,  and  in  reality  attaches  but  little  value  to  the  results  of  the 
operation  which  it  is  desired  to  perform  on  him ;  and  though  in  the  infant  the 
tissues  are  more  easily  cut  and  torn,  they  are,  on  the  other  hand,  better  dis- 
posed to  effect  prompt  agglutination.  I  will  add,  that  when  the  future  is  well 
performed  the  motions  necessary  for  the  ingestion  of  a  few  drops  of  milk  or 
soup,  oppose  but  a  feeble  obstacle  to  success.  Besides,  the  hare-lip  seldoiiji 
permits  the  little  patient  to  accustom  itself  to  sucking.  The  prolonged 
existence  of  the  evil  entails  more  disadvantages  than  seem  to  be  imagined. 
It  impedes  the  development  of .  the  intellectual  faculties  by  the  difficulty  it 
produces  in  the  pronunciation;  and  consequently  in  the  use  of  the  ordinary 
means  of  education.  When  i;t  is  complicated  with  the  palatine  division,  the 
longer  we  wait  the  more  the  boileS  separate  for  want  of  resistance  from  without. 
In  this  last  case  suction  and  deglutition  itself  may  be  rendered  extremely 
difficult,  and  death  from  inanition  become  inevitable ;  examples  of  which  have 
actually  occurred.  Besides,  tp  the  arguments  of  Lassus,  Sabatier,  M.  Roux, 
&c.,  we  may  oppose  the  daily  practice  6f ^English  surgeons ;  the  success  obtained 
by  Muys,.Roonhuysen,  Le  Dran,  Bell,  and  Busch,  on  infants,  even  a  few  days, 
a  few  weeks,  or  a  few  month3  old ;  and  the  three  cases  recently  published  by 
M.  Delmas  of  Montpellier.  For  the  rest,  I  would  operate  in  the  first  months 
and  as  soon  after  birth  as  possible,  unless  I  intended  to  w^it  the  expiration  of 


OPERATIVE  SURGERV.  393 

early  infancy.  From  the  period  of  the  second  year  the  patient  being  more 
unmanageable  is  yet  not  much  more  reasonable,  and  the  disadvantages  of  his 
situation,  which  are  no  longer  of  a  nature  to  jeopard  his  existence,  permit  us 
to  temporize  for  three  or  four  years  longer.  Therefore  I  would  select  the  first 
six  months  of  life,  or  from  the  fifth  to  the  tenth  year,  to  perform  the  suture  of 
the  lips  :  that  is,  I  would  advise  that  patients  who  have  not  been  operated 
upon  in  the  first  period  should  wait  until  the  second.  After  all,  if  the  borders 
of  the  division  are  so  widely  separated  as  to  render  it  almost  impossible  to 
bring  them  in  contact,  it  would  without  doubt  be  useless  to  attempt  tlie  suture. 
I  saw  it  tried  without  success  in  1822,  at  the  hospital  St.  Louis,  by  M.  J. 
Cloquet  upon  an  infant  about  a  month  old,  under  these  circumstances.  But 
it  is  doubtful  whether  at  a  later  period  we  might  not  succeed  better.  Why 
not  begin  in  difficult  cases  by  diminishing  the  opening  with  a  good  compress- 
or, such  as  the  spring,  from  which  M.  Pointe,  of  Lyons,  and  subsequently 
M.  Maunoir,  of  Geneva,  have  found  so  much  advantage?  Why  not  separate 
from  the  bone  the  two  divisions  of  the  lip  as  far  as  the  os  malae,  so  as  to  be  enabled 
to  bring  them  more  easily  towards  each  other ;  as  appears  to  have  been  already- 
advised  by  J.  Fabricius,  Horn,  Nuck,  Roonhuysen,  &c.  ?  i 
In  whatever  manner  he  intends  to  operate,  the  surgeon  ought,  before  taking 
the  instrument  in  his  hand,  to  be  deeply  penetrated  with  the  idea  that,  notwith- 
standing all  its  simplicity,  the  operation  on  the  hare-lip  requires  skill  and 
dexterity ;  that  if  he  does  not  ever  appreciate  these  according  to  their  true 
value,  he  necessarily  performs  it  badly,  and  in  proportion  to  the  honor  it  does 
him  when  he  derives  from  it  all  possible  success,  so  will  it  injure  him  when  he 
succeeds  but  imperfectly.                                                             * 

§  2*  Excision. 

Cancerous  tumors  and  all  cancerous  degenerations  are  not  more  sus- 
ceptible of  cure  upon  the  lips  than  elsewhere.  Extirpation,  when  practicable, 
is  almost  the  only  remedy.  It  is  doubtful  whether  caustics,  still  successfully 
employed  it  is  said  by  M.  Fleury  of  Clermont,  Helmont,  &c.,  may  be 
substituted  in  its  place.  In  another  article  it  was  my  duty  to  point  out  the 
course  to  be  pursued  when  the  maxillary  bone  itself  is  affected ;  consequently 
I  intend  to  speak  here  only  of  what  concerns  the  soft  parts.  When  the 
disease  occupies  but  a  small  extent  of  the  labial  border,  or  when  it  runs  more 
vertically  than  horizontally,  the  operation,  as  simple  as  it  is  easy,  may  be 
performed  in  two  ways: 

1st.  The  first  consists  in  circumscribing  the  cancer  by  two  oblique  inci- 
sions within  a  triangular  flap,  a  kind  of  V,  of  which  ihe  base  shall  correspond 
with  the  free  border  of  the  lip.  The  patient  and  assistant  are  placed  as  for 
the  hare-lip.  The  surgeon  seizes  the  morbid  tubercle  with  the  thumb  and 
fore-finger  of  one  hand,  while  with  a  pair  of  scissors  or  a  bistoury  in  the  other 
he  describes  his  flap,  taking  care  to  cut  in  the  sound  parts,  and  to  proceed 
from  the  buccal  opening  towards  the  point  of  the  V,  which  he  is  to  take  away. 
The  excision  made,  it  only  remains  for  him  to  bring  together  the  edges  of  the 
wound  which  hereby  results,  to  preserve  it  united  by  means  of  the  suture,  and 
to  treat  it  as  that  of  the  hare-lip.  This  method,  the  only  one  followed  for  a 
long  time,  is  as  applicable  to  the  superior  as  to  the  inferior  lip,  to  the  middle 
50 


394  NEW  ELEMENTS  OF 

portion  as  to  the  angles  of  the  buccal  opening,  and  is  to  be  preferred  as  long 
as  the  loss  of  substance  need  not  be  considerable:  for  example,  need  not  com- 
prise more  than  the  half  of  one  of  the  lips. 

2d.  The  other  is  apparently  still  more  simple.  It  is  reduced  to  a  simple 
crescentic  incision,  including  in  its  concavity  all  the  unsound  tissues ;  which 
is  performed  either  with  the  bistoury,  or  with  scissors  curved  in  the  flat ;  and 
which  leaves  behind  it  a  furrow  of  greater  or  less  depth.  It  is  applicable  only 
to  the  inferior  lip,  and  when  the  aifection  extends  more  vertically  than  trans- 
versely. Some  moderns  have  without  cause  claimed  this  idea.  It  was  in 
application  at  the  time  of  Le  Dran.  Louis  quotes  a  patient  who  submitted  to 
it,  in  whom  it  was  said  the  lip  was  renewed.  Camper  gives  it  as  his  own 
contrivance.  It  is  even  found  in  Fabricius  ab  Aquapendente,  who  remarks 
very  justly  that  a  large  portion  of  the  lip  may  thus  be  removed  while  the 
deformity  resulting  from  it  is  much  less  than  mjght  have  been  imagined. 
Whatever  may  be  the  case,  it  was  almost  entirely  forgotten  when  Messrs. 
Richerand  and  Dupuytren  raised  it  to  consideration  amongst  us.  Two  cir- 
cumstances concur  in  rendering  easy  the  elevation  of  the  lip  towards  the 
dental  arch  after  the  excision  performed  in  this  manner.  These  are  the 
eccentric  repulsion  of  the  sound  tissues  caused  by  the  development  of  the 
cancer,  and  the  gradual  tractions  excited  afterwards  by  the  cicatrix  upon  the 
integuments  of  the  chin  or  of  the  superior  part  of  the  neck.  The  fact  is,  that 
the  surrounding  soft  parts  in  subjects  who  have  thus  lost  the  whole  lip  from 
one  commissure  to  the  other,  have  been  seen  to  lift  themselves  up  and  con- 
verge sufficiently  towards  the  mouth  to  cover  the  roots  of  the  teeth,  and  even 
still  higher.  In  the  most  happy  cases  the  mucous  membrane  of  the  gums 
unites  with  the  corresponding  part  of  the  wound,  and  yielding  to  the  cutaneous 
cushion  which  tends  to  draw  it  outwards,  is  reflected  forwards  so  as  to  furnish 
to  the  margin  of  the  new  lip  the  rosy  pellicle  which  constitutes  its  natural 
character.  In  the  least  fortunate  circumstances,  on  the  contrary,  a  consider- 
able portion  of  the  jaw  remains  uncovered;  speech  is  rendered  incomplete; 
the  patient  continually  letting  fall  his  saliva,  is  obliged  to  wear  a  metallic 
instrument  on  his  chin  furnished  with  sponge.  But  happily  at  the  present 
day  there  exist  other  means  of  obviating  this  inconvenience.  (See  Chei- 
loplasm.) 

§  3.  Eversion — Mucous  Enlargements, 

BosselureSy  a  species  of  reddish  prominence  which  many  subjects  have  on 
the  internal  surface  of  the  free  border  of  the  lips,  is  a  deformity  to  which  as 
yet  surgery  has  been  but  little  attracted.  It  is  sometimes  observed  on  the 
superior  lip,  sometimes  on  the  inferior,  and  at  times  on  both  at  once ;  in  some 
cases  under  the  form  of  one  or  several  tubucles,  scarcely  visible;  at  other  times 
with  the  aspect  of  a  transverse  eminence,  which  forces  the  lip  out  upon  the 
skin  whenever  the  patient  laughs  or  speaks.  It  is  commonly  a  congenital 
blemish,  which  rarely  disappears  of  itself,  and  which  is  sometimes  manifested 
accidentally,  particularly  in  persons  who  blow  the  horn  or  who  are  obliged 
to  make  loud  cries.  Its  presence  is  not  dangerous,  and  is  accompanied  with 
no  other  inconvenience  than  of  rendering  the  countenance  less  agreeable. , So 
the  greater  part  of  those  who  are  affected  by  it  carry  it  during  life,  without 


OPERATIVE    SURGERY.  395 

thinking  of  getting  freed  from  it.  However,  it  is  very  inconvenient  to  certain 
classes ;  huntsmen,  musicians,  and  orators  for  example.  Witness  two  patients 
operated  upon  in  1829,  by  Messrs.  Roux  and  Boyer.  Its  cure  is  extremely 
easy.  Excision  is  performed  with  curved  scissors  or  the  ordinary  bistoury. 
While  an  assistant  stretches  the  lip  by  its  two  angles  and  brings  in  view  its 
internal  surface,  the  surgeon  seizes  ^he  projection  as  extensively  as  possible 
with  good  forceps  held  in  his  left  hand,  as  in  excision  of  the  superfluous 
portion  of  the  conjunctiva  in  ectropion,  and  attempts  to  remove  it  entire ; 
leaving  in  its  place  a  regular  wound  which  requires  no  dressing,  and  which  in 
general  cicatrizes  very  readily.  Numerous  facts  found  in  different  authors, 
or  gathered  from  the  lectures  of  M.  Dupuytren,  prove  that  at  the  end  of  a 
week  or  two  the  cure  is  complete  and  the  deformity  entirely  gone. 

There  is  no  doubt  that  the  same  operation  would  be  applicable  to  eversion 
of  the  lips  produced  by  sJfy  other  cause,  contractions  or  old  cicatrices  for 
example,  since  this  state  of  the  mouth  bears  the  greatest  analogy  to  ectropion 
or  eversion  of  the  eye-lid,  and  is  remediable  by  the  same  surgical  means. 

§  4.  Hypertrophy. 

The  enlargement  of  the  upper  lip,  almost  natural  in  scrofulous  habits,  may 
be  carried  so  far  as  to  constitute  a  grave  malady,  or  at  least  a  very  troublesome 
deformity.  In  some  cases  the  whole  of  the  organ  acquires  such  a  develop- 
ment, that  its  posterior  face  looks  downwards  and  its  free  border  directly 
forwards.  While  any  morbid  action  exists;  while  the  hypertrophy  is  not 
decidedly  fixed  and  reduced  to  the  state  of  a  simple  vice  of  conformation,  we 
should  confine  ourselves  to  appropriate  medicines,  internal  or  external, 
general  or  topical.  But  when  every  resource  pointed  out  by  sound  reason  has 
been  vainly  employed,  and  when  the  affection  is  purely  local,  nothing  but  cut- 
ting instruments  can  triumph  over  it,  unless  the  use  of  compression  and  caustics 
be  thought  preferable.  The  operation  by  which  the  patient  is  freed  from  it  was 
first  used  in  1826,  by  M.  Paillard,  who  has  performed  it  three  times  with 
complete  success,  and  who  cites  three  other  cases  of  success  obtained 
by  MM.  Marjolin  and  Belmas.  It  consists  in  raising  the  lining  of  the  lip, 
and  reducing  it  to  its  natural  thickness  by  excising  a  sufiicient  portion  of 
its  tissue. 

The  assistant,  who  keeps  the  head  of  the  patient  pressed  against  his  breast, 
is  also  charged  with  stretching  the  lip  and  making  it  project,  by  taking  hold 
of  the  left  commissure  with  the  fore-finger  and  thumb  of  the  corresponding 
hand.  Placed  in  front  and  a  little  to  the  right,  the  operator  seizes  the  other 
commissure  then  with  the  right  hand  ;  armed  with  a  good  bistoury,  he  makes 
an  incision  from  one  labial  angle  to  the  other,  and  perpendicularly  upon  the 
margin  of  the  diseased  lip,  and  a  little  nearer  the  mucous  membrane  at  its 
extremities  than  in  its  centre ;  thus  having  circumscribed  all  which  he  intends 
to  bring  away,  he  seizes  the  flap  with  the  forceps  and  dissects  it  rapidly  with 
the  same  bistoury  from  the  free  margin  to  the  adherent  edge,  and  from  the 
left  to  the  right  extremity  of  the  organ  as  far  as  the  sound  tissues,  endeavoring 
to  give  it  all  necessary  breadth  and  thickness,  and  taking  care  to  bring 
it  gradually  nearer  the  raucous  covering  before  terminating  its  excision  near 
the  alveolo -labial  fossa  with  a  last  stroke  of  the  bistoury,  or  with  good 


396  NEW    ELEMENTS   OF 

scissors.  The  wound  sometimes  bleeds  profusely,  although  in  general  it 
readily  heals.  No  dressing  is  necessary.  The  wounded  surface  being  con- 
tinually lubricated  by  the  saliva  is  soon  cleansed.  In  cicatrizing  it  reacts  upon 
the  integuments;  gradually  draws  them  forwards ;  even  tends  to  incline  them 
downwards,  and  in  case  of  complete  cure  the  lip  not  only  is  restored  to  the 
thickness,  but  even  to  the  direction  of  its  normal  condition. 


§  5.  Cheiloplasm. 

The  art  of  restoring  or  reconstructing  mutilated  or  destroyed  lips,  has  made 
in  our  days  the  most  astonishing  progress.  But  a  short  time  since,  a  loss  of 
substance  considerable  enough  to  render  simple  cheiloraphy  useless,  seemed 
to  be  beyond  the  resources  of  surgery.  Now,  on  the  contrary,  the  most 
hideous  deformities  do  not  restrain  the  skillful  operator.  If  a  lip  be  wanting 
on  either  side,  in  whole  or  in  part,  alone  or  with  a  portion  of  the  cheek,  it  is 
almost  always  possible  to  reproduce  it  by  borrowing  from  the  neighboring 
parts  the  tissues  which  are  necessary.  For  the  rest,  the  surgeon  must 
invent  rather  than  learn  the  art  of  cheiloplasm.  It  is  an  operation  which  can 
scarcely  be  confined  to  detailed  rules,  and  which  must  be  modified  almost  as 
often  as  performed.  All  the  modes  of  rhinoplasm  have  been  applied  to  it. 
Tagliacozzi  is  said  to  have  succeeded  by  the  Itatian  method ;  that  is,  by 
borrowing  from  the  arm  the  materials  for  the  new  lip.  Delpech,  Lallemand, 
Dupuytren,  Dieffenbach,  and  Textor  have  tried  the  Indian  method,  which  con- 
sists in  taking  a  tegumentary  flap  from  the  neighboring  parts,  and  after  invert- 
ing and  twisting  it,  fixing  it  in  the  place  of  the  destroyed  tissues.  In  fine, 
the  French  method,  as  it  is  styled  by  M,  Romand  in  the  thesis  which  he 
defended  on  this  subject  in  1830,  a  method  characterized  by  the  dissection 
and  separation  of  the  internal  surface  and  the  stretching  the  musculo-cuta- 
neous  cushion  which  borders  on  the  opening  to  be  supplied,  reckons  already 
a  great  number  of  trials.  All,  even  to  the  ancient  method  of  Celsus,  in  which 
incisions  whether  vertical  or  horizontal,  external  or  internal,  were  performed 
beyond  the  deformity,  have  found  defenders.  Its  object  being  to  remedy  lesions 
of  form  and  of  different  natures,  it  was  to  be  presumed  that  each  of  these 
methods  would  soon  comprise  several  distinct  processes. 

Manual — 1.  Ancient  Process. — If  there  exist  but  a  hollow  in  either  lip, 
although  very  deep,  provided  that  its  transverse  extent  be  not  too  consider- 
able, cheiloplasm  differs  but  very  little  from  the  operation  for  the  hare-lip. 
The  first  thing  necessary  is  to  convert  the  abnormal  deficiency  into  a  recent 
wound,  and  give  it  the  form  of  a  V,  by  paring  off  its  edges  and  all  the  diseased 
portion  with  the  scissors  or  bistoury.  In  the  second  place,  the  surgeon 
dissects  one  after  the  other  the  two  flaps  of  soft  parts,  separates  them 
from  the  maxillary  bone,  turns  them  outwards  to  beyond  the  point  of  the 
bleeding  triangle,  and  to  ah  extent  proportioned  to  the  void  to  be  filled. 
Nothing  then  is  easier  than  to  stretch  them,  the  one  towards  the  other,  and 
to  bring  them  in  contact.  In  other  respects  the  suture  is  effected  as  for  the 
hare-lip,  and  with  the  same  precautions ;  the  posterior  surface  of  the  new  lip 
unites  with  the  subjacent  parts  at  the  same  time  that  its  two  halves  become 
mutually  agglutinated ;  and  after  the  cure  its  free  margin  differs  in  reality 
from  what  it  was  before  the  disease  but  by  being  a  little  diminished  in  length. 


OPERATIVE   glJRGERY.  S97 

Nevertheless  this  process  has  the  disadvantage  of  contracting  the  mouth  con- 
siderably, and  of  sometimes  deforming  its  aperture  quite  disagreeably.  Celsus 
very  probably  had  in  view  something  analagous,  when  he  advised  to  practice 
a,  transverse  incision,  then  a  crescentic  one  between  the  malar  bone  and  the 
commissure  on  the  internal  surface  of  each  cheek,  in  order  to  permit  the  elon- 
gation of  the  two  halves  of  the  divided  lip.  There  is  every  reason  to  think 
at  least  that  this  kind  of  cheiloplasm  was  already  thought  of,  of  which  Galen  and 
Paulus  asgineta  also  make  some  mention. 

2.  Chopart'S  Process. — The  preceding  method  may  suffice  when  the  defi- 
ciency of  substance  is  not  of  great  breadth ;  but  in  other  cases  it  must  be 
rejected,  and  preference  be  given  to  one  of  the  processes  which  remain  to  be 
described.  That  which  according  to  Carpue,  seems  to  have  been  designed  by 
Chopart,  and  which  I  have  seen  fully  succeed  with  two  subjects  operated  on 
by  M.  Roux,  is  one  of  the  most  valuable.  If  there  is  cancer,  the  surgeon 
commences  by  making  on  each  side  of  the  disease  and  beyond  its  limits,  an 
incision  which  descends  vertically  from  the  free  border  of  the  lip  to  a  point 
below  the  jaw ;  he  then  dissects  the  quadrangular  flap  traced  by  these  two 
wounds ;  detaches  it  from  the  bone,  proceeding  from  above  downwards,  pre- 
serving to  it  all  possible  thickness  without  cutting  too  near  the  periosteum ; 
prolongs  it  below  the  chin  or  towards  the  thyroid  cartilage  in  proportion  to 
the  extent  of  the  diseased  parts  to  be  destroyed.  This  done,  he  cuts  trans- 
versely and  squarely  all  the  diseased  portion,  encroaching  a  little  upon  the 
sound  tissues,  and  thus  takes  off  with  a  single  stroke  the  whole  of  the  cancer ; 
then  taking  the  flap  which  he  has  just  formed,  carries  it  up  and  adjusts  it  upon 
the  chin,  and  by  gentle  pulling  easily  brings  its  superior  margin  upon  a  level: 
with  the  upper  lip,  or  the  remains  of  the  lower :  unites  it  by  means  of  three  or 
four  points  of  the  twisted  suture  on  each  side  to  the  lateral  portions  of  the 
face,  beginning  always  with  the  superior  needle ;  the  patient  is  advised  to 
keep  his  head  bent  forwards  for  some  days  after  the  operation  to  prevent  all 
dragging  and  laceration  of  the  parts.  One  must  witness  it  to  conceive  with 
what  facility  these  flaps  stretch  and  yield.  In  one  of  the  cases  in  which  I 
was  assistant  to  M.  Roux,  the  operator  being  obliged  to  remove  the  whole 
thickness  of  the  lip  beyond  the  limits  of  the  orbicularis  muscle,  extended  his 
flap  to  about  the  middle  of  the  subhyoid  region.  Yet  nothing  was  easier  than 
to  bring  up  its  edge  to  a  level  with  the  point  primitively  occupied  by  the  lip. 
In  four  days  union  appeared  to  be  effected.  All  the  needles  were  brought 
away.  No  suppuration  supervened,  either  in  its  lateral  edges  or  on  the  pos- 
terior face  of  the  flap,  and  its  superior  margin  soon  became  invested  with  a 
reddish  pellicle,  in  a  great  measure  resembling  that  which  naturally  lines  the 
buccal  opening ;  so  that  on  the  fifteenth  day  the  patient,  who  was  forty-eight 
years  old,  exhibited  scarcely  any  trace  of  the  operation.  The  second  subject 
was  not  less  fortunate,  and  I  have  not  learned  that  any  thing  unpleasant  has 
since  occurred  to  either.  This  new  lip,  nevertheless,  having  no  constrictor 
muscle,  usually  remains  immovable,  fixed  against  the  teeth,  and  as  it  were 
retained  from  behind  ;  but  such  slight  inconveniences  cannot  enter  into  com- 
parison with  those  induced  by  the  necessity  of  wearing  a  silver  lip,  and 
patients  are  too  fortunate  to  be  rid  of  it  at  this  price. 

3.  Process  of  M.  Roux,  of  St.  Maximin. — M.  Roux,  of  St.  Maximin,  has 
several  times  practised  cheiloplasm  by  a  process  peculiar  to  himself,  and  from 


S98  NEW   ELEMENTS   OF 

which  he  has  obtained  remarkable  results.  Instead  of  forming  a  flap  to  be 
brought  up  after  excision  of  the  diseased  part,  this  practitioner  begins  by  cir- 
cumscribing with  incisions  suitably  directed,  all  which  is  necessary  to  destroy 
in  removing  the  cancer.  Then  by  a  careful  dissection,  he  detaches  from  the 
maxillary  bone  and  the  anterior  region  of  the  neck  the  surrounding  soft  parts, 
and  thus  forms  from  the  skin  and  cellular  tissue  a  kind  of  apron,  which  he 
brings  up  to  a  level  with  the  superior  lip  and  fixes  it  in  front  of  the  jaw  either 
with  adhesive  stiips,  or  when  it  is  necessary  previously  to  prolong  the  com- 
missures by  a  transverse  incision,  unites  and  suspends  it  by  some  points  of 
suture  on  each  side  to  the  superior  edges  of  the  wound.  The  patient,  the 
assistants,  and  the  surgeon  are  placed  as  in  the  operation  for  the  hare-lip.  If 
the  disease  extends  beyond  the  transverse  boundaries  of  the  inferior  lip,  M. 
Roux  makes  with  the  scissors  a  first  incision,  crescent  shaped,  an  inch  or  more 
long,  which  extends  in  the  same  degree  each  commissure,  prolonging  them 
towards  the  masseters ;  he  performs  another  on  each  side  with  the  bistoury, 
beginning  at  the  external  extremity  of  the  former,  and  bringing  them  below 
the  cancer,  unites  them  on  the  chin ;  removes  all  the  degenerated  portions, 
and  in  some  cases  lays  bare  the  whole  body  of  the  jaw ;  dissects  what 
remains  of  the  cheeks  by  their  internal  surface ;  returns  to  the  chin ;  descends 
to  the  submaxillary  margin  as  far  as  the  subhyoid  region ;  preserves  as  much 
thickness  as  possible  to  the  integuments  lined  with  cellular  tissue,  which  he 
insulates ;  bringing  them  upwards,  he  attaches  their  extremities  to  the  raw 
prolongation  of  the  commissures  so  as  to  preserve  entirely  free  a  sufficient 
length  to  represent  the  margin  of  the  inferior  lip,  and  supports  the  whole  with 
strips  of  diachylon,  a  sling,  and  retaining  bandage.  When,  on  the  other 
hand,  one  side  of  the  lip  is  untouched,  and  the  organic  change  is  prolonged  for 
some  distance  on  the  cheek  of  the  opposite  side,  it  suffices  to  extirpate  the 
cancer  with  three  incisions.  The  one  a  little  curved,  transverse,  and  above 
the  diseased  commissure ;  the  second,  whether  straight  or  curved  is  of  little 
consequence,  equal  in  length  to  the  first  and  continuous  with  it,  descending 
4)bliquely  in  front  towards  the  chin ;  the  third  beginning  near  the  sound  com- 
missure, and  terminating  by  union  with  the  second.  This  after  the  dissection 
is  brought  towards  the  first,  and  the  suture  is  to  keep  them  in  contact.  By 
this  proceeding  the  last  ascends  to  the  place  of  the  free  margin  of  the 
destroyed  lip,  which  it  nearly  represents,  and  the  form  of  the  mouth  is  pre- 
served. 

4.  Process  of  Professor  Roux, — In  the  case  of  a  girl  in  whom  there 
remained  but  a  very  small  portion  of  the  inferior  lip,  and  who  had  also  lost 
since  infancy  more  than  half  of  the  superior  lip,  the  maxillary  bones  had  so 
deviated  outwards  as  to  make  a  considerable  projection  through  the  opening. 
To  remedy  this  horrible  deformity,  M.  Roux,  of  La  Charite,  determined  to 
perform  the  operation  at  two  different  times,  and  executed  it  in  the  following 
manner :  after  havins:  transformed  the  inferior  half  of  the  wound  into  a  tri- 
angle  by  excision  of  its  borders,  he  had  recourse  to  the  saw  to  remove  about 
an  inch  of  the  jaw,  and  diminish  its  contour  or  prominence ;  then  approxi- 
mating its  two  portions  he  easily  brought  together  the  flaps  of  the  recent 
wound,  kept  them  united  by  the  twisted  suture,  and  thus  succeeded  in  restor- 
ing the  inferior  Up,  and  curing  more  than  half  of  the  diseased  cheek  without 
much  difficulty.   The  success  of  this  first  step  was  complete ;  but  M.  Roux,> 


OPERATIVE   SURGERY.  S99 

who  wished  to  act  in  the  same  manner  for  the  second,  and  remove  also 
a  portion  of  the  superior  jaw,  found  an  insurmountable  obstacle  in  the  opposi- 
tion of  the  patient,  who  was  satisfied  with  this  first  amelioration  of  her 
copdition.  It  is  very  evident,  however,  that  the  osseous  excision  here  would 
have  presented  much  more  difficulty  than  below ;  and  that  to  effect  it  it  would 
have  been  necessary  to  use  the  mallet  and  chisel,  or  cutting-nippers,  in  lieu 
of  the  saw.  By  excision  of  the  bone,  the  surgeon  hoped  sufficiently  to 
diminish  the  transverse  dimensions  of  the  face,  to  render  practicable  the 
coaptation  of  the  opposite  points  of  the  wound.  Supposing  it  could  have  been 
attained  without  it,  it  is  probable  that  the  cicatrix,  if  it  would  have  formed, 
being  acted  upon  by  the  hard  parts,  would  be  afterwards  toni,  or  at  least 
there  would  have  remained  a  very  ugly  prominence  on  the  corresponding  side 
of  the  countenance.  Apart  from  this  double  complication,  the  method  of 
M.  Roux,  of  St.  Maximin,  would  in  my  opinion  merit  the  preference. 

5.  Modification  of  M.  Lisfranc. — In  October  1829,  M.  Lisfranc  had  to 
treat  an  old  man  whose  inferior  lip  was  entirely  disorganized  by  a  cancer. 
A  crescentic  incision,  with  its  concavity  upwards,  permitted  him  to  detach 
and  excise  all  the  diseased  tissues.  From  the  middle  of  this  incision  he  began 
another,  which  he  conducted  perpendicularly  towards  the  hyoid  bone ;  dissect- 
ing successively  from  the  median  line  towards  the  sides,  and  from  above 
downwards,  the  two  flaps  thus  marked  out  as  in  the  T  incision,  he  w^as 
enabled  to  bring  them  up  in  front  of  the  chin  and  use  them  in  replacing  the 
lip  which  he  had  just  extirpated.  Several  points  of  the  twisted  suture  kept 
them  in  apposition,  and  sufficed  with  the  four-tailed  bandage  supplied  with 
lint,  to  prevent  their  descent  to  their  natural  place.  Every  thing  announced 
complete  success,  when  about  the  fifteenth  or  sixteenth  day  the  patient 
suddenly  died.  About  the  same  period,  or  a  little  earlier,  the  fourteenth 
of  July,  Mr.  Morgan  pursued  the  same  plan  in  London  upon  an  old  man, 
who  seems  to  have  received  great  relief.  The  operation  is  certainly  more 
easy  by  this  process  than  by  that  of  M.  Roux,  of  St.  Maximin ;  but  it  is  doubt- 
ful whether  we  can  give  as  much  regularity  to  the  free  margin  of  the  new  Up 
as  by  the  process  of  Chopart.  For  the  rest  it  is  a  modification  which  may 
have  its  value,  and  which  enters  in  part  into  the  first  method  I  have  pointed 
out.  The  fundamental  point  is  the  dissection  of  the  tissues  which  envelope 
the  bones  of  the  face  within  the  compass  of  the  wound.  All  the  rest  belongs 
to  the  several  variations  caused  by  the  kind  of  lesion  to  be  destroyed.  It  is 
the  part  of  the  surgeon  to  multiply  or  diminish  the  number  of  incisions ;  to 
determine  their  form,  direction,  and  depth,  every  time  he  is  called  upon 
to  employ  them.  The  advantages  of  this  method,  the  origin  of  which  extends 
back  to  Frabricius  ab  Aquapendente,  particularly  to  Franco;  which  M. 
Roland,  of  Toulouse,  practised  once  with  success;  which  M.  Blandin  has 
also  tried  ;  which  I  myself  tested  in  1830,  at  the  hospital  St.  Antoine,  and 
afterwards  at  La  Pitie  in  1831,  after  the  removal  of  the  inferior  maxillary 
bone,  and  which  has  very  well  succeeded  in  a  patient  operated  upon  in  Octo- 
ber last,  by  M.  Lisfranc,  are  incontestible.  The  two  fruitless  essays  of  M. 
Delpech  prove  that  the  Indian  method  holds  only  a  second  rank,  and  that 
only  when  the  loss  of  substance  is  too  deep  or  of  too  great  extent  to  admit  of 
remedy  by  the  extension  of  the  tissues.  The  method  of  Celsus,  or  of  M.  Dief- 
fenbach,  is  in  reality  but  a  simple  variety  of  it,  good  to  be  called  in  a* 


400  NEW   ELEMENTS   OF 

accessary  in  some  particular  cases.  As  to  the  Italian  method,  it  no  loii^W 
belongs  to  the  restoration  of  the  lips,  but  to  rhinoplasm.  The  following  article 
will  bring  us  to  appreciate  better  the  value  of  these  remarks ; — 

§  6.  Genoplasm, 

The  cheeks  are  also  susceptible  of  being  more  or  less  completely  recon- 
structed. A  loss  of  substance  in  them  almost  always  includes  at  the  same 
time  a  portion  of  the  lips,  and  renders  the  countenance  truly  hideous.  Thus 
for  twenty  years  no  effort  has  been  left  untried  to  remedy  it.  M.  Delpech  and 
M.  Lallemand  seem  to  be  the  first  among  the  moderns  who  have  given 
it  attention. 

1.  Indian  Method. — A  young  girl,  ten  years  of  age,  had  on  the  inferior  part 
of  the  left  cheek  a  wound  followed  by  gangrene,  irregularly  circular,  twa 
inches  in  diameter,  including  nearly  half  an  inch  of  the  inferior  lip,  and  a  few 
lines  only  of  the  superior.  To  close  this  vacancy,  M.  Lallemand  began 
making  raw  the  whole  of  its  circumference,  giving  it  the  form  of  an  ellipse,  of 
a  little  more  curvature  above  than  below,  and  of  which  the  external  extremity 
of  the  great  diameter  fell  between  the  masseter  and  the  depressor  anguli  oris^ 
while  the  other  ran  above  and  without  the  prominence  of  the  chin.  He  then 
proceeded  to  cut  upon  the  side  of  the  neck,  below  the  maxillary  angle  and  in 
front  of  the  sterno-mastoid  muscle,  a  flap  of  the  same  shape  but  fully  a  third 
larger,  dissecting  it  carefully  and  giving  it  all  possible  thickness,  taking  care 
not  to  wound  the  external  jugular  vein  and  the  ascending  branches  of 
the  cervical  plexus.  This  flap,  oblique  from  above  downwards,  and  from 
^behind  forwards,  being  no  longer  connected  with  the  living  parts  but  by 
a  kind  of  root  about  an  inch  wide,  the  superior  edge  of  which  formed  a  part 
of  the  wound,  was  conducted  gradually  and  without  twisting  by  a  movement 
of  its  whole  body  from  below  upwards  into  the  latter,  where  the  operator 
fixed  it  by  different  points  of  interrupted  suture,  plaster  strips,  compresses 
of  charpie,  and  several  turns  of  a  bandage.  The  elliptic  form  was  preferred  for 
the  purpose  of  facilitating  the  union  of  the  wound  in  the  neck,  and  twisting 
was  avoided,  because  the  surgeon  was  apprehensive  lest  gangrene  should 
be  determined  to  the  borrowed  parts,  as  M.  Delpech  experienced  in  a 
case  where  he  had  to  obtain  the  integuments  beneath  the  jaw,  and  brought 
them  up  by  doubling  them  in  front  of  the  chin.  M.  Lallemand's  operation 
succeeded  only  after  many  accidents.  The  wound  was  torn  open  several 
times  in  consequence  of  the  cries  and  indocility  of  the  child,  and  more  per- 
haps from  the  presence  of  a  canine  tooth  which  had  deviated  outwards, 
and  which  it  became  necessary  to  extract.  The  cure  was  however  at  length 
completed.  Mr.  Texor,  who  practiced  according  to  the  Indian  method  in 
1827,  obtained  from  it  he  says  perfect  success.  All  the  needles  were  with- 
drawn on  the  seventh  day,  and  cicatrization  was  complete  on  the  twenty- 
seventh.  Since  then  M.  Dupuytren  has  made  an  attempt  of  a  similar  kind 
after  the  principles  of  M.  Lallemand,  and  in  a  case  much  more  complicated. 
His  operation  belongs  both  to  cheiloplasm  and  genoplasm.  .  The  patient  was 
a  child,  of  nine  years  of  age,  who  in  consequence  of  gangrene  had  lost  the 
left  half  of  the  inferior  maxillary  bone,  as  well  as  the  corresponding  part  of 
the  cheek  below  the  labial  commissure,  and   to  within  three  lines  of  the 


OPERATIVE   SURGERY.  401 

masseter  muscle.  The  operation  was  performed  in  the  month  of  August  1829. 
The  flap  was  taken  from  before  the  sterno -mastoid  muscle,  twisted  upon  itself, 
and  fixed  to  the  freshened  edges  of  the  wound  by  five  points  of  suture.  The 
anterior  needle  first,  and  afterwards  that  which  formed  the  connection  below, 
cut  through  the  tissues  and  became  detached.  Its  inferior  edge  only  became 
gangrenous  and  suppurated.  An  opening  an  inch  in  length,  having  its  base  at 
the  free  edge  of  the  lip,  was  the  consequence.  In  every  other  part  union  took 
place.  To  remove  this  new  opening  M.  Dupuytren  treated  it  as  a  simple 
hare-lip,  but  the  tongue  which  had  contracted  unnatural  adhesions  on  this  side 
was  an  obstacle  to  the  final  success  of  an  agglutination,  which  at  first  seemed 
to  have  perfectly  succeeded.  The  fact  at  least  proves  that  torsion,  so  much 
feared  by  M.  Lallemand,  does  not  necessarily  induce  mortification  of  the 
flap  which  is  subjected  to  it,  and  that  in  strictness  we  may  go  to  the  neck  for 
the  integuments  necessary  to  fill  up  wounds  on  the  cheek  attended  with  loss 
of  substance. 

2.  French  Method, — a.  Process  of  M.  Roux,  of  St.  Maocimin. — In  a  case 
similar  to  that  of  M.  Lallemand,  M.  Roux,  of  St.  Maximin,  followed  another 
mode.  The  cancer  had  destroyed  the  left  cheek,  including  part  of  the  lips, 
and  produced  at  this  place  an  ulcer  measuring  two  inches  perpendicularly, 
and  one  and  a  half  transversely.  By  means  of  two  crescentic  incisions, 
which,  beginning  at  the  lips,  were  united  in  front  of  the  masseter  muscle,  the 
surgeon  made  an  incision  of  the  carcinoma,  and  obtained  instead  a  fresh  ellip- 
tic wound  a  little  more  extended  in  breadth  than  in  height,  so  that  he  might  be 
able  to  approximate  its  borders ;  he  then  dissected  away  at  first  all  the  inferior 
lip,  nearly  to  the  right  masseter  and  beneath  the  chin  ;  he  performed  the  same 
on  the  left  cheek,  and  the  curved  borders  of  the  solution  of  continuity  were 
afterwards  easily  brought  to  face  each  other.  The  twisted  suture,  adhesive 
strips,  and  the  retaining  bandage  applied  as  usual,  prevented  all  subsequent 
displacement,  and  the  cure  took  place  in  a  very  short  time. 

b.  Process  of  M.  Gensoul. — A  woman  about 'fifty  years  of  age,  had  had 
gangrene  of  the  left  cheek  in  her  ninth  year ;  admitted  to  the  hospital  of 
Lyons  in  June  1829,  she  exhibited  on  the  left  side  of  the  mouth  an  enormous 
loss  of  substance,  which  left  exposed  a  great  part  of  both  jaws,  the  two  lateral 
incisors,  the  two  canine,  and  the  first  three  molar  teeth  of  this  side  all  consi- 
derably deviating  outwards.  The  circumference  of  the  ulcer  which  had  been 
long  cicatrized  adhered  intimately  to  the  bone,  and  had  produced  anchylosis 
of  the  inferior  maxilla.  After  separating  it  from  the  bone  and  making  it  raw, 
M.  Gensoul  detached  the  rest  of  the  cheek  as  well  as  the  corresponding  ex- 
tremity of  the  lips,  above,  below,  and  then  behind,  from  the  adjacent  tissues, 
as  far  as  the  neck  on  one  side  and  upon  the  masseter  on  the  other ;  he  then 
had  recourse  to  the  mallet  and  chisel  to  remove  the  projection  of  the  promi- 
nent maxilla,  as  well  as  the  teeth  implanted  in  it.  He  was  then  able  to  approxi- 
mate the  two  edges  of  the  wound  and  perform  the  suture.  A  small  salivary 
fistula  is  all  that  now  remains  of  so  vast  a  disorganization. 

c.  Process  of  Professor  Roux. — The  following  is  a  case  which  I  witnessed^ 
and  which,  though  to  be  confounded  with  the  preceding  cases,  yet  diff*ers  in 
some  points  of  view: — a  young  woman  twenty  years  old,  endowed  with 
indomitable  fortitude  and  uncommon  docility,  had  two  years  previously  the 
ala  of  the  nose,  the  half  of  the  superior  lip,  and  all  the  cheek  situated  above 

51 


402  NEW   ELEMENTS   OF 

the  horizontal  line  of  the  mouth,  destroyed  by  gangrene.  There  was  also 
necrosis  of  a  portion  of  the  maxillary  bone,  from  which  resulted  a  communi- 
cation of  the  sore  with  the  nasal  fossas  and  the  maxillary  sinus ;  and  the 
tongue  was  continually  thrust  from  the  mouth.  Having  entered  La  Charite 
in  the  summer  of  1826,  M.  Roux  yielded  to  her  urgent  entreaties  and  under- 
took her  cure.  To  accomplish  it  he  performed  seven  different  operations, 
which  occupied  a  whole  year.  The  first  attempt  permitted  him  to  insulate 
the  left  side  of  the  inferior  lip,  and  displace  it  by  carrying  it  upwards  to  serve  for 
renewing  the  destroyed  portion  of  the  superior.  Every  thing  in  this  operation 
succeeded  to  the  wish  of  the  operator.  The  buccal  opening  was  thereby  com- 
pletely separated  from  the  sore,  which  was  reduced  to  a  large  circular  ulcer, 
which  M.  Roux  tried  in  vain  to  close  by  paring  its  edges  and  bringing  them 
together  with  the  suture.  A  flap  detached  from  the  posterior  face  of  the  lip 
by  separating  the  lining  membrane  and  inverting  it  upwards,  succeeded  no 
better.  It  was  the  same  with  an  attempt  to  accomplish  it  by  integuments 
from  the  palm  of  the  hand.  He  took  the  course  of  bringing  upwards  and 
outwards,  to  unite  it  with  the  ala  of  the  nose  and  the  corresponding  half  of  the 
sore,  the  flap  which  the  superior  lip  had  borrowed  from  the  one  beneath.  A 
triangular  opening  as  in  the  hare-lip,  and  of  considerable  size  at  the  left 
commissure  of  the  mouth,  was  the  result  of  this  new  displacement.  The 
surgeon  did  not  hesitate  a  short  time  after  to  pare  the  edges ;  they  were  easily 
adapted,  the  suture  was  performed,  and  this  was  the  least  troublesome  of  all 
his  efforts.  At  present,  three  years  after  the  cure,  there  remain  in  this  patient 
no  traces  of  her  ancient  deformity  except  a  slight  contraction  of  mouth,  and 
on  the  cheek  some  marks  such  as  follow  a  burn. 

All  these  modes  of  performing  genoplasm  having  been  devised  for  as  many 
individual  and  dissimilar  cases,  it  would  be  superfluous  to  compare  them  in 
order  to  point  out  their  differences.  The  able  surgeon  must  see  which  is 
most  proper  for  the  case  before  him.  It  is  much  the  same  in  cheiloplasm ; 
consequently  I  have  thought  proper  to  leave  the  decision  to  the  sagacity  of 
the  reader.  Franco  had  conceived  the  idea  of  this  operation,  and  his  observa- 
tion demonstrates  beyond  doubt  that  he  understood  cheiloplasm,  and  especially 
genoplasm,  almost  as  well  as  modern  operators.  **  A  James  Janot,"  says  he, 
•'  had  a  defluxion  which  fell  in  his  cheek,  and  destroyed  the  said  cheek  or  the 
greater  part  of  it,  and  likewise  the  mandibles,  from  which  he  lost  several 
teeth,  and  there  remained  a  hole  through  which  you  might  put  a  goose's 
egg.  To  come  to  the  cure,  I  took  a  little  razor  and  cut  the  edge  or  skin 
all  around.  Afterwards  I  divided  the  skin  opposite  the  ear,  and  towards 
the  eye,  and  towards  the  inferior  mandible ;  then  I  cut  within  lengthwise  and 
crosswise  to  lengthen  the  lips,  taking  care  always  not  to  come  through,  for 
the  skin  was  not  to  be  cut.  I  immediately  applied  seven  wound  needles,  of 
which,  at  the  end  of  four  or  five  days,  three  fell  out,  which  had  to  be  re- 
placed by  others.  In  short  he  was  cured  within  fourteen  days."  But  the 
simple  narration  of  this  long  history  should  be  read  in  the  author  himself. 

§  7.  Abnormal  Coarctations, 

In  consequence  of  tetters,  burns,  ulcerations,  &c.,  the  anterior  orifice  of 
the  mouth  is  sometimes  so  contracted  as  to  disfigure  the  patient  and  interfere 


OPERATIVE    SURGERY.  403 

with  the  functions  of  this  cavity.  At  the  sight  of  such  an  evil,  the  first  re- 
source that  presents  itself  to  the  mind  is  mechanical  dilatation.  Unfortu- 
nately this  only  succeeds  temporarily,  and  perhaps  never  has  procured  perma- 
nent relief.  After  dilatation  comes  incision  of  the  commissures,  which  we 
should  be  careful  to  extend  a  little  further  than  we  wish  the  mouth  to  open, 
as  in  cicatrizing  the  wound  will  always  contract.  If  it  were  easy  to  cause 
the  two  edges  of  the  solution  of  continuity  to  cicatrize  separately  this  opera- 
tion would  perfectly  attain  the  end  proposed ;  but  this  is  not  the  case.  Not- 
withstanding the  cloths  spread  with  cerate,  the  leaf  of  lead  interposed,  and 
the  little  hooks  by  which  continual  traction  is  exercised  upon  the  angles  of 
the  wound,  it  still  most  frequently  ends  in  becoming  agglutinated  and  restor- 
ing things  to  their  previous  condition  if  the  deformity  itself  be  not  even 
aggravated.  Some  practitioners  have  thought  to  surmount  this  obstacle  by 
treating  coarctation  of  the  lips  with  a  leaden  wire.  A  trocar  carried  through 
from  the  skin  towards  the  mouth  makes  a  passage  for  the  wire,  the  buccal 
extremity  of  which  being  brought  back  through  the  natural  opening,  is  to  be 
united  with  the  other,  so  that  the  surgeon  may  twist  them  as  m  fistula  in  ano, 
and  insensibly  cut  through  the  interposed  tissues.  This  process,  less  start- 
ling to  patients  although  much  longer  than  the  preceding,  is  however  not  more 
certain.  In  proportion  as  the  wire  cuts  through  the  parts  they  reunite  beyond 
it,  so  that  in  the  end  the  ligature  is  not  more  eificacious  than  incision. 

Excision, — Aware  of  these  obstacles  and  the  insufficiency  of  known  means, 
M.  DieiFenbach  supposed  that  by  excising  a  portion  of  the  thickness  of  each 
labial  angle,  to  the  extent  of  an  inch  for  example,  leaving  the  mucous  mem- 
brane wholly  untouched,  a  complete  success  might  be  obtained.  Facts  have 
justified  his  theory,  and  already  he  reckons  several  instances  which  leave 
nothing  further  to  be  desired.  His  process,  more  easy  to  comprehend  than 
to  execute,  is  however  within  the  reach  of  all.  The  surgeon  inti'oduces  the 
extremity  of  a  finger  in  the  mouth  of  the  patient,  to  support  and  protect  the 
organic  cushion  which  he  intends  to  preserve.  With  the  other  hand  he  car- 
ries one  blade  of  the  scissors  upon  the  edge  of  the  coarcted  opening  a  little 
above  the  commissure,  and  enters  it  with  precaution  from  before  backwards 
between  the  mucous  membrane  and  the  other  tissues,  until  on  a  level  with  the 
point  where  he  wishes  to  place  the  corresponding  angle  of  the  lips,  and  cuts 
at  a  single  stroke  and  squarely  all  that  is  included  between  the  blades  of  the 
instrument;  he  then  makes  a  second  incision  a  little  lower  down,  parallel 
and  similar  to  the  first,  pursuing  the  same  course  with  the  inferior  lip  as  with 
the  upper;  he  then  unites  them,  and  by  a  small  crescentic  section  at  their 
posterior  extremity,  insulates  the  strip  thus  formed  and  cuts  it  off,  always 
without  touching  the  mucous  membrane,  which  he  detaches  afterwards  all 
round  the  loss  of  substance;  the  same  is  performed  on  the  opposite  side;  he 
then  gently  separates  the  jaws  so  as  to  stretch  the  portion  forming  the  floor  of 
the  wound,  and  divides  into  two  equal  portions  this  membranous  layer 
until  within  three  lines  of  its  genal  extremity ;  brings  it  outwards  and  reflects 
it  first  upon  the  labial  commissure  which  he  has  just  established,  then  upon 
the  inferior  edge,  and  lastly  on  the  superior  edge  of  the  division ;  fixes  it  there 
as  well  as  to  the  red  pellicle  of  each  margin  of  the  lips,  by  a  sufficient  number 
of  fine  short  needles,  or  the  twisted  suture,  alone  or  combined  with  the  inter- 
rupted suture ;  and  employs  it,  in  fine,  as  a  kind  of  border,  and  unites  it  to  the 


404  NEW   ELEMENTS  OF 

integuments  in  a  sort  of  hem,  in  the  manner  that  a  shoemaker  unites  to  the 
leather  of  his  shoes  the  last  binding  which  is  to  cover  their  edges.  If  the 
mucous  layer,  which  need  not  be  made  very  thin,  be  well  stretched  and  well 
fastened  upon  the  bleeding  edges  of  the  wound,  it  adheres  with  the  greatest 
facility  in  the  course  of  a  few  days.  The  artificial  portion  of  the  lips  having 
in  consequence  been  brought  to  the  same  state  of  organization  as  the  natural 
portion,  their  adhesion  is  no  more  to  be  apprehended  at  the  sides  than  towards 
the  middle.  Nothing  is  more  ingenious  than  this  process,  and  it  bids  fair  to 
be  generally  adopted.  Applicable  to  every  shade  and  degree  of  the  disease, 
whether  acquired  or  congenital,  and  to  all  ages,  its  only  difficulty  is  its  deli- 
cacy of  execution.  It  ought,  therefore,  be  always  attempted  when  the 
coarctation  is  not  surrounded  by  too  great  an  alteration  in  the  internal  mem- 
brane of  the  lips. 

Art,  2. — Salivary  Apparatus, 

§  1.  Fistulss, 

A.  Of  the  Parotid  Gland  or  its  Excretory  Ducts. — No  means  have  been 
left  untried  in  the  cure  of  salivary  fistulas,  and  it  must  be  admitted  that  nearly 
all  have  met  with  some  share  of  success. 

1.  Cauterization,  whether  with  hot  iron  or  chemical  substances,  employed 
successfully  by  Galen  on  a  patient  in  whom  the  fistula,  caused  by  critical 
inflammation  of  the  gland,  was  situated' beneath  the  ear;  by  Pare,  the  two 
Fabricii,  Heuermann,  M.  Boyer,  Langenbeck,  and  a  host  of  others,  succeeded 
very  well  in  fistulas  of  the  gland  itself;  that  is,  in  those  which  took  their  origin 
from  some  of  the  radicles,  and  not  from  the  principal  trunk  of  the  excretory 
salivary  canals.  Galen  used  catheteric  plasters ;  Pare,  aqua  fortis ;  Diemer- 
broeck  and  Jourdain,  actual  cautery;  M. Higginbottom,  sulphuric  acid;  and 
M.  Boyer,  the  nitrate  of  silver.  The  lapis  infernalis  deserves  the  preference, 
both  because  it  is  more  convenient  and  because  it  produces  an  eschar  drier  and 
more  adherent  than  any  other.  However,  if  the  ulceration  be  deep  and  nar- 
row, a  troche  of  minium  may  be  substituted  for  the  nitrate  of  silver,  as  I  tried 
with  success  in  November,  1831,  at  La  Pitie,  on  a  man  who  had  a  parotid 
fistula  in  consequence  of  the  opening  of  an  abscess  behind  the  maxillary 
limits.  Styptics  and  astringents,  equally  lauded  by  some  practitioners  and 
among  the  rest  by  Becket,  being  less  efficacious  than  caustics,  have  been  long 
since  abandoned. 

2.  Compression,  used  with  success  by  Beaupre,  Le  Dran,  and  Ruffin,  who 
invented  a  machine  for  the  purpose ;  extolled  also  by  Imbert,  Jourdain,  and 
Richter,  is  nearly  always  sufficient  when  it  can  be  borne  by  the  patient,  and 
when  the  state  of  the  parts  permits  its  employment.  For  this  end  charpie  or 
graduated  compresses  are  applied  upon  the  fistulous  orifice ;  then  with  a  four- 
tailed  bandage  and  a  halter,  or  turns  of  a  bandage  properly  distributed,  this 
point  is  acted  upon  in  a  manner  to  keep  in  contact  the  parietes  of  the  diseased 
duct. 

S.  Irritating  Injections,  proposed  by  Louis,  are  intended  to  inflame  the 
fistulous  opening  and  determine  the  adhesion  of  its  sides.  They  may  consist 
of  barley-water  with  honey,  the  decoction  of  Provence  roses  in  red  wine,  and 


OPERATIVE    SURGERV. 


|405 


even  of  alcohol,  according  to  the  irritability  of  the  tissues  in  which  adhesiye 
inflammation  is  desired.  It  is  a  remedy  which  holds  only  a  third  rank,  be- 
cause it  is  attended  with  more  risk  of  accidents,  and  does  not  always  cure. 
Yet  in  some  cases  of  obstinate  fistula  it  is  not  to  be  despised. 

4.  If  neither  of  these  means  succeed,  excision  may  be  tried  by  comprising 
the  ulcer  within  an  elliptical  incision,  and  uniting  its  sides  by  adhesive  strips 
or  the  twisted  suture.  If  the  disease  still  persist,  nothing  remains  but  to 
attempt  extirpation  of  the  gland ;  but  this  project,  ascribed  to  Pouteau  by  M. 
Hedelhoffer,  has  never  I  believe  been  put  into  execution.  It  would,  indeed, 
form  a  case  in  which  it  might  be  said  that  the  remedy  was  worse  than  the  dis- 
ease :  the  more  truly  so,  as  fistulae  sometimes  disappear  spontaneously,  of 
which  M.  Richerand  gives  two  examples. 

B.  Of  the  Duct  of  Steno. — Applied  to  fistulae  of  the  stenonian  duct,  these 
various  treatments,  although  of  less  efiicacy,  still  reckon  a  certain  number  of 
undeniable  cures. 

1.  Cauterization,  for  example,  alone  or  assisted  by  compression,  procured 
for  Louis  an  unhoped  for  cure  upon  a  subject  who  had  carried  his  fistula  for 
nineteen  years,  and  submitted  to  several  operations  without  success.  Fer- 
rand,  Nedel,  Mursinna,  Imbert,  Jourdain,  and  M.  Langenbeck  have  been  no 
less  successfiil. 

2.  Compression,  without  caustic,  and  as  a  single  means,  has  on  its  part 
appeared  sufficient.  Maisonneuve,  who  first  advised  it  in  this  case,  established 
it  between  the  fistula  and  the  gland  for  the  rational  purpose  of  closing  the 
passage  to  the  saliva,  and  permitting  the  opening  to  cicatrize.  His  patient, 
who  had  received  a  sabre  cut  on  the  cheek,  was  radically  cured  at  the  end  of 
twenty  days.  Louis,  and  with  him  most  of  the  moderns,  have  thought  that  by 
this  mode  inflammation  will  be  almost  necessarily  determined  to  the  whole  ex- 
tent of  the  parotid  gland,  and  consequently  it  could  not  fail  to  be  dangerous. 
Desault  thought  to  dissipate  these  fears  by  directing  compression  upon  the  gland 
itself,  in  which  he  proposed  to  induce  atrophy.  Whether  this  atrophy  really 
took  place,  as  Desault  affirms,  or  whether  the  parotid  gland  continued  its 
functions  afterwards,  as  M.  Boyer  seems  to  think,  it  is  the  fact  that  the  fis- 
tula cicatrized  early,  and  the  patient  had  no  return  of  it  afterwards.  How- 
ever it  may  be,  there  are  in  the  designs  of  these  authors  two  ideas  which  it  is 
necessary  not  to  confound  ;  that  of  Maisonneuve,  who  wished  to  suspend  for  a 
time  the  flow  of  the  saliva ;  and  that  of  Desault,who  preferred  to  dry  up  its  source. 
Without  believing  with  Heuermann  that  the  parotid  gland  would  form  abscess, 
ulcerate,  or  pass  to  the  state  of  scirrhus  or  cancer,  I  cannot  yet  admit  that 
such  means  are  harmless ;  they  ought,  in  my  opinion,  to  be  reserved  for  sub- 
jects whom  every  other  operation  alarms  or  has  failed  to  cure. 

3.  Ligature  of  the  Duct, — Zang,  who  partakes  of  the  opinions  both  of 
Maisonneuve  and  of  Desault,  recurs  to  the  process  of  Viborg  for  determining 
atrophy  of  the  parotid  gland.  Instead  of  compression,  which  is  always  un- 
certain, this  surgeon  proposes,  as  the  object  is  to  prevent  the  passage  of  the 
saliva,  to  apply  a  ligature  to  the  duct  of  Steno  beyond  the  fistula.  Numerous 
experiments  upon  animals  towards  the  close  of  the  last  century  convinced 
him  that  this  ligature  is  not  dangerous,  and  is  always  successful.  To  apply 
it,  it  is  best  to  make  a  vertical  incision  about  an  inch  long  over  the  anterior 
margin  of  the  masseter  muscle,  immediately  below  the  zygomatic  arch,  and 


406  NEW   ELEMENTS   OF' 

divide  successively  the  skin,  the  adipose  layer,  and  then  a  fibro-cellular  ex- 
pansion which  spreads  over  the  buccinator  muscle.  The  duct  being  exposed, 
is  to  be  isolated  from  the  other  tissues,  particularly  the  branch  of  the  facial 
nerve  which  runs  along  its  superior  edge.  Nothing  then  is  easier  than  to  pass 
a  thread  around  it  and  obliterate  it.  Doubtless,  if  the  sacrifice  of  the  func- 
tions of  the  parotid  gland  has  been  previously  determined,  the  advice  of  Viborg 
ought  to  be  followed  to  the  exclusion  of  that  of  Desault  and  of  Flajani ;  but 
compression,  having  the  advantage  of  requiring  no  incision,  will  nevertheless 
be  adopted  in  preference  by  timid  and  pusillanimous  patients ;  whence  it  fol- 
lows that  these  two  modes  will  have  in  practice  each  its  particular  appli- 
cation. 

4.  TTie  Twisted  Suture,  as  in  hare -lip,  when,  the  anterior  portion  of  the 
canal  remains  free,  is  sufficient  in  many  cases,  according  to  Flajani,  Percy, 
Zang,  &c.,  and  most  frequently  renders  all  other  means  unnecessary,  if 
applied  in  good  time. 

5.  To  Re-establish  the  Natural  Passage. — Morand  first,  and  after  him  Louis, 
are  the  two  authors  to  whom  is  due  the  idea  of  dilating  the  duct  of  Steno  to 
cure  fistula  of  that  part.  Placed  in  front  of  the  patient  the  surgeon  takes  the 
labial  angle  between  the  thumb,  introduced  within  the  mouth,  and  the  first  two 
fingers  of  the  left  hand  upon  the  right  cheek,  but  with  the  right,  if  the  fistula 
is  on  the  left  side;  stretches  and  turns  it  outwards;  then  introduces  with  the 
other  hand  the  head  of  a  fine  stylet  armed  with  a  thread,  into  the  natural 
orifice  of  the  parotid  duct ;  withdraws  it  through  the  fistulous  opening,  where 
he  leaves  the  little  seton,  the  two  extremities  of  which  he  unites  by  a  knot,  and 
which  is  made  use  of  the  next  day  to  draw  a  cord  of  silk  into  the  mouth  from 
the  exterior  to  the  interior;  he  renews  this  seton  every  day,  bringing  it  out  by 
the  wound,  and  increases  its  size  every  time  by  the  addition  of  a  thread.  When 
it  is  too  difficult  to  penetrate  by  the  mouth,  Louis  introduces  the  stylet 
through  the  sore;  it  should  indeed  be  quite  indifferent  whether  it  be  introduced. 
by  one  way  or  the  other.  In  this  last  case,  however,  the  thumb  should  take 
the  place  of  the  fingers  in  order  to  straighten  the  canal  and  to  incline  its  orifice 
forwards  when  the  stylet  is  about  to  come  through ;  not  because  it  makes  a  bend 
in  passing  through  the  buccinator,  as  is  generally  admitted  from  the  observation 
of  Louis,  but  because  it  enters  the  mucous  membrane  at  an  acute  angle,  which 
closes  it  in  a  great  measure,  and  seems  to  throw  its  opening  a  line  back- 
wards. 

When  the  saliva  passes  freely  into  the  mouth  and  the  ulcer  is  contracted  to  the 
size  of  the  seton,  it  is  to  be  removed,  or,  what  is  better,  cut  off  on  a  level  with 
the  integuments,  and  drawn  forwards  about  a  line  by  its  buccal  extremity  so  as 
not  to  be  wholly  withdrawn  until  the  fistula  is  entirely  closed  by  means  of 
repeated  cauterizations  and  desiccative  applications.  If  it  were  always  easy 
to  find  the  anterior  termination  of  the  divided  canal ;  if  this  canal  were  not 
generally  long  obliterated  when  the  surgeon  is  called  in ;  if,  lastly,  it  were 
very  important  to  preserve  it,  the  process  of  Louis,  exactly  traced  out  from 
the  idea  of  Mejean  in  the  treatment  of  lachrymal  fistula,  would  certainly 
have  obtained  general  assent ;  but  the  fact  is  otherwise,  and  the  following  mode 
is  generally  adopted  by  operators  at  the  present  day. 

6.  Establishment  of  a  New  Passage. — Deroy,  who,  as  it  is  said  by  Saviard, 
seem^  to  have  devised  this  method,  perforated  the  cheek  with  a  hot  iro^i^ 


OPERATIVE  SURGERY.  407 

thus  removing  a  portion  of  matter  and  curing  his  patient.  Shortly  after  Chesel- 
den  gave  the  same  advice.  Duphenix  performed  it  in  a  different  manner.  He 
made  use  of  a  long  narrow  bistoury,  inserting  it  from  above  downwards  and 
from  before  backwards,  turning  it  several  times  on  its  axis  to  make  his  open- 
ing of  a  round  form;  he  then  introduced  in  its  place  a  canula  shaped  like  the 
point  of  a  pen,  designed  to  conduct  the  saliva  into  the  mouth,  the  external 
extremity  of  which,  concealed  within  the  cheek,  was  to  correspond  with  the 
parotid  opening  of  the  fistula.  The  edges  of  the  ulcer  were  then  pared,  and 
in  conclusion  Duphenix  had  immediate  recourse  to  the  twisted  suture.  The 
canula  left  to  itself  came  away  on  the  sixteenth  day,  and  the  cure  was  com- 
pleted. According  to  Monro  a  shoemaker's  awl  was  advantageously  substi- 
tuted for  the  cautery  of  Deroy  and  the  bistoury  of  Duphenix.  With  this 
instrument,  of  which  the  celebrated  Edinburgh  surgeon  seemed  to  be  very  fond, 
he  traversed  the  cheek  in  the  natural  direction  of  the  canal,  and  for  a  seton 
used  a  thread  passed  through  the  wound.  When  the  passage  had  become 
callous  he  withdrew  the  thread,  saw  the  saliva  flow  into  the  mouth,  and  then 
gave  his  attention  to  the  small  external  ulcer.  Platner,  a  great  partisan  of 
this  mode  of  operating,  recommends  the  patient  to  gargle  with  brandy  in 
order  to  hasten  the  induration  of  the  internal  orifice  of  the  new  duct,  and  at 
the  same  time  to  compress  the  exterior  of  the  wound,  or  to  touch  it  with 
nitrate  of  silver.  After  perforating  the  parts  /.  L,  Petit  advises  to  enlarge 
the  buccal  opening  by  introducing  within  it  every  day  a  small  piece  of  sponge, 
until  the  fistula  is  closed.  Tessort  saw  the  saliva  return  to  the  mouth, 
from  passing  a  simple  thread  through  the  cheek ;  the  use  of  adhesive  strips 
sufficed  for  the  ready  cure  of  the  ulcer.  Flajani  advises  to  pass  a  double  silk 
thread  through  the  fistula  by  means  of  a  needle,  and  in  the  rest  to  follow  the 
example  of  Monro.  In  a  patient  who  could  not  support  compression,  Desault 
employed  a  hydrocele  trocar  to  pass  the  thread  through  the  cheek ;  to  the  internal 
extremity  of  this  thread  was  tied  a  seton,  which  he  drew  from  the  mouth  to 
the  bottom  of  the  fistula,  yet  in  sucii  a  way  as  not  to  prevent  cicatrization. 
The  seton  was  withdrawn,  and  replaced  daily  by  one  a  little  larger,  and  dis- 
continued several  days  before  the  thread  which  held  it,  and  when  the  opening 
had  become  almost  completely  closed.  Like  Desault,  Bilguer  also  had 
recourse  to  the  trocar;  but  instead  of  the  seton  he  left  a  leaden  canula  within 
the  internal  half  of  the  wound,  whicli  he  closed  over  it.  Richter  carried  into 
the  mouth  a  piece  of  cork  to  support  and  receive  the  point  of  the  trocar ;  and 
used  a  seton  of  thread,  the  size  of  which  he  gradually  increased.  He  with- 
drew it  when  the  new  canal  was  become  sufficiently  firm,  and  cauterized  the 
opening  on  the  exterior,  or  scarified  it  and  brought  its  edges  together.  In 
more  obstinate  cases  he  introduced  by  the  mouth  into  the  artificial  duct,  and 
there  left  to  remain,  a  canula  of  gold  or  silver,  furnished  with  a  button  to 
prevent  its  slipping  away.  More  recently,  in  1824,  M,  .^^^i,  intending  to 
improve  the  process  called  Beclard's,  has  rather  modified  that  of  Desault. 
The  canula  of  a  small  trocar  served  him  to  conduct  through  the  cheek  a  tent 
of  lead,  pierced  laterally  with  several  holes,  supported  by  a  thread  from 
without  which  kept  it  within  the  wound,  and  divided  to  the  extent  of  about 
a  line  from  its  internal  extremity  into  three  branches,  which  being  bent 
over  in  the  mouth  prevented  its  being  drawn  out  bj  the  thread.  When  the 
fistula  is  sufficiently  reduced,  M.  Atti  touches  it  with  lapis  infernalis  after 


408  NFW    ELEMENTS   OF 

bringing  away  tne  tnread,  and  attempts  to  close  it  entirely.  The  tent  of 
lead  left  Within  the  cheek  escaping  after  some  time  into  the  mouth,  leaves 
behind  a  new  canal  which  perfectly  supplies  the  place  of  the  original.  The 
successes  which  the  author  adduces  in  support  of  his  ideas  confirm  their 
correctness,  and  his  process  is  without  dispute  at  the  same  time  one  of  the 
most  simple,  the  most  ingenious,  and  the  most  certain  that  can  be  imagined* 
It  is  assuredly  preferable,  for  example,  to  that  of  Mr,  Charles  Bell,  who,  like 
Flajani,  passes  a  needle  through  the  cheek  to  carry  first  a  thread  and  then  a 
seton  into  the  fistula,  and  when  the  internal  opening  is  callous,  attaches  a  hair 
or  very  fine  thread  to  the  external  extremity  of  this  thread,  and  then  treats  it 
like  Desault  or  Bilguer. 

7.  In  the  hope  of  rendering  the  operation  more  prompt,  and  union  of  the 

ulcer  more  immediate,  surgeons  for  these  thirty  years  have  directed  their 

views  to  another  course.    Rejecting  all  species  of  foreign  bodies,  M*  Lang- 

enbeck  proposed  to  dissect  and  insulate  the  posterior  end  of  the  duct  of  Steno  ; 

to  make  at  the  bottom  of  the  fistula  an  opening,  which  would  admit  of  its  being 

conducted  into  the  mouth,  and  to  fix  it  in  its  new  relations,  immediately  to 

unite  the  edges   of  the  opening.      But  this  professor  has  not  as  yet,  to  my 

knowledge,  found  imitators,  and  ought  not  in  future.     M,  Latta  says  that  the 

best  mode  of  curing  salivary  fistulas  consists  in  passing  a  string  of  catgut 

through  the  cheek ;  then  to  try  to  engage  its  external  extremity  in  the  parotid 

duct,  leaving  the  other  within  the  mouth,  and  close  the  wound  by  the  suture  or 

by  plasters ;  as  if  it  were  always  possible  to  find  the  orifice  of  the  Stenonian 

duct  at  the  bottom  of  an  ulcer !  Zang,  however  extols  this  mode  of  proceeding 

when  the  fistula  is  very  large  and  the  anterior  portion  of  the  canal  obstructed, 

but  he  advises  the  use  of  the  canula  of  the  trocar  for  introducing  the  catgut; 

that  this  cord  be  sharpened  to  a  point  at  the  extremity  which  is  to  penetrate 

the  duct  towards  the  gland,  and  that  it  should  not  entirely  fill  the  artificial 

canal,  but  permit  the  saliva  to  flow  along  its  side.     Placing  the  practice  of 

Latta  and  Zang  upon  its  true  ground,  it  is  easily  perceived  that  it  differs  in 

reality  from  that  of  Desault  and  Charles  Bell,  only  in  their  dispensing  with 

retaining  their  tent  from  without  by  means  of  a  foreign  body.     This  allows 

them  to  close  the  fistula  at  once,  and  that  whether  they  have  succeeded  or  not 

in  inserting  the  end  of  the  cord  into  the  natural  duct  of  the  gland.     It  is  then 

possible  to  effect  a  cure  in  this  manner,  as  by  most  of  the  processes  heretofore 

described ;  but  it  has  the  inconvenience  of  not  holding  the  seton  firmly  enough 

within  the  substance  of  the  cheek,  and  of  permitting  it  to  escape  too  soon.    It 

is  an  objection  which  might  be  equally  applied  to  Percy,  who  says  he  has 

frequently  succeeded  by  using  a  leaden  wire  instead  of  the  catgut  employed 

by  the  Germans.    To  obviate  this  objection  M,  de  Guise  took  the  following 

method  with  a  young  person,  whose  fistula,  already  chronic,  had  resisted 

various  methods.    A  hydrocele  trocar  carried  through  the  sore  from  without 

inwards,  and  from  before  backwards,  allowed  him  to  carry  through  its  canula 

a  leaden  wire  into  the  mouth.    By  a  second  puncture  in  the  course  of  the 

natural  canal,  that  is,  from  behind  forwards  and  always  from  without  inwards, 

he  was  enabled  to  carry  the  other  extremity  of  the  wire  into  the  buccal  cavity, 

to  bend  the  two  portions  on  the  internal  surface  of  the  cheek,  and  to  unite  the 

external  opening  by  the  twisted  suture.    After  several  days,  agglutination 

seemed  complete.    The  coil  of  lead,  whose  convexity  corresponded  with  the 


OPERATIVE    SCROERY*  409. 

fistula,  and  which  embraced  in  its  concavity  the  internal  cushion  of  the  cheek, 
was  carefulW  withdrawn,  and  the  cure  was  no  longer  doubtful.  Three  observ- 
ations, recorded  in  the  name  ofBeclardinthe  Archives,  prove  that  this  surgeon 
has  often  imitated  M.  de  Guise  with  success.  Instead  of  leaving  the  two 
extremities  of  the  leaden  wire  loose  in  the  mouth,  he  united  and  twisted  them 
together  for  the  purpose  of  insensibly  cutting  through  the  interposed  tissues, 
as  in  fistula  in  ano.  Moreover,  in  making  the  second  puncture  he  carried 
the  trocar  through  the  mouth  in  order  that  the  beak  of  the  canula  might  not 
prevent  its  being  withdrawn  the  same  way  after  having  placed  the  second  end 
of  the  tent,  which  is  not  possible  when  it  is  directed  from  the  exterior  to  the 
interior,  as  at  first.  Finding  that  it  wks  not  as  easy  to  carry  the  trocar  through 
the  mouth  as  through  the  sore,  and  desiring  to  remedy  the  inconvenience  com- 
plained of  by  Beclard,  M.  Grosserio  proposed  a  trocar  fitted  with  a  canula 
deprived  of  its  shoulder.  With  this  modification  it  is  quite  as  easily  with- 
drawn through  the  mouth  in  the  second  step  of  tlie  operation  as  through  the 
wound  in  the  first.  In  fine,  M,  Miraulty  who  has  since  made  the  same  propo- 
sition, thinks  that  a  seton  of  thread  will  be  better  than  a  wire  of  lead,  and  that 
with  the  assistance  of  a  serre-noeud  modelled  on  that  of  Desault  the  end  would 
be  more  easily  attained  than  by  simple  torsion.  Acting  on  the  idea  of  M.  Mirault, 
M.  Eoux  used  a  seton  of  silk  with  full  success.  Lastly,  M,  Vernhes  has 
been  equally  fortunate  with  a  gold  wire  passed  from  above  downwards,  and  not 
across  as  by  M.  de  Guise,  and  which  he  used  like  Beclard,  to  cut  through  the 
interposed  substance  by  gradually  twisting  it  upon  itself.  Perhaps  also  we 
might  confine  ourselves  to  puncturing  in  some  way  the  parotid  duct  posteriorly, 
so  as  to  establish  an  internal  fistula  in  the  salivary  passage  and  be  enabled 
to  close  the  one  without.  But  this  process,which  I  proposed  in  1 823,  has  not  as  yet 
been  put  to  the  test.  Like  that  of  M.  de  Guise  and  all  its  gradations,  it  would 
only  be  applicable  in  cases  where  the  wound  of  the  canal  is  not  too  near  the 
masseter  muscle.  To  determine  the  relative  value  of  so  many  different  pro- 
cesses, it  would  be  necessary  to  represent  every  shade  of  difference  that  may 
be  exhibited  in  salivary  fistulae.  In  this  point  of  view  there  are  few  which 
have  not  their  advantageous  side.  However,  the  seton  after  the  manner  of 
Desault  or  Charles  Bell,  the  tent  of  lead  of  M.  Atti,  that  of  Percy,  of  Latta 
or  Zang,  are  best  in  every  respect,  and  ought  to  be  preferred.  To  follow  M.  de 
Guise  or  Beclard  with  the  modification  proposed  by  M.  Grosserio,  it  is  required 
that  the  fistula  be  at  some  distance  from  the  masseter  muscle;  in  which 
case  it  is  the  most  certain  method,  and  undeniably  superior  to  all  others. 

C.  Fistula  of  the  Submaxillary  Gland.- — If  it  happen,  of  which  examples 
have  been  deduced,  that  a  sore  or  an  ulcer  of  the  subhyoid  region  should 
extend  to  the  submaxillary  gland  and  remain  fistulous,  to  effect  its  cure  all 
the  means  would  have  to  be  tried  which  have  passed  in  review  on  the  occa- 
sion of  fistulas  of  the  parotid  gland.  If  nothing  can  dry  up  the  source  of 
such  an  evil ;  if  especially  the  secretory  organ  itself  be  altered  to  a  great 
degree,  and  threatened  with  an  unfortunate  degeneration,  extirpation,  which 
Pouteau  was  bold  enough  to  conceive  for  the  parotid,  would  here  be  a  laat 
resource,  which  should  not  be  neglected.  M.  Amussat  has  performed  it 
with  entire  satisfaction.  The  process  to  be  followed  in  such  a  case  will  be 
discussed  hereafter. 

'  52      '  ■  ■  .  . 


410^  NEW   ELEMENTS   OF 


§  2.  JRanula  or  Frog^s -tongue. 


History. — Ranula  is  a  disease  of  little  importance,  and  generally,  accord- 
ing to  Boyer,  not  dangerous.  It  has  more  than  once,  however,  been  seen  to 
endanger  the  life  of  the  patient,  and  in  every  case  is  sufficiently  troublesome 
to  create  the  desire  of  getting  rid  of  it.  De  Hilden  records  one  which  filled 
I.  the  whole  mouth;  Marchetti  another,  which  compressed  the  carotid  arteries 
and  the  trachea.  Alix  is  said  to  have  operated  on  one,  which  was  on  the 
point  of  suffocating  a  child ;  and  Taillardaut  on  another,  so  voluminous  as  to 
prevent  the  patient  from  eating.  Burns  relates,  that  a  man  who  waited  in 
the  study  of  Cline  had  his  respiration  so  embarrassed  by  the  presence  of  a 
ranula,  that  he  dropped  down  insensible  after  having  experienced  violent 
convulsions.  Although  the  ancients  understood  but  imperfectly  the  nature 
of  this  disease ;  though  some  made  it  an  encysted  tumor,  with  Celsus ;  though 
others,  with  Aetius,  considered  it  as  a  varicose  dilatation  of  the  sublingual 
veins,  or  with  Abul-Kasem  as  cancer;  with  Paracelsus,  as  an  aposteme  of  the 
vessels  of  the  tongue ;  or  as  an  ordinary  abscess  with  Aranzi;  they  neverthe- 
less attempted  its  cure  by  almost  all  the  means  employed  since  Louis  endea- 
vored to  prove  that  it  is  nothing  more  than  a  tumor  caused  by  an  accumulation 
of  saliva,  either  in  the  maxillary  gland  itself,  converted  into  a  cyst,  or  in  its 
excretory  duct,  enormously  dilated.  Instead  of  pure  and  limped  saliva;  of 
inspissated  saliva,  of  mucus,  of  purulent  matter ;  or  of  a  viscous  substance  more 
or  less  consistent,  the  morbid  pouch  is  sometimes  filled  witlf  gravel,  sand,  or 
even  true  calculi.  In  a  case  reported  by  Tulpius,  it  was  formed  by  a  con- 
cretion so  hard  as  to  require  the  employment  of  actual  cautery  to  destroy  it. 
Schultz,  E.  Koenig,  and  V.  Rieddlin  cite  cases  of  the  same  kind,  which  have 
also  been  met  with  by  J.L.  Petit,  Freeman,  Sabatier,  Taillardaut,  Loder,  and 
M.  Boyer.  In  all  these  observations  the  indication  was  precise.  A  free 
incision  of  the  tumor  permitted  the  extraction  of  the  foreign  substances,  and 
the  cure  was  speedily  effected. 

Indication. — Ranula,  properly  speaking,  requires  other  attentions.  Expe- 
rience proves  that  evacuation  of  the  fluid  is  not  sufficient  to  prevent  its 
return.  Incision,  caustics,  tents,  dilatation,  excision,  extirpation,  canulae,  the 
seton,  &c.,  have  each  in  turn  had  its  partisans  on  this  point. 

1.  Incision,  which  first  presents  itself,  at  once  empties  the  tumor  and  seems 
to  have  cured  the  disease.  Besides,  nature  would  seem  to  have  suggested 
the  first  idea  of  this,  since  the  ranula  frequently  opens  spontaneously.  Hip- 
pocrates recommended  it,  and  performed  it  with  a  lancet.  Celsus  and  Aetius 
mention  it,  but  do  not  seem  to  place  much  confidence  in  it;  nor  did  Rhazes, 
who  was  apprehensive  for  the  vessels  which  the  bistoury  might  divide  at  the 
same  time.  Although  somewhat  bolder,  Abul-Kasem  did  not  venture  to  have 
recourse  to  it,  except  in  sublingual  tumors  of  a  light  color  and  fluctuating, 
fearful  that  by  incising  others  there  would  be  danger  of  their  passing  into  a 
cancerous  condition ;  that  is  to  say,  Abul-Kasem  had  been  led  unwittingly  to 
distinguish  true  ranula  from  the  tumors  with  which  in  his  time  it  was  con- 
founded. Instead  of  plunging  the  instrument  into  the  cyst  itself,  Paracelsus 
merely  opened  the  vessels  running  into  it,  and  consequently  can  scarcely  be 
considered  as  one  of  the  partisans  of  incision  of  the  ranula.  When  fluctua- 
tion was  perceived,  Aranzi,  who  did  not  distinguish  it  from  abscess,  advise* 


OPERATIVE    SURGERY.  411- 

it  to  be  opened  with  the  lancet,  and  P.  Forrest  asserts  that  it  will  not  return, 
if,  after  opening  it,  the  surgeon  takes  care  to  press  it  and  evacuate  all  the 
matter.  According  to  Bartholin,  Six  waited  until  inflammation  had  ceased  in 
the  tumor,  and  then  pierced  it  through  and  through  to  evacuate  its  contents. 
Notwithstanding  the  reasons  of  V.  D.  Wiell  and  daily  experience,  Jourdain, 
about  the  middle  of  the  last  century,  still  maintained  that  a  large  incision 
with  the  lancet  very  frequently  cured  ranula,  and  that  its  treatment  may  be 
confined  to  this.  There  are,  indeed,  some  subjects  who  are  thus  finally  rid 
of  their  disease,  but  every  one  at  the  present  day  agrees  that  it  is  but  a  pal- 
liative remedy,  and  that  generally  the  salivary  cyst  is  sure  to  be  refilled. 

2.  Catheterics. — Injections. — Tents. — To  preserve  to  the  operation  a  part 
of  its  ancient  simplicity ;  to  prevent  the  wound  from  closing  too  rapidly ;  to 
obtain,  in  fine,  a  cure  which  incision  alone  was  far  from  always  obtaining, 
Paracelsus  kept  detersive  substances  within  the  wound ;  Purmann  introduced 
styptics  into  it,  and  was  imitated  with  success  by  V.  D.  Wiell ;  Camper 
touched  it  with  lapis  infernalis,  and  Acrel  left  in  it  a  dossil  of  lint  steeped  in 
spirit  of  salt;  Callisen  advised  to  place  in  it  lint  alone,  or  to  cauterize  its 
cavity  with  a  mineral  acid ;  by  which  means  he  said  the  cyst  would  become 
detached  and  might  be  brought  away.  A  surgeon  of  Saltzburg,  quoted  by 
Sprengel,  found  it  more  convenient  to  make  injections  of  camphorated  spirits 
or  oil  of  turpentine,  and  cured  his  patient.  It  was  the  same  in  the  case  men- 
tioned by  M.  Haime,  of  Tours,  which  he  also  cured  by  means  of  injections, 
thereby  causing  adhesion  of  the  parietes  of  the  cyst.  Leclerc  was  no  less 
fortunate  with  the  nitrate  of  mercury,  and  the  observation  of  Sabatier  proves 
that  a  tent  of  charpie  renewed  or  cleansed  every  day  sufficed,  after  incision 
of  the  ranula,  to  render  the  wound  fistulous  and  the  cure  radical.  Yet  as  it  is 
not  rare  for  the  disease  to  resist  this  combination  of  means,  it  has  been  devised 
to  destroy  a  part  of  the  sac  which  constitutes  it. 

3.  CaiUerization.-^-Ca.us\ics  were  employed  from  the  time  of  Aetius. 
Dionis  preferred  a  mixture  of  sulphuric  acid  and  honey ;  but  the  hot  iron  has 
found  a  greater  number  of  partisans  than  escharotics,  properly  so  called. 
These  latter  are  indeed  more  difficult  of  management,  more  uncertain  in 
their  action,  and  almost  always  dangerous  when  carried  into  a  part  so  delicate 
as  the  mouth.  Pare,  who  had  experienced  their  disadvantages,  conceived  the 
design  of  plunging  into  the  tumor  a  kind  of  trocar,  at  a  white  heat,  through 
a  metallic  plate  intended  to  protect  the  adjoining  parts.  In  this  way  he  pro- 
duced a  loss  of  substance,  the  wound  became  fistulous,  and  the  ranula  never 
returned.  Aquapendente  carried  his  cautery  through  a  barred  canula.  Loui's 
advises  much  the  same  thing ;  that  is,  he  prefers  the  actual  cautery  to  a  cut- 
ting instrument.  He  merely  remarks,  that  by  making  the  orifice  in  front  we 
expose  the  saliva  to  spout  out  and  escape  involuntarily  from  the  mouth. 
Nevertheless,  cauterization  is  rather  rarely  employed  in  our  day,  as  much 
perhaps  on  account  of  the  fright  it  gives  the  patient  as  of  its  not  being  very- 
infallible.  M.  Larrey,  who  advises  that  the  red  hot  iron  should  traverse  the 
tumor  through  its  whole  extent,  is  almost  the  only  one  who  continues  to  accord 
it  the  preference. 

4.  Excision. — In  introducing  the  process  of  La  Cerlata,  who  held  the 
ranula  with  a  hook  and  excised  it  with  a  razor ;  or  that  of  Aquapendente,  who 
fieized  it  with  forceps  and  cut  it  off  with  scissors,  or  passed  around  it  a  ligature  > 


412  NEW   ELEMENTS   OF 

Tulpius,  J.  L.  Petit,  Desault,  and  Richter  have  labored  to  show  that  after  the 
removal  of  a  sufficiently  large  flap  from  the  cyst,  the  tumor  is  seldom 
reproduced.  The  fact  is,  that  Desault,  in  his  practice  at  the  Hotel -Dieu,  has 
generally  succeeded  in  this  manner,  which  M.  Coley  has  so  much  praised,  and 
of  which  M.  Boyer,  who  followed  the  same  plan,  has  the  highest  opinion.  It 
is  performed  in  different  ways.  The  most  simple  and  most  certain  is  the 
following:  the  jaws  of  the  patient  being  separated  as  widely  as  possible,  the 
surgeon,  armed  with  a  straight  bistoury,  commences  by  making  a  crescentic 
incision  with  its  convexity  external  through  nearly  all  the  gingival  surface  of 
the  tumor ;  he  then  seizes  with  good  dissecting  forceps  the  flap  thus  marked 
out  and  detaches  it  with  the  scissors,  giving  it  the  form  of  an  ellipse.  Gene- 
rally bo  vessel  of  importance  is  opened.  It  is  seldom  that  more  than  a  few 
drops  of  blood  flow,  or  that  the  patient  feels  much  pain.  Dressings  are 
unnecessary,  and  the  wound,  which  becomes  smaller  and  smaller  every  day, 
but  usually  without  closing  entirely,  prevents  the  danger  of  relapse. 

5.  Extirpation. — Loder  and  Sabatier  have,  however,  seen  the  disease  resist 
this  treatment,  and  many  authors  have  also  maintained  that  the  certain 
mode  is  to  extirpate  the  ranula,  or  destroy  it  entirely  with  caustics.  A  rather 
obscure  passage  in  his  works  leads  to  the  opinion  that  Celsus  himself  advised 
this  last  resource.  Treating  of  sublingual  tumors  he  says,  when  they  do  not 
yield  to  puncturing  we  should  incise  the  skin  that  covers  them  in  order 
to  extract  them,  taking  care  not  to  wound  the  vessels,  while  an  assistant  sepa- 
rates the  lips  of  the  wound.  Mercuriali,  the  first  author  who  distinctly 
prescribes  it,  raises  the  tumor  with  a  hook,  cuts  it  at  its  base  in  the  mouth, 
and  says  if  the  whole  of  the  cyst  is  not  destroyed  the  disease  will  not  fail  to 
be  reproduced.  Diemerbroeck  commenced  with  a  crucial  incision,  and  extir- 
pated it  entire.  Without  going  so  far,  Alix  cut  into  it  freely,  but  lengthwise, 
and  brought  away  with  the  scissors  as  much  of  the  cyst  as  he  could.  In  a  very 
serious  case,  Marchetti,  who  had  introduced  a  seton  into  the  mouth  penetrat- 
ing from  the  supra-hyoid  region,  was  notwithstanding  obliged  to  extirpate  all 
he  could  of  the  tumor,  and  destroy  what  remained  with  a  hot  iron.  It  seems 
evident  however  that  complete  extirpation  is  seldom  indispensable,  at  least 
when  the  disease  is  not  threatened  with  fearful  degeneracy  or  transformed  into 
a  solid  tumor.  Otherwise  it  is  quite  sufficient  to  excise  the  portion  pro- 
jecting into  the  mouth;  the  more  so,  since  by  then  touching  the  bottom 
of  the  wound  plentifully  with  nitrate  of  silver,  sloughing  will  be  readily 
produced. 

6.  j9i7a?a/ton.— Although  the  disease  consists  generally  in  the  course  of  the 
saliva  not  being  free;  although  Louis,  imitated  by  Leclerc,  succeeded  in 
opening  the  ducts  of  Wharton,  which  appeared  like  two  apthae  on  the  sides  of 
the  fraenum ;  though  he  was  able  to  dilate  them  by  placing  a  sound  within  them, 
and  the  patients  thus  treated  were  cured;  yet  it  must  be  acknowledged 
in  accordance  with  Richter,  that  dilatation  would  here  be  the  most  defective 
and  trifling  resource,  and  sometimes  even  altogether  impracticable.  Excision 
after  the  manner  of  M.  Boyer  has  great  and  indisputable  advantages  over  it, 
without  being  subject  to  the  same  uncertainty  and  the  same  difficulties. 

7.  Permanent  Canula. — This  has  not  prevented  some  modern  operators  to 
decide  for  incision,  which  they  have  thought  to  render  more  efficacious  by 
combining  it  with  the  use  of  a  canula  left  within  the  opening  of  the  cyst.    The 


OPERATIVE  SURGERY.  413 

idea  of  such  an  association  had  not,  I  believe,  been  published  before  Sabatier. 
Still  this  author  only  speaks  of  a  canula  left  in  the  wound  long  enough  to 
render  it  callous.  But  at  his  time  it  had  evidently  presented  itself  to  the 
minds  of  some  other  practitioners,  since  he  makes  menti(»n  of  a  patient  who 
had  worn  one  for  three  years,  and  whom  he  advised  to  continue  its  use.  It 
was  about  an  inch  long,  with  a  lenticular  button  at  one  of  its  extremities, 
which  prevented  it  from  penetrating  too  far,  and  did  not  sensibly  affect  the 
speech  or  mastication  of  the  person  who  used  it.  This  canula  M.  Dupuytren 
has  modified  in  an  ingenious  manner,  by  making  it  considerably  shorter,  and 
terminating  each  extremity  with  a  lenticular  plate.  After  opening  and 
emptying  the  cyst,  this  professor  engages  within  it  one  of  the  buttons  of  his 
instrument,  the  other  disk  of  which  remains  in  the  mouth.  The  tissues  which 
embrace  the  neck  of  the  insti'ument  in  a  short  time  contract  so  as  to  prevent 
its  derangement  in  any  way.  The  saliva  escapes  by  its  canal,  and  the  patient 
wears  it  as  long  as  it  is  deemed  necessary,  sometimes  even  during  life,  without 
any  real  inconvenience.  M.  Dupuytren  has  the  plates  of  his  instrument, 
which  should  be  of  gold,  silver,  or  platina,  convex  on  their  free  surface  only, 
and  concave  inwards,  so  that  the  food  may  not  find  its  way  between  it  and  the 
parietes  of  the  cyst.  Nothing,  it  is  true,  prevents  the  trial  of  this  method, 
which,  according  to  the  new  editors  of  Sabatier,  constantly  succeeds  at  the 
Hotel-Dieu.  But  I  do  not  see  that  it  has  in  reality  a  great  advantage  over 
simple  excision,  which  on  the  other  hand  is  rarely  followed  with  failure  in  the 
practice  of  M.  Boyer.  It  is  seen  from  this  view  of  the  subject  that  the  treatment 
of  ranula  is  wholly  founded  on  that  of  hydrocele,  as  M,  Haime  has  moreover 
remarked,  with  Purmann,  who  endeavored  to  produce  adhesive  inflammation 
of  the  salivary  cyst  in  the  way  that  adhesive  inflammation  is  caused  in  the 
tunica  vaginalis.  The  seton  itself  has  not  been  wanting  in  this  case,  and  it 
might  be  used  with  some  probability  of  success,  if  other  modes  were  not  a 
thousand  times  more  rational.  As  proved  by  the  practice  of  Dr.  Physick,  who 
has  long  employed  it,  and  the  observations  of  Mr.  Lloyd,  who  also  used  it  in 
London,  and  the  work  recently  published  by  M.  Langier,  this  resource  is  not 
without  a  certain  degree  of  efficacy. 

§  3.  Salivary  Tumors  foreign  to  the  Excretory  Canal. 

Tumors,  apparently  salivary,  are  sometimes  seen  elsewhere  than  at  the  sides 
of  the  tongue.  I  attended  a  patient  in  the  hospital  Saint  Antoine,  who  had 
one  for  a  long  time  between  the  lip  and  the  left  superior  alveolar  arch,  of  which 
he  rid  himself  every  month  by  opening  it  with  a  bistoury  or  lancet.  M.  Graefe 
says  he  has  often  observed  it  in  the  substance  of  the  lips.  Wilmer  mentions 
one  which  was  located  in  the  inferior  maxilla ;  and  M.  Dupuytren  has  often 
met  with  them  in  the  substance  of  the  bone  itself.  The  one  treated  by  M. 
Latour  occupied  a  great  portion  of  the  cheek  ;  and  M.  Ricord  has  published, 
under  the  title  of  "  Hydatid  of  the  Canine  Fossa,"  a  case  which  probably 
belongs  to  the  same  species  of  lesion.  All  the  above  mentioned  modes  are 
applicable  to  them ;  but  when  a  radical  cure  is  to  be  obtained  recourse  must 
be  had  to  excision,  either  simple  or  aided  by  cauterization,  or  to  extirpation. 

A  wound  of  the  salivary  ducts  may  also  give  rise  to  tumors  of  this  nature, 
even  over  the  course  of  ^e  duct  of  Steno.   M.  Verhnes,  of  Tarn,  has  recently 


414  NEW  ELEMENTS    OP 

made  known  an  interesting  example  of  it :  in  consequence  of  traumatic  lesion 
there  arose  on  the  inside  of  the  cheek  a  small  oblong  tumor  filled  with  saliva, 
which  M.  Verhnes  succeeded  in  curing  bj  passing  through  it  a  small  trocar, 
carrying  with  it  a  double  gold  wire  which  he  employed  as  a  seton.  If  a 
similar  case  should  present  itself,  the  practice  of  this  surgeon  should  be 
imitated  ;  at  least,  if  we  are  unwilling  to  simply  trusc  to  the  process  of  Beclard 
in  salivary  fistulae,  or  rather  to  the  treatment  applicable  to  ranula. 

Art,  S.-^The  Tongue. 

§  1.  Tied  Tongue, 

The  species  of  fibro-mucous  fold  which  fixes  the  free  portion  of  the  tongue 
to  the  posterior  face  of  the  chin,  and  which  is  called  fraenum  when  its  dimen- 
sions are  well  proportioned,  takes  the  name  of  Jilet  when  it  is  too  long  antero- 
posteriorly,  or  too  short  perpendicularly.  The  child  in  this  case  finds  it  im- 
possible to  suck.  •  The  point  of  the  tongue  being  arrested  against  the  inferior 
limits  of  the  mouth,  cannot  be  brought  without  to  seize  the  nipple.  It  is, 
therefore,  a  disposition  which  might  have  serious  consequences  if  not  imme- 
diately remedied.  Yet  we  should  be  cautious  in  deciding  that  the  child  has 
a.  Jilet  when  it  does  not  suck,  or  when  it  is  slow  in  speaking.  Such  accidents, 
which  might  be  produced  by  a  thousand  causes,  do  not  depend  on  the  fraenum 
of  the  tongue,  if  the  finger  when  passed  into  the  mouth  can  be  seized  by  it, 
and  if  it  is  possible  for  its  point  to  arrive  at  the  lips ;  and  it  is  only  in  the 
contrary  case  that  the  division  of  the  filet  is  to  be  thought  of. 

History, — Nothing  indicates,  unless  it  be  an  expression  of  Cicero,  that  this 
trifling  operation  had  been  described  before  Celsus,  who  in  performing  it 
lifted  the  tongue  with  forceps,  and  recommended  caution  in  not  cutting  the 
vessels.  Instead  of  forceps,  Paulus  Egineta.and  Abul-Kasem  used  a  hook, 
the  more  certainly  to  avoid  hemorrhage.  Avicenna  traversed  the  base  with  a 
ligature,  and  thus  dispensed  with  a  cutting  instrument.  De  la  Cerlata,  who 
blamed  mid  wives  for  tearing  it  away  or  cutting  it  with  the  nail,  destroyed 
it  with  a  peculiar  instrument,  raising  the  tongue  with  two  fingers.  The 
pointed  scissors  of  Friederich  are  justly  rejected  by  F.  ab  Aquapendente, 
who  inveighed  against  the  evil  custom  of  matrons,  already  condemned  by  De 
la  Cerlata.  After  raising  the  tongue,  J.  Fabricius  seized  the  filet  between 
two  fingers,  and  divided  it  with  little  strokes  of  a  curved  bistoury,  and  says 
moreover  that  this  operation  is  rarely  indispensable.  De  Hilden  is  of  the 
same  opinion,  and  performed  it  with  a  cleft  instrument  which  served  at  tlie 
same  time  as  scissors  and  a  fork  to  support  the  tongue.  The  blunt  fork  and 
the  large  scissors  invented  later  by  Scultetus  and  Solingen,  are  useless.  The 
idea  of  dividing  the  filet  with  a  red  hot  bistoury,  as  performed  by  Lanfranc, 
would  at  the  present  day  be  ridiculous.  The  springed  instrument  of  J.  L. 
Petit,  praised  by  Platner,  appeared  unsuitable  to  Le  Dran,  who  maintains  that 
blunt  scissors  are  always  sufficient,  and  that  it  is  superfluous  to  tear  the 
wound  with  the  finger  to  enlarge  it  when  the  incision  has  been  made,  as  Dio- 
nis  did.  The  cleft  spatula  of  Richter  and  Callisen,  the  curved  and  blunt 
scissors  invented  by  G.  Schmitt,  are  not  in  use  amongst  us,  although  they 
may  yery  well  attain  the  end  proposed  by  their  aut^rs.    Always  ingrenious 


OPERATIVE    SURGERY.  415 

in  constructing  new  instruments,  M.  Colombat  has  just  proposed  one  which 
seems  to  me  entirely  useless,  as  well  as  the  excision  which  he  wishes  to  sub- 
stitute for  simple  incision. 

Operation. — The  method  of  Le  Dran  is  now  followed  ;  that  is,  the  child  be- 
ing placed  with  its  head  bent  backwards  against  the  nurse,  or  some  other  person 
who  will  not  be  intimidated  by  its  cries,  the  surgeon  raises  the  tongue  with 
one  or  two  fingers  of  the  left  hand,  while  with  the  other,  armed  with  blunt 
scissors,  he  rapidly  divides  its  frasnum.  But  as  the  volume  of  the  fingers 
often  hinders  the  rest  of  the  operation,  there  has  been  generally  adopted, 
since  J.  L.  Petit,  a  grooved  sound,  the  plate  of  which  being  split  supplies 
their  place,  and  at  the  same  time  protects  the  vessels.  When  the  filet  is 
well  engaged  in  the  bifurcation  of  this  plate,  the  operator  raises  its  body  a 
little  towards  the  forehead  of  the  child,  so  as  to  throw  the  tongue  backwards 
and  upwards  ;  he  then  introduces  his  scissors  beneath,  and  with  a  single  stroke 
cuts  the  membrane  thus  stretched,  taking  care  to  direct  the  point  of  the 
instrument  a  little  downwards,  to  be  more  sure  of  running  no  risk  of  touching 
the  raninal  arteries.  The  wound  requires  no  attention,  and  it  is  extremely 
rare  that  the  little  patient  suffers  from  it  for  more  than  a  few  hours.  The 
motions  of  the  organ  prevent  agglutination,  and  on  this  point  I  do  not  see  the 
necessity  of  touching  with  the  nitrate  of  silver,  as  advised  by  M.  Hervez,  of 
Chegoin.  Tetanus,  which  resulted  from  it  in  the  child  spoken  of  by  J. 
Fabricius,  who  had  been  operated  upon  by  a  quack,  has  never  been  observed 
since.  According  to  some  authors,  two  serious  accidents,  hemorrhage  and 
inversion  of  the  tongue  into  the  pharynx,  may  be  manifested  after  the  section 
of  the  filet.  The  first  happened  to  Roonhuysen  himself,  who  could  not 
arrest  the  bleeding  but  by  inserting  vitriol  into  the  bottom  of  the  wound. 
Maurain  ran  still  greater  risk  ;  he  had  to  resort  to  the  actual  cautery.  J.  L. 
Petit  cites  two  cases  in  which  the  operation  had  been  badly  performed,  the 
subjects  of  which  would  evidently  have  died  if  instant  relief  had  not  been 
afforded.  A  circumstance  which  aggravates  the  danger  in  this  case  is,  that 
instead  of  being  spit  out  the  blood  is  swallowed  as  it  flows,  and  if  not  watched 
the  child  may  sink  before  the  cause  is  discovered.  By  using  the  sound,  and 
the  precaution  to  cut  nearer  the  floor  of  the  mouth  than  the  tongue,  it  is  almost 
impossible  that  such  hemorrhage  should  take  place.  If  it  does,  however,  it 
may  be  arrested  by  applying  to  the  bleeding  point  the  head  of  a  stylet  heated 
to  whiteness;  or,  as  practised  by  J.  L.  Petit,  by  means  of  a  fork  of  wood  an 
inch  long  wrapped  with  linen,  resting  against  the  internal  face  of  the  maxil- 
lary symphysis  with  one  part  and  embracing  with  the  other  the  apex  of  the 
wound,  while  a  small  bandage  passed  across  within  the  mouth,  brought  back, 
then  crossed  below  the  jaw,  and  carried  up  over  the  ears  to  be  fastened  to  the 
child's  cap,  prevents  motion  of  the  tongue.  Two  small  blades  united  in  the 
middle  in  the  form  of  pincers,  with  which  the  bleeding  part  is  seized,  and 
which  is  made  to  act  by  pushing  a  wedge  between  the  two  portions  of  its 
other  exti'emity,  will  accomplish  the  same  end,  and  attain  it  with  even  still 
more  certainty.  The  natural  softness  of  the  tissues  and  the  retraction  of  the 
arteries,  will  in  general  render  the  ligature  recommended  by  Courtois  alto- 
gether inapplicable 

As  to  Inversion,  the  moderns  scarcely  admit  its  possibility.  J.  L.  Petit, 
who  witnessed  three  examples,  explains  it  by  saying  that  the  fraenum  being 


41 6  NEW    ELEMENTS    OF 

once  cut,  the  tongue  becomes  free  and  is  turned  back  and  directed  toward* 
the  throat  with  the  more  facility  ;  as  the  child,  which  until  then  could  not  take 
the  breast,  sucks  it  with  a  kind  of  voracity.  In  one  case,  this  practitioner  drew 
it  three  times  from  the  pharynx ;  but  at  the  fourth  the  patient  died  for  want  of 
relief.  J.  L.  Petit  has  seen  the  inversion  during  life,  and  verified  its  existence 
after  death  ;  it  is  a  fact  therefore  undeniable.  I  do  not  see,  besides,  why  it  is 
so  difficult  to  comprehend,  or  why  there  is  any  question  of  what  travellers 
relate  of  those  orientals  and  negroes,  who,  to  avoid  too  severe  chastisement, 
cause  their  own  death  by  swallowing  their  tongue.  It  may  be  prevented  by 
not  carrying  the  division  of  the  fraenum  too  deeply.  To  remedy  it,  we  must 
with  the  finger  bring  back  the  tongue  to  its  natural  situation,  and  cause  the 
child  continually  to  suck  while  there  is  danger,  and  when  it  does  not  suck, 
to  keep  the  tongue  down  with  the  bandage  just  mentioned  in  speaking  of 
hemorrhage. 

§  2.  Anchyloglossis. 

Adhesions  of  the  tongue  to  the  mouth  have  always  attracted  the  attention 
of  surgeons.  Whether  congenital  or  acquired;  the  result  of  simple  inflam- 
mation or  produced  by  more  extensive  lesions ;  whether  recent  or  of  long 
standing,  the  knife  is  the  only  means  of  overcoming  them.  Aetius  says,  the 
abnormal  membrane  or  cicatrix  is  to  be  seized  with  a  hook,  and  divided  with 
all  necessary  precautions.  Towards  the  middle  of  the  seventeenth  century, 
J.  Hellwig,  being  consulted  by  an  individual  who  could  not  articulate, 
destroyed  by  dissection  the  adhesions  of  his  tongue,  and  thus  restored  him 
to  speech.  In  our  days  the  practice  is  not  different ;  but  we  must  be  cautious 
not  to  be  deceived  by  a  disposition  sometimes  met  with  in  infants.  The  tongue 
is  then  merely  pasted  as  it  were  against  the  palatine  vault,  as  witnessed  by 
Louis,  or  to  the  floor  of  the  mouth ;  which  has  caused  more  than  one  gossip 
to  suppose  that  the  child  had  no  tongue.  The  finger,  the  handle  of  a  scalpel, 
or  a  spatula,  is  always  sufficient  to  destroy  this  simple  agglutination,  which 
perhaps  is  in  reality  the  commencement  of  a  true  anchyloglossis.  The  con- 
duct to  be  observed  with  adults  is  the  same,  if  we  are  called  before  the  adhe- 
sions, resulting  from  extended  inflammation,  have  acquired  any  considerable 
firmness. 

1.  If  there  are  but  a  few  small  filaments  on  the  sides  of  the  fraenum,  they 
are  divided  the  same  as  the  filet  with  scissors,  and  with  the  same  precautions. 
We  divide  in  the  same  manner  those  which  are  not  unfrequently  established 
between  the  cheeks  and  the  margin  of  the  tongue,  in  consequence  of  mercurial 
inflammation  of  those  parts ;  as  also  of  other  phlegmasiae  of  the  mouth, 
examples  of  which  have  been  communicated  to  the  Academy  by  Messrs. 
Duval,  CuUerier,  and  Bernard.  If  they  are  of  some  breadth,  they  should  be 
excised  instead  of  being  simply  divided.  After  having  been  detached  from 
the  buccal  wall  by  a  stroke  of  the  scissors,  they  are  again  taken  hold  of  near 
the  tongue,  and  removed  by  a  second  stroke  of  the  same  instrument.  They 
may  likewise  be  removed  by  seizing  each  in  its  turn  about  the  middle  with 
forceps,  while  the  edges  are  detached  with  scissors  or  the  bistoury. 

2.  When  these  adhesions  are  intimate,  or  as  they  are  termed,  cellular  and 
■^  not  membranous  nor  filamentous,  the  dissection  has  to  be  performed  with 


OPERATIVE  SURGERY.  417 

great  management  and  precaution.  The  surgeon,  placed  behind  and  at  the 
right  of  the  patient  (whose  head  is  bent  against  a  pillow,  the  arm  of  a  nurse, 
or  the  breast  of  an  assistant),  tries  to  separate  by  means  of  the  left  index 
finger,  a  spatula,  or  some  appropriate  instrument,  the  free  part  of  the  tongue 
from  the  point  of  the  mouth  to  which  it  is  attached ;  he  divides  gradually 
with  a  straight  bistoury,  chipping  as  it  were  all  the  lamellae  and  all  the  unna- 
tural ligaments  which  it  is  intended  to  destroy,  recollecting,  at  the  inferior 
region  especially,  to  incline  the  edge  of  the  knife  towards  the  wall  of  the 
mouth,  or  to  separate  it  as  much  as  the  state  of  the  parts  will  admit  from  the 
body  of  the  tongue  itself,  in  order  more  certainly  to  avoid  the  vessels;  to  have 
the  blood  sponged  as  it  flows  during  this  dissection ;  to  stop  from  time  to  time 
to  allow  the  patient  to  breathe  and  gargle,  and  if  there  be  hemorrliage  to 
cauterize  wdth  heated  iron ;  in  other  cases  he  is  to  prescribe  some  styptic  or 
astringent  wash ;  and  concludes  by  passing  his  finger  over  all  points  of  the 
wound  to  satisfy  himself  that  no  prejudicial  adhesion  exists.  Mild  gargles, 
frequent  and  extensive  motions  of  the  tongue,  carrying  the  end  of  the  finger 
between  the  divided  surfaces  to  prevent  readhesion,  are  all  that  remain  to  be 
advised  for  completing  the  cure,  which  is  generally  effected  from  the  fifth  to 
the  thirtieth  day,  but  which  requires  all  this  attention  to  be  certainly  accom- 
plished. 

^  §  3.  Excision. 

History, — Gangrene,  induration,  fungous  tumors,  schirrus,  and  cancerous 
ulcers,  are  the  principal  affections  which  may  require  extirpation  of  the  tongue 
in  whole  or  in  part.  This  is  an  operation  which  has  but  lately  entered  into 
practice.  From  the  idea  that  the  tongue  is  the  exclusive  organ  of  speech, 
although  J.  Lange  is  said  to  have  performed  it  several  times  on  account  of 
gangrene,  such  a  resource  was  only  thought  of  with  trembling  before  Louis 
showed  that  many  individuals  deprived  of  a  great  part  of  this  organ  have  con- 
tinued, nevertheless,  to  speak  and  appreciate  the  taste  of  substances.  The  la- 
borer spoken  of  by  Roland  of  Saumur,  who  had  lost  his  tongue  as  far  as  its  root 
in  consequence  of  gangrene,  spoke,  spit,  and  swallowed  without  difficulty, 
and  had  perception  of  tastes ;  the  girl,  observed  at  Lisbon  by  De  Jussieu ; 
Margaret  Cuting,  mentioned  in  the  Philosophical  Transactions ;  Marie  Gulard, 
quoted  by  Bonami  and  Louis ;  the  girl,  A.  M.  Federlin,  whose  story  was 
made  known  by  Auran;  the  young  man  w^hose  tongue  was  torn  out  by  the 
corsairs  because  he  would  not  become  a  mussulman,  and  whom  Tulpius 
affirms  that  he  saw;  and  another,  observed  by  Zacchius,  who  had  had  his 
tongue  cut  out  by  robbers,  were  in  the  same  case.  It  is  known,  besides,  that 
in  Germany,  Italy,  Spain,  &c.,  malefactors  were  for  a  long  time  punished  by 
cutting  out  the  tongue,  and  that  for  the  most  part  they  still  preserved  the 
faculty  of  speech.  Every  one,  in  fine,  is  acquainted  with  the  two  cases 
related  with  so  much  simplicity  by  A.  Pare ;  first,  of  a  mower  who  had  been 
dumb  for  three  years  from  having  lost  a  portion  of  his  tongue,  and  being 
tickled  by  one  of  his  comrades  while  holding  a  vessel  between  his  teeth,  made 
an  effort,  and  to  his  great  surprise  uttered  several  words ;  and  beginning  from 
this  adventure  learned  in  the  end  to  speak  distinctly  with  his  porringer  or  a 
little  cup  of  wood  :  second,  a  youth  whose  tongue  had  been  cut  out,  recovered 
53 


418  NEW   ELEMENTS    OF 

his  speech  by  making  use  of  the  instrument  invented  by  the  above  mentioned 
mower.  But  if  it  is  well  proved  that  the  loss  of  the  tongue  is  not  always 
followed  by  complete  loss  of  speech,  it  is  no  less  proved  that  its  amputation 
has  more  than  once  been  performed  without  very  evident  necessity.  It  is  dis- 
pensed with  at  the  present  day,  for  example,  and  Pimpernelle  is  not  imitated, 
although  the  organ  be  so  swelled  as  to  cause  it  to  protrude,  unless  there  is  also 
a  true  scirrhous  or  cancerous  degeneration. 

Manual. — The  operation  is  conducted  in  different  modes,  and  must  vary 
according  as  the  disease  occupies  one  portion  more  than  another.  Hooked 
forceps  and  curved  scissors  are  sufficient  for  the  excision  of  pedunculous 
tumors,  wiiicli  seldom  occur  except  on  the  dorsal  face  of  the  tongue.  The 
ligature  would  not  have  the  same  advantages;  and  to  prevent  any  doubt  of 
having  removed  the  whole,  it  would  be  well  to  sear  the  bottom,  of  the  wound 
with  a  hot  iron.  If  the  alteration  is  confined  to  the  tegumentary  layer, 
which,  it  may  be  remarked,  is  much  more  common  than  is  thought,  it  will  be 
requisite,  as  proposed  by  Lisfranc,  and  as  Walens,  in  imitation  of  Bartholin, 
seems  to  have  practised  long  since,  only  to  remove  the  degenerated  laminae, 
and  to  spare  with  prudence  the  fleshy  tissue  which  ordinarily  remains  sound . 
^^'hen  the  cancerous  ulcer  is  deeper,  and  situated  on  the  edges,  the  curved 
bistoury  is  no  longer  used  to  destroy  it,  as  by  the  surgeon  mentioned  by 
Ruysch.  The  point  of  the  tongue,  wrapped  with  a  dry  cloth,  is  drawn  out  by 
the  hand  of  an  assistant,  who  inclines  it  to  the  side  opposite  the  disease.  The 
operator,  armed  with  a  straight  bistoury,  commences  by  an  incision  of  several 
lines  on  the  inferior  face  and  along  the  whole  length  of  the  organ;  he  then 
makes  another  upon  the  dorsal  surface,  and  thus  includes  the  cancer  and  even 
a  certain  portion  of  the  sound  parts  ;  then  lifting  it  with  the  forceps  or  hook, 
promptly  completes  its  excision.  Actual  cautery,  without  being  absolutely 
required,  may  become  necessary  in  the  end,  as  in  the  preceding  case.  When 
the  disorganization  is  of  greater  depth ;  when  especially  it  extends  further 
backwards,  and  when  besides  it  appears  possible  to  save  one  half  of  the  tongue, 
we  may  be  allowed  to  tliink  of  the  ligature  which  M.  Mayor,  of  Lausanne, 
calls  the  ligature  en  masse.  It  will  be  more  secure  from  hemorrhage  than  the 
bistoury ;  and,  applied  in  a  certain  manner,  nothing  prevents  its  being  carried 
to  the  neighborhood  of  the  larynx.  The  process  of  this  surgeon  is  one  of  the 
most  easy.  The  organ  is  first  transpierced  from  beneath  upwards  and  from 
before  backwards,  at  its  most  remote  part  with  a  good  bistoury,  which  being 
drawn  forwards  divides  its  whole  length  into  two  equal  parts  without  touching 
the  neighboring  arteries.  The  operator  then  carries  a  noose  of  strong  cord 
of  threads  over  the  affected  division,  to  a  point  beyond  the  disease;  passes  its 
two  ends  separately  into  a  metallic  head  of  a  square  shape  and  pierced  with 
two  openings  slightly  convergent ;  then,  together,  through  four,  five,  six,  seven, 
eight,  or  nine  balls  of  the  same  nature  pierced  with  a  single  hole,  as  the  beads 
of  a  rosary,  and  finally  tlirough  a  canula  designed  to  support  and  push  forward 
these  beads,  and  which  itself  is  to  be  supported  by  a  tourniquet  or  little  axle, 
on  wliich  the  extremity  of  the  ligature  is  fastened.  Having  thus  embraced  the 
base  of  the  flap  which  is  to  be  destroyed,  he  turns  the  little  axis,  and  when  the 
constriction  is  carried  sufficiently  far,  fixes  the  free  portion  of  the  apparatus  to 
the  labial  commissure  either  by  means  of  a  thread  or  with  a  small  bandage. 
Daily,  and  even  several  times  during  the  day,  pressure  is  increased  in  the  same 


OPERATIVE    SURGERY.  419 

manner.  The  tissues  become  blackened  and  soon  mortify  and  fall  off,  or  mar 
be  excised  without  danger  on  the  third  or  fourth  day.  The  serre-noeud  of 
M.  Mayor,  a  real  improvement  of  the  instrument  deyised  bj  Messrs.  Bouchet 
and  Braun,  has  the  advantage  in  consequence  of  its  flexibility  of  moulding 
itself  without  difficulty  to  the  inequalities  of  the  tongue,  and  of  occasioning 
but  little  obstruction  in  the  interior  of  the  mouth,  and  of  allowing  a  constric- 
tion at  the  same  time  gentle,  firm  and  permanent.  When  it  cannot  be  had, 
the  serre-noeud  of  Desault,  or  that  of  Levret,  may  be  here  employed  as  well 
as  for  the  ligature  of  polypi  in  general.  If  the  whole  breadth  of  the  tongue  is 
to  be  removed  only  at  its  point,  or  even  near  its  base,  the  ligature  will  still  be 
applicable.  The  confirmation  of  this  is  to  be  found  in  the  observations  of  La 
Motte  and  Godard,  each  in  a  different  case.  Sir  Ev.  Home  and  Mirault  passed 
a  double  ligature  through  the  centre,  and  brought  its  two  portions  to  be  tied  on 
the  sides  of  the  organ,  which  was  thus  divided,  and  dropped  off  by  suppura- 
tion. But  whenever  the  tumor  does  not  extend  too  far  backwards,  and  a  little 
sound  tissue  is  found  on  its  edges,  excision  with  a  cutting  instrument  is  pre- 
ferable. Louis,  like  the  ancients,  after  having  seized  it  with  a  hooked  forceps, 
such  as  the  forceps  of  Museux,  performed  the  amputation  of  the  tongue  by 
cutting  it  fairly  and  simply  across  with  a  bistoury.  At  present  a  much  more 
rational  process  is  followed.  Having  seized  the  morbid  mass  with  a  strong 
hook  or  hooked  forceps,  the  surgeon  with  one  hand  draws  it  out  of  the  mouth, 
and  with  the  other  circumscribes  it,  and  removes  it  with  two  strokes  of  the 
scissors  from  the  sound  parts,  in  the  form  of  a  V,  the  point  of  which  looks 
backward  and  should  fall  upon  the  median  line;  he  immediately  approximates 
the  two  sides  of  the  wound  and  unites  it  by  three  stitches,  one  on  its  dorsal 
surface,  the  second  at  its  point,  and  the  third  on  its  inferior  surface.  Its  agglu- 
tination is  often  complete  by  the  second  day;  the  threads  may  be  brought 
away  on  the  third  or  fourth  day,  and  the  cure  is  generally  complete  about  the 
eighth  or  tenth:  such  at  least  are  the  observations  of  M.  Boyer,  M.  Langen- 
beck,  &.C.  By  this  mode  the  deformity  is  as  little  evident  as  possible,  and  the 
exact  coaptation  of  the  bleeding  surfaces  soon  arrests  tiie  hemorrhage  enough 
to  render  unnecessary  the  employment  of  any  other  haemostatic  means.  Trans- 
verse amputation  ought  therefore  to  be  reserved  for  cases  which  leave  no  chance 
for  the  formation  of  lateral  flaps.  Every  tumor,  whether  scirrhous  or  car- 
cinomatous, which  does  not  penetrate  too  deeply,  and  which  is  prominent  at 
the  periphery  of  the  tongue,  may  be  easily  destroyed  by  the  process  of  Faure 
or  of  Louis ;  that  is,  with  curved  scissors  or  the  actual  cautery.  Those  which 
penetrate  to  the  fleshy  tissue  and  are  situated  on  the  surface  or  one  of  the 
edges  without  going  too  far  backwards  or  invading  the  whole  breadth  or  thick- 
ness of  the  organ,  require  on  the  contrary  the  use  of  the  bistoury  by  the  pro- 
cess which  I  have  pointed  out,  and  which  approaches  a  little  the  method  of  P. 
le  Memnonite.  If  the  disease,  although  very  extensive  in  surface,  remain  super- 
ficial and  leave  the  tissues  sound  beneath  it,  we  must  follow  the  indication 
pointed  out  by  Walee,  imitate  LislVanc,  dissecting  and  removing  what  is  dis- 
eased, and  respecting  and  preservino;  what  is  not.  If  it  be  necessary  to  destroy 
an  entire  half  of  the  tongue  including  its  base,  the  ligature  of  M.  Mayor  is 
applicable,  and  in  my  opinion  to  be  preferred.  While,  if  it  become  necessary 
to  remove  the  whole,  the  process  of  Mr.  Home  has  the  advantage ;  as  well  as 


420  NEW   ELEMENTS    OF 

in  all  cases  m  which  excision,  after  the  manner  of  M.  Boyer,  is  not  sufficient 
to  remove  the  tumor  or  centi'al  change  of  structure. 

After  Treai7iunt. — It  is  extremely  rare  that  after  any  of  these  several  ope- 
rations there  is  need  of  dressing  or  apparatus.  But  in  the  contraiy  case  the 
pocket  of  Pibrac  would  be  useful.  It  is  a  little  purse  destined  to  lodge  the 
free  or  movable  portion  of  the  tongue,  and  may  be  lined  v.ith  lint  or  any 
other  piece  of  dressing.  The  two  branches  of  silver  which  sustain  its  base,  and 
support  each  a  riband  at  its  free  extremity,  are  bent  in  such  a  manner,  that  by 
drawing  upon  what  remains  without  the  other  portion  is  forced  to  enter  the 
mouth.  Supposing  a  perplexing  hemorrhage  to  supervene,  a  hemorrhage  which 
the  resources  pointed  out  above  shall  not  definitively  arrest,  i  ecourse  must  be 
had  to  the  ligature;  then  the  lingual  artery  is  to  be  sought  for  at  its  passage 
over  the  os  hyoides,  unless  it  be  thought  best  to  tie  the  carotid  itself.  It  would 
even  be  prudent  to  begin  with  this,  if  the  tongue  is  to  be  amputated  near  its 
root  with  a  cutting  instrument. 


Art.  4. — Isthmus  of  the  Fauces, 

§  1.  Excision  of  Part ,  or  the  Whole  of  the  Tonsils, 

History. — After  repeated  inflammations,  the  tonsils  often  remain  so  large  as 
to  impede  deglutition,  hearing,  and  even  respiration.  The  hardness  which  they 
at  the  same  time  acquire,  has  for  centuries  given  rise  to  the  opinion  that  they 
pass  to  a  schirrous  state.  But  since  the  time  of  Claudinus,  and  more  espe- 
cially of  B.  Bell,  the  falsity  of  this  opinion  is  generally  admitted  ;  although 
to  my  surprise  I  find  it  advanced  in  the  recent  work  of  Messrs.  Roche  and 
Sanson.  Every  surgeon  at  the  present  day,  knows  that  the  induration  of  the 
amygdalae  with  swelling  is  but  an  hypertrophy ;  and  tliat  it  seldom  or  never 
gives  place  to  scirrhus  or  cancer.  The  treatment  to  which  it  has  been  sub- 
mitted has  been  very  various.  Without  counting  scarification,  which  was 
recommended  by  Asclepiades  the  Bithynian,  Heister,  Maurain,  Celsus,  and 
some  moderns,  it  has  been  treated  by  cauterization,  ligature,  extirpation,  and 
excision. 

1.  Cauterization. — Mesue,  who  appears  to  have  been  the  first  who  dared  to 
apply  caustics  to  the  tonsils,  made  use  of  the  actual  cautery.  Brunus 
followed  the  same  practice,  at  least  when  he  intended  to  destroy  the  whole  of 
the  disease.  Mercatus,  who  comes  later,  adopted  a  golden  cautery  moderately 
heated,  which  he  carried  through  a  canula  to  the  tonsil  to  be  burned.  M.  A. 
Severin,  less  particular  than  Mercatus,  was  content  with  an  iron  instrument, 
and  used  it  the  same  as  Affisius  his  friend,  only  upon  tonsils  with  a  broad  base. 
After  saying  that  Ed.  Mol  cauterized  the  tonsils  very  successfully  by 
piercing  them  repeatedly  with  a  hot  iron,  Wiseman  still  admits  that  he 
prefers  the  use  of  escharotics,  which  Junker,  Heister,  and  Freind  ,advise 
under  different  forms.  The  lapis  infernalis,  employed  successfully  by  Mo- 
rand,  is  still  sometimes  used ;  but  it  is  not  useful,  nor  are  the  sulphates  of  iron, 
of  copper,  or  of  alumine,  except  in  cases  of  recent  or  inconsiderable  indura- 
tion.    Red  hot  iron,  which  Louis  appears  to  have  partially  adopted,  is  prefer- 


OPERATIVE  SURGERY*  421 

able  when  there  is  need  of  free  and  energetic  cauterization ;  but  is  evidently 
applicable  only  to  fungous  and  cancerous  tonsils,  except  in  cases  where  it  is 
feared  that  some  part  is  left  which  ought  to  be  removed,  that  the  disease  will 
be  renewed,  or  the  blood  escape  too  plentifully  after  excision.  But  as  these 
different  circumstances,  pointed  out  by  Percy  and  Boyer,  are  rare  exceptions, 
it  follows,  even  receiving  them  as  facts,  that  cauterization  should  scarcely 
ever  be  admitted. 

2.  Ligature. — Devised  to  avoid  hemorrhage  with  certainty  and  excite  less 
apprehension  in  the  patient,  and  employed  for  a  long  period  in  France,  the 
ligature  h^d  yet  been  clearly  prescribed  by  no  one  before  Guillemeau,  who  in 
applying  it  made  use  of  a  kind  of  serre-noeud  forceps,  very  ingeniously 
arranged.  F.  de  Hilden  is  tlie  second  author  who  recommends  it.  The 
canula,  supplied  with  a  grooved  ring  which  he  had  invented  for  this  purpose 
to  carry  and  fasten  the  thread,  has  not  been  more  generally  adopted  than  the 
instrument  of  Guillemeau.  Cheselden,  who  was  one  of  its  principal  partisans, 
applied  it  by  means  of  a  simple  probe  when  the  tumor  was  pedunculous.  In 
other  cases,  with  a  curved  needle  he  passed  a  double  thread  through  the 
gland,  in  order  to  strangulate  each  half  separately.  Sharp  operated  exclu- 
sively in  this  manner,  which  Lecat,  after  Castellanus,  Levret,  and  Heuermann 
modified,  particularly  in  using  threads  of  different  color,  so  that  it  was  impos- 
sible to  confound  them.  Bell  took  a  silver  wire  or  a  piece  of  catgut;  fixed  it 
in  a  canula  slightly  curved,  which  he  carried  to  the  superior  part  of  the 
pharynx  through  the  corresponding  nasal  fossa;  then  enlarging  the  noose 
with  his  finger  placed  it  around  the  tonsil,  and  used  his  canula  as  a  serre- 
noeud.  A  thread  of  Brittany  carried  through  the  mouth  on  a  double  hook, 
and  fixed  by  means  of  his  ordinary  serre-noeud,  sufficed  with  Desault. 
Heuermann  maintained  that  the  polypus  instruments  of  Levret  answer  best  for 
this  ligature,  which  may  be  equally  performed  with  the  chaplet-shaped  instru- 
ment of  M.  Moyer,  or  in  imitation  of  C.  Siebold,  by  means  of  a  silver  wire 
conveyed  with  forceps.  The  disadvantages  of  the  ligature,  already  remarked 
by  Van  Swieten  and  Moscati,  are  obvious  to  all,  and  are  so  inherent  in  the 
operation  itself,  that  no  one  now  employs  it,  notwitlistanding  the  success 
attributed  to  it  by  Dr.  Physick;  and  we  can  scarcely  comprehend  the  efforts 
made  recently  in  England  by  Messrs.  Chevallier  and  C.  Bell  to  restore 
its  use. 

3.  Extirpation,  which  Celsus  seems  to  mean  by  these  words :  oportet  digito 
circumradere  (tonsillas)  et  evellere,  has  been  positively  prescribed  by  Paulus 
Egineta,  ipsam  totam  (tonsillam)  ex  fundo  per  scalpellum  resecamus),  who 
performed  it  with  a  curved  bistoury.  Ali  Abbas  invented  for  this  purpose  a 
kind  of  hook  which  he  called  senora,  and  Abul-Kasem  a  small  knife  in  form 
of  a  sickle.  Instead  of  the  ancylotome  of  Paulus,  J.  Fabricius  advises  first 
to  insulate  the  gland  with  an  elevator,  then  to  seize  it  with  the  forceps  and 
draw  it  dexterously  forward,  so  that  it  shall  yield  without  difliculty,  and 
as  of  its  own  accord.  It  may  be  possible,  strictly  speaking,  to  extract  the 
amygdalae  by  enucleating  them  with  the  nail  and  the  finger,  as  it  probably  was 
done  in  the  time  of  Celsus ;  but  this  would  be  to  increase  unnecessarily  the 
sufferings  of  the  patient,  and  it  is  evident  that  such  an  eradication  must  be 
dangerous.    For  the  rest,  extirpation  of  the  tonsils  is  entirely  useless ;  rescis- 


422  NEW   ELEMENTS  OF 

sion  has  for  a  long  time  superseded  it.  If  however  it  is  to  be  tried,  nothing 
can  be  more  simple.  A  hook,  or  the  forceps  of  Museux,  to  draw  forward  and 
disengage  the  gland  from  between  the  columns  of  the  velum  palati,  and  a 
narrow  probe-pointed  bistoury  to  cut  its  roots,  will  suffice  as  in  ordinary 
excision.  Care  however  must  be  taken  not  to  go  beyond  the  lateral  limits  of 
the  pharynx,  else  the  venus  plexus  or  some  still  more  important  vessel,  the 
carotid  for  example,  which  is  found  on  the  sides  of  this  muscular  funnel,  may 
be  wounded,  and  thus  cause  a  formidable  hemorrhage. 

4.  Excision. — Although  Aetius  is  the  first  who  formally  declared  that  only 
the  projecting  portion  of  the  tonsils  should  be  removed,  and  that  its  extirpa- 
tion was  never  necessary,  yet  rescission  had  been  recommended  before  his 
time.      The   operation   which  Asclepiade  designates  under  the   name  of 
homoirotomie  can  be  nothing  else.     And  has  not  Celsus  also  described  it  in 
this  phrase  ?  Si  ne  sic  quidem  resolvuntur,  hamulo  excipere  et  scalpello  excidere. 
Those  who  have  admitted  it  sinco,  have  nearly  all  attempted  to  modify  more 
or  less  the  method  of  performing  it.    Rhazes  says  that  the  tumor  is  to  be 
seized  with  a  hook,  and  one-fourth  of  it  to  be  cut  off;  but,  according  to  him,  it 
is  so  dangerous  an  operation  that  it  is  better  to  have  recourse  to  bronchotomy. 
Instead  of  the  hook  and  ancylotome  of  the  ancients,  of  the  curved  bistoury 
and  double  hook  of  Mesue,  Wiseman  begun  by  tying  the  tonsil,  and  then 
used  the  thread  as  a  hook  while  he  excised  the  gland  with  scissors.     Heister, 
as  well  as  Mesue,  speaks  of  a  double  hook  and  bistoury.    Moscati,  who  was 
at  first  the  partisan  of  the  ligature  already  proscribed  by  Cavallini,  and  who 
afterwards  practised  excision  with  a  curved  bistoury  fixed  on  a  slip  of  wood, 
adopted  a  different  process :  he  began  by  incising  the  tonsil  crucially  with  a 
convex  bistoury,  after  which  he  cut  off  its  four  portions  separately,  leaving 
intervals  of  three  or  four  days  between  the  operations.     Maurain,  who  justly 
criticises  the  method  of  Moscati,  prescribes,  like  Levret,  that  the  whole  pro- 
tuberance be  taken  off  at  a  single  stroke  with  curved  scissors  made  expressly 
for  the  purpose.     Lecat  returns  to  the  double  hook  of  Heister,  and  advises 
a  small  concave  knife  with  a  blunt  point,  or  curved  and  blunt  scissors.     At 
the  same  epoch  Foubert  recommends  the  gland  to  be  embraced  with  polypus 
forceps,  and  pressed  forcibly  in  order  to  contuse  the  vessels,  while  the  exci- 
sion is  performed  by  a  single  stroke  of  the  bistoury.    Caque,  of  Rheims, 
boasts  very  much  of  a  simple  hook  and  a  blunt  pointed  knife,  with  an  edge 
nearly  straight  and  bent  upon  the  handle.  Louis  asserts  that  the  ordinary  bis- 
toury will  serve  the  purpose,  and  that  if  the  gland  is  cut  from  below  upwards,  it 
will  certainly  prevent  its  falling  into  the  opening  of  the  larynx  and  exposing 
the  patient  to  suffocation,  as  in  the  cases  which  excited  so  much  apprehension 
in  the  minds  of  Wiseman  and  Moscati.    With  this  view  another  surgeon  o 
Rheims,  Museux,  invented  the  forceps  which  bears  his  name,  and  maintains 
that  the  tonsil  once  seized  by  this  instrument  cannot  possibly  escape,  and  that 
nothing  is  then  easier  than  its  excision  either  with  scissors  or  the  bistoury. 
Desault  preferred  tlie  ordinary  double  hook  and  the  kiotome,  a  kind  of  flat 
canula  six  inches  long  by  one  broad,  deeply  hollowed  out  at  its  extremity,  to 
receive  the  tonsil,  enclosing  a  movable  blade,  cutting  at  the  point  which 
traverses  the  hollow  of  the  sheath,  and  acted  upon  by  the  thumb.  This  instru- 
ment of  Desault,  although  ingenious,  is  no  longer  used,  at  least  in  France. 


OPERATIVE    SURGERlr.  423 

A  harrow  bistoury,  straight  and  blunt  pointed,  such  as  is  found  in  every 
surgeon's  case,  is  much  more  convenient,  and,  as  M.  Boyer  observes,  merits 
preference  in  every  respect. 

Appreciation.' — Authors  have  differed  so  much  in  the  manner  of  performing 
an  operation  so  simple,  only  because  in  indocile  subjects,  children  for  ex- 
ample, and  those  who  have  a  small  deep  mouth,  or  where  it  is  opened  with 
difficulty,  it  often  presents  great  difficulties.  A  glance  at  the  several  stages 
of  the  operation  will  permit  us,  I  trust,  to  reduce  to  their  true  value  the 
principal  assertions  of  the  operators  who  have  just  been  quoted.  The  first 
thing  then  to  be  done  is  to  keep  the  moutli  of  the  patient  open  and  govern 
the  motions  of  the  tongue.  Hence  the  various  glosso-catoches  of  the  ancients, 
and  the  numerous  species  of  speculum  which  have  succeeded  each  other  from 
the  time  of  Ambrose  Pare  to  our  own;  hence  the  chevalet,  the  handle  of 
which,  curved  like  an  S,  enabled  Caque  to  draw  back  the  labial  commissure 
and  keep  the  jaws  apart ;  the  plate  of  silver,  which  was  applied  on  the  tongue, 
while  its  handle,  a  little  more  elevated,  rested  upon  the  inferior  dental  range, 
which  it  depressed ;  the  other  more  complicated  instrument,  proposed  by  M. 
Lemaistre  at  the  Hotel-Dieu,  afterwards  by  M.  Gamier  to  the  medical 
society  of  emulation,  which,  without  obstructing  the  movements  of  the  ope- 
rator, was  to  keep  the  mouth  steadily  open  and  the  tongue  depressed ;  the 
blade  of  box  or  ebony  bent  at  a  right  angle,  much  resembling  for  the  rest  a 
shoeing  horn,  and  which  is  regarded  by  Messrs.  Roche  and  Sanson  as  very 
advantageous ;  hence  again  the  instrument,  at  the  same  time  more  complete 
and  more  complicated,  of  M.  Colombat.  But  a  spatula,  or  the  handle  of  a 
silver  spoon  and  a  piece  of  cork,  are  of  equal  avail  and  less  embarrassing 
than  any  of  these  ingenious  inventions.  The  preliminary  ligature  of  Wise- 
man is  evidently  an  episode  more  vexatious  than  excison  itself.  As  to  the 
hook,  it  is  to  be  feared,  that  if  single  it  will  tear  through  the  tissues 
and  escape ;  and  if  double,  it  may  be  too  difficult  to  disengage  it,  and  particu- 
larly if  quadruple,  as  in  the  forceps  of  Museux.  It  is  objected  besides  to 
these  last  that  they  impede  by  their  volume  the  play  of  other  instruments, 
and  that  they  are  not  easily  borne  by  the  patient.  In  fine,  the  three-pointed 
hook,  devised  by  Marjolin  on  the  occasion  of  a  young  subject  difficult  to 
manage,  would  prove  still  more  embarrassing  than  the  instrument  of  the 
surgeon  of  Rheims,  if  it  should  become  necessary  to  withdraw  it  before  the 
end  of  the  operation.  These  objections,  no  doubt,  have  some  foundation, 
although  the  greater  part  of  the  disadvantages  pointed  out  are  very  trifling. 
After  all,  the  choice  of  the  hook  is  not  an  important  affair.  Provided  the  single 
hook  has  a  certain  degree  of  strength,  its  curve  a  certain  extent,  and  that 
it  seize  the  gland  behind  at  the  union  of  its  external  third  with  its  internal 
two-thirds,  it  will  allow  of  traction  with  as  much  force  as  the  double  hook, 
and  will  not  lacerate  the  tissues  more.  Neither  Louis  nor  M.  Roux  has  found 
in  it  any  thing  to  complain  of,  and  for  my  own  part  I  have  always  found  its 
use  very  convenient.  For  the  rest,  the  double  hook  employed  by  Desault,  and 
which  is  now  daily  used  by  M.  Boyer  and  many  others,  has  in  my  opinion 
only  the  disadvantage  of  being  somewhat  difficult  to  place.  The  forceps  of 
Museux,  preferred  by  M.  Dupuytren,  although  less  easy  to  handle,  present  an 
advantage  which  is  not  found  in  the  hook  of  M.  Marjolin — that  of  not  being 
liable  when  withdrawn  to  wound  the  parts  within  the  mouth. 


424  NEW   ELEMENTS   OF 

As  to  cutting  instruments  there  is  no  choice  except  between  the  scissors 
and  the  probe-pointed  bistoury.  With  the  former  there  is  less  danger  (espe- 
cially by  selecting  scissors  with  blunt  points,  or  buttoned  and  curved  in  the 
fiat)  of  dividing  what  it  is  necessary  to  preserve.  But  the  division  is  less 
neat,  and  they  occupy  a  little  more  space  in  the  pharynx  and  mouth  than  the 
bistoury.  When  pressed  between  their  blades  the  gland  sometimes  retreats, 
and  requires  to  be  divided  at  several  strokes.  With  respect  to  the  bistoury, 
the  reason  for  excluding  all  but  the  probe-pointed  is  that  the  others  will  almost 
infallibly  wound  the  posterior  wall  of  the  pharynx,  the  external  side  of  which 
it  would  also  be  very  easy  to  penetrate.  The  knife  of  Caque  is  too  large; 
the  narrower  and  straight  bistoury  is  undoubtedly  the  best  that  can  be  em- 
ployed. If  the  kiotome  had  not  been  recommended  by  a  man  as  celebrated 
as  Desault,  and  regarded  in  so  advantageous  alight  by  Mr.  S.  Cooper,  it  would 
scarcely  deserve  to  be  mentioned.  The  instruments  being  selected,  it  remains 
to  be  considered  how  we  shall  perform  the  excision.  By  cutting  from  above 
downwards,  as  advised  by  some,  there  is  reason  to  apprehend  that  the  bistoury 
will  wound  the  base  of  the  tongue,  and  if  only  held  by  a  pedicle,  the  gland 
may  escape  and  fall  upon  the  larynx ;  but  then  it  would  be  so  easy  by  carry- 
ing the  finger  into  the  fauces  to  bring  it  through  the  mouth,  that  the  acci- 
dent which  was  on  the  point  of  happening  to  Wiseman  and  Moscati,  is  in 
reality  scarcely  to  be  feared.  Louis,  who  dreaded  it,  says  that  by  cutting^ 
from  below  upwards  nothing  of  the  kind  is  to  be  apprehended,  and  the  tongue 
will  be  out  of  all  danger  of  being  touched.  Admitting  the  justness  of  this 
principle,  Messrs.  Boyer  and  Marjolin  have  nevertheless  thought  proper  to 
adopt  it  only  in  part.  According  to  them,  if  there  is  no  danger  to  the  tongue 
it  is  otherwise  with  the  velum  palati,  and  to  avoid  all  risk  to  this  part  they 
follow  the  advice  of  Richter,  cutting  first  from  above  downwards,  then  from 
below  upwards,  and  conclude  with  the  middle  portion  of  the  tumor.  There 
is  nothing  to  censure  in  this  excess  of  precaution,  except  its  inutility.  M. 
Roux  operates  generally  like  Louis,  and  finds  the  method  sufficient ;  and  I 
have  no  reason  to  regret  having  done  the  same.  If  care  is  taken  to  make  the 
tonsil  project  sufficiently  by  drawing  it  forward,  and  to  rest  a  little  of  ihe 
flat  part  of  the  instrument  against  the  columns  of  the  pharyngeal  isthmus,  as 
if  to  shave  oft'  its  curvature,  a  much  neater  and  quicker  section  is  obtained 
there  without  any  real  cause  for  apprehension. 

Manual. — The  patient  is  seated  on  a  chair  fronting  a  window,  so  that  the 
light  may  fall  directly  upon  the  bottom  of  the  fauces,  while  the  head  is  held 
back  by  an  assistant.  Placed  in  front,  the  surgeon  fixes  a  cork,  shaped  for  the 
purpose,  as  deeply  as  possible  and  vertically  between  the  molar  teeth  of  one 
side,  so  as  to  keep  the  jaws  separated ;  he  depresses  the  tongue  if  it  is  in  the 
way,  and  draws  out  the  commissure  of  the  lips ;  catches  the  tonsil  and  engages  it 
firmly  from  behind  with  his  hook,  using  the  left  hand  for  the  left  side  and  the 
right  hand  for  the  right ;  he  pulls  it  forwards  and  disengages  it  from  between 
the  columns  ;  takes  in  the  other  hand  the  bistoury,  enveloped  with  a  linen  fillet 
to  within  ten  to  fifteen  lines  of  its  point,  carries  it  betv/een  the  hook  and  the 
tongue  beneath  the  base  of  the  gland,  turns  its  edge  upwards,  and  cuts  freely  by 
a  sawing  movement,  as  if  to  make  it  describe  a  segment  of  a  circle  which  will 
terminate  at  the  base  of  the  uvula,  and  thus  detaches  all  the  superfluous  por- 
tion of  the  tumor  at  a  single  stroke ;  he  then  withdraws  at  once  the  bistoury,  the 


OPERATIVE   SURGERY.  425 

hook,  and  the  excised  mass,  relieves  the  jaws  of  the  cork  which  fatigues  them, 
lets  the  patient  spit,  and  gives  him  cold  water  or  vinegar  and  water  to  wash 
and  gargle  his  mouth.  If  only  one  tonsil  be  affected,  the  operation  is  over ;  if 
botli,  he  lets  some  minutes  elapse,  the  blood  ceases  to  flow,  and  he  proceeds 
to  the  excision  of  the  other  in  exactly  the  same  manner.  Several  days  may  be 
permitted  to  intervene,  if  the  patient,  being  fatigued,  absolutely  requires  it ; 
but  in  general  they  choose  to  be  relieved  at  one  sitting  rather  than  to  return  to 
it  at  separate  periods,  and  the  pain  they  experience  is  commonly  so  trivial  that 
they  submit  to  it  without  much  apprehension. 

£fter  Treatment. — If  the  blood  is  not  soon  arrested,  a  solution  of  alum, 
water  of  Rabel,  or  any  other  styptic  liquor,  may  be  immediately  given  as  a 
gargle,  or  applied  to  the  wound  alone  by  means  of  forceps,  if  it  should  be 
necessary  to  use  it  energetic  and  very  concentrated.  In  case  of  imminent 
danger  actual  cautery  forms  a  last  resource,  which  must  not  be  neglected,  and 
which  is  much  more  efficacious  than  the  complicated  compression  proposed 
by  Jourdain.  In  an  adult,  upon  whom  I  operated  in  the  beginning  of  1831, 
at  the  house  of  Madame  Reboul,  the  loss  of  blood  at  the  end  of  two  hours  was 
such  that  it  was  necessary  to  apply  powdered  alum  immediately  to  the 
wound.  If  a  bungler  had  opened  the  carotid,  as  M.  Portal,  A.  Burns,  and 
Beclard  say  they  have  seen,  the  ligature  of  the  primitive  trunk  would  still 
offer  some  chance  of  safety.  For  the  rest,  the  medical  treatment  consists  of 
emollient  gargles  and  diluent  drinks,  and  the  regimen  of  soups,  broths,  and 
afterwards  a  little  more  substantial  aliment.  Generally  no  fever  supervenes, 
and  from  the  fourth  to  the  fifth  day  the  health  is  in  a  great  measure  re- 
established. 

§  2.  Abscess ;  Incision  of  the  Tonsils. 

The  surgeon  is  sometimes  obliged  to  open  with  an  instrument  abscesses 
which  form  in  the  substance  of  the  tonsils,  in  consequence  of  phlegmonous 
inflammation.  The  sharpened  iron  of  Hippocrates  and  Celsus,  the  long 
bistoury  and  needle  used  by  Leonidas,  the  razor  of  Lanfranc,  the  small  piece 
of  polished  wood  of  Plater,  the  sagittella  of  Arculanus,  the  beaked  bistoury 
invented  by  Vigo,  the  pharyngotome  of  J.  L.  Petit,  that  of  Jourdain,  and  the 
lancet  of  Roger  of  Parma,  are  all  advantageously  superseded  by  the  ordinary 
bistoury  in  this  trivial  operation.  Pressure  with  the  finger  or  the  nail,  or  an 
emetic  opportunely  administered,  very  frequently  suffices.  The  mouth  and 
the  patient  are  disposed  as  in  excision  of  the  tonsils,  and  the  bistoury  is  to  be 
wrapped  with  a  bandage  until  within  six  lines  of  its  point,  before  it  can  be 
allowed  to  be  plunged  into  the  abscess.  The  opening  of  abscesses  which  are 
sometimes  developed  in  the  substance  of  the  velum  palati,  the  uvula,  or  even 
the  base  of  the  tongue,  is  performed  with  the  same  precautions  and  requires 
no  farther  care. 

§  S.  Excision  of  the  Uvula. 

The  elongation  of  the  uvula,  whether  from  infiltration,  inflammation,  or 
organic  degeneracy,  is  a  condition  which  received  much  more  attention  from 
the  ancients  than  from  the  moderns,  and  perhaps  deserves  more  consideration 
than  is  generally  accorded  to  it  at  the  present  day.     From  its  contact  with 

54 


426  NEW  ELEMENTS  OF 

the  base  of  the  tongue,  the  apex  of  the  uvula  produces  a  very  Inconvenient 
tickling,  and  sometimes  gives  rise  to  symptoms  which  seemed  to  belong  to 
much  more  serious  causes,  gastritis  and  phthisis  for  example,  and  which  may 
lead  to  serious  errors  of  diagnosis ;  as  well  as  of  therapeutics,  if  the  surgeon 
is  unacquainted  with  their  peculiarities.  Consequently,  it  is  important  that 
there  should  not  be  too  much  delay  before  applying  a  remedy  to  alterations  of 
the  uvula ;  and  its  removal,  it  is  to  be  remembered,  as  proved  by  Physick, 
Beckern,  and  liisfranc,  is  the  only  means  of  removing  certain  obstinate  symp- 
toms which  are  apt  to  be  mistaken  for  more  serious  affections. 

1.  Cauterization. — The  inflammation  of  this  part,  even  when  acute,  yields 
readily  to  cauterization  with  nitrate  of  silver,  when  not  too  far  advanced.  I 
have  used  it,  like  M.  Toirac,  in  many  patients,  and  found  in  it  nothing  but 
what  should  meet  with  approbation.  The  mixture  of  quick  lime,  tartar,  alum, 
and  vermilion,  praised  by  Demosthenes,  and  the  caustics  in  general  proposed 
by  Galen,  are  at  most  applicable  to  cases  of  serous  infiltration.  The  cauteries 
of  gold  or  iron,  used  by  Montagnana  and  Arculanus,  the  nitric  and  sulphuric 
acids,  proposed  by  Vigier  and  Nuck,  are  now  justly  bandoned.  No  one  at 
tile  present  day  would  follow  the  ridiculous  advice  given  by  Mesue,  after- 
wards repeated  by  Nuck  and  Bass,  which  is,  to  pull  the  hair  to  the  point  of 
tearing  the  skin  from  the  cranium  and  tie  it  with  a  ribbon  near  the  base,  after 
forming  it  into  a  toupet. 

2.  Astringents. — Sal  ammoniac,  nut-galls,  according  to  S.  Largus ;  walnut- 
shells,  according  to  Galen ;  burnt  alum,  to  Rhazes,  and  pepper  and  ginger, 
still  recommended  by  Purmann,  are  scarcely  used  at  present,  except  by  old 
women  and  country  people,  who,  when  the  palate  is  down,  think  also  to  raise 
it  by  passing  beneath  it  a  silver  spoon  considerably  heated. 

3.  The  Ligature,  carried  round  the  base  of  the  organ  by  means  of  the  grooved 
ring  of  Castellanus,  as  Pare  directs,  with  the  porte-ligature  of  F.  de  Hilden 
and  Scultetus,  or  in  any  other  way,  without  being  as  dangerous  as  Dionis 
pretends,  is  nevertheless  unnecessary;  and  excision  with  a  cutting  instrument 
is  the  only  means  which  is  now  opposed  to  chronic  lesions  which  have  pro- 
duced the  elongation,  or  what  is  termed  the  fall  of  the  uvula. 

4.  JSxcision  is  an  operation,  moreover,  which  has  been  practised  in  every 
age  and  in  various  modes.  Hippocrates  treats  of  it,  and  directs  it  to  be  per- 
formed with  dexterity.  Celsus  and  Galen  followed  the  same  process.  Paulus 
had  instruments  express — a  staphylagra  to  hold  the  organ,  a  staphylotome  to 
cut  it,  and  a  staphylocaust  to  cauterize  the  wound.  He  mentions  still  another 
instrument,  invented  by  Serapion.  Mesue,  who  forbids  the  uvula  ever  to  be 
cut  away  entirely,  excised  it  with  a  golden  bistoury  reddened  in  the  fire,  after 
having  engaged  it  in  the  ring  of  a  sheath  made  for  the  purpose.  In  place  of 
this  sheath,  G.  de  Salicet  directs  the  employment  of  a  tube  of  elder,  in  which 
he  placed  the  uvula  to  divide  it  either  with  hot  iron  or  the  bistoury.  Guy  de 
Chauliac  advises  forceps  or  a  hook,  a  concave  bistoury  or  scissors.  The 
scissors,  without  forceps  or  hook,  were  sufficient  for  Fabricius,  M'ho  then  cau- 
terized the  wound  to  recal  its  vitality.  A  Norwegian  peasant,  Thorbern, 
invented  an  instrument  in  part  similar  to  that  of  Mesue  and  Arnaud,  that  is, 
a  kind  of  kiotome,  which  opens  to  engage  the  uvula  in  a  circular  hole  near  its 
extremity,  which  has  only  to  be  closed  to  complete  the  operation.  Job  a  Mek- 
ren,  who  saw  the  uvula  extend  to  the  lips,  is  of  opinion  that  nothing  can  be 


OPERATIVE  SURGERY.  427 

employed  more  convenient  than  scissors  with  long  blades.  The  instrument 
of  Thorbern,  improved  bj  Raw,  soon  after  reproduced  by  Bass  under  the 
form  of  a  spatula  funiished  with  a  cutting  tongue,  did  not  prevent  Fritze  from 
making  further  modifications.  Levret,  who  was  also  a  partisan  of  the  ligature, 
has  extolled  scissors  with  concave  edge  (as  for  the  tonsils),  and  the  polypus 
forceps.  Richter  found  that  scissors  with  blunt  points  served  his  purpose  very 
well ;  and  B.  Bell  adopted  a  curved  bistoury,  probe -pointed,  and  nearly  similar 
to  that  of  Pott  for  hernia.  But  the  scissors  of  Percy  are  the  most  ingenious  and 
the  most  simple  for  the  excision  of  the  uvula.  A  prolongation  of  three  or  four 
lines,  bent  at  a  right  angle,  terminates  one  of  their  blades,  and  prevents  the 
organ  slipping  before  them  when  once  it  is  engaged.  Their  only  fault,  a& 
well  as  that  of  most  of  the  instruments  mentioned  above,  is  that  they  are  not 
indispensable  and  can  answer  no  other  purpose ;  whence  it  follows,  that  the 
new  staphylotomes  recently  invented  by  Messrs.  Rousseau  and  Bennatti  are 
also  superfluous  instruments. 

Manual. — The  patient  is  seated  as  for  excision  of  the  tonsils.  With  the 
left  hand  armed  with  a  fine  hook,  dressing  forceps,  or,  still  better,  polypus 
forceps,  which  from  the  notch  or  opening  at  their  extremity  w  ill  retain  it 
still  more  securely,  the  surgeon  hooks  the  uvula ;  inclines  it  forward  and  a 
little  to  the  right ;  then  with  straight  blunt  scissors  cuts  it  by  a  single  stroke 
at  some  distance  from  its  base.  It  is  not  with  the  vain  purpose  of  preventing 
its  falling  into  the  larynx  that  we  first  endeavor  to  fix  it,  but,  being  very  pliant 
and  movable,  it  would  otherwise  escape  from  the  blades  of  the  instrument. 
Oribasius,  Rhazes,  Avenzoar,  &c.,  are  mistaken  in  saying  that  its  entire 
removal  is  dangerous,  and  that  it  ahvays  aftects  respiration  and  the  voice. 
S.  Braun  is  still  further  from  the  truth  when  he  asserts  that  it  constantly  pro- 
duces dumbness.  The  case  quoted  by  Wedel,  and  which  tends  to  prove  that 
food  and  drinks  return  by  the  nose,  is  evidently  only  an  exception.  The 
observations  of  SchefFer,  Becken,  Myrrhen,  and  Physick,  fully  demonstrate 
that  the  loss  of  this  organ  rarely  produces  any  disturbance  in  the  system.  It 
is  better  to  remove  too  much  than  too  little,  so  as  not  to  be  obliged  to  repeat 
the  operation.  Besides,  the  resolution  of  the  inflammatory  engorgement 
which  soon  commences  causes  the  uvula,  whose  base  had  been  more  or  less 
concealed  in  the  velum  palati,  to  be  found  much  longer  than  at  first  there  was 
reason  to  expect. 

§  4.  Staphyloraphy. 

The  abnormal  divisions  of  the  velum  palati  are,  as  in  the  lips,  sometimes 
congenital  and  sometimes  acquired.  That  the  first  occupy  nearly  always  the 
median  line  is  owing  to  the  palatine  vault  not  being  completed  posteriorly,  and 
its  two  portions  not  united  at  the  usual  period.  Yet  they  are  found  sometimes 
a  little  on  one  side,  but  have  never  yet  been  seen  double.  The  second,  an 
ordinary  result  of  traumatic  lesions,  and  more  particularly  of  syphilitic  ulcer- 
ations, are  met  with  on  the  right  and  left  as  well  as  in  the  middle,  and  in  the 
form  of  hollows  whose  depth  is  usually  limited  by  the  edge  of  the  vault,  while 
the  other  kind  often  extend  to  the  dental  range,  so  as  to  be  continuous  with  a 
hare-lip,  simple  or  double,  if  the  patient  is  simultaneously  affected  with  that 
disease. 


428  NEW  ELEMENTS   OF 

A.  History. — Nothing  from  the  ancients  indicates  that  they  had  thought  of 
overcoming  this  defect  of  conformation.  More  enterprising  or  more  skillful, 
the  moderns  have  attempted  to  fill  up  this  chasm,  and  their  efforts  have  been 
crowned  with  the  greatest  success.  Casting  the  eye  upon  a  fissure  of  the 
palate,  the  idea  of  staphyloraphy  must  have  presented  itself  a  thousand  times 
to  the  mind ;  but  to  think  of  it  was  not  all-— -the  application  of  the  idea  was  t6 
be  prosecuted,  and  no  one  had  ventured.  The  attempts  which  M.  Colombe 
says  he  had  made  since  1813,  on  the  dead  body,  and  wished  to  repeat  in 
1815  on  a  patient  who  refused,  have  not  been  known  to  the  public ;  that  of 
which  M.  Graefe  has  published  the  details  in  Hufeland's  Journal  for  1817, 
and  which  he  dates  back  to  the  end  of  1816,  passed  equally  unnoticed.  It 
was  then  reserved  for  M.  Roux  to  fix  attention  on  this  subject;  In  1819,  a 
young  American  physician.  Dr.  Stephenson,  gave  him  the  first  opportunity. 
The  operation  succeeded  to  his  wish,  and  formed  a  kind  of  epoch.  All  the 
public  journals  lavished  on  this  chirugical  victory  the  eulogies  it  deserved. 
Dr.  Stephenson  himself  made  known  his  cure  in  a  thesis,  defended  at  London 
in  1821.  The  year  following,  1822,  Mr.  Alcock  was  not  less  successful  than 
the  Parisian  surgeon.  It  was  then  that  the  rights  of  M.  Graefe  to  its  priority 
were  brought  to  mind  by  his  countrymen,  at  the  same  time  that  persons  from 
all  parts  came  to  Paris  to  witness  the  performance  of  staphyloraphy,  which 
soon  took  rank  among  the  delicate  but  regular  operations  of  surgery.  There 
is  every  reason  to  believe,  however,  that  it  had  been  practised  before.  In  his 
memoirs  on  different  medical  subjects,  published  in  1764,  Robert  says  in  effect : 
"a  child  had  the  palate  deft  from  the  veil  to  the  incisors.  M.  Le  Monnier,  a 
very  skillful  dentist,  attempted  with  success  to  unite  the  two  edges  of  the  fissure , 
firstm?Lkin^  several  points  of  suture  to  hold  them  together,  and  then  wade  them 
raw  with  a  cutting  instrument.  Inflammation  supervened,  which  terminated 
in  suppuration,  and  was  followed  by  union  of  the  two  lips  of  the  artificial 
wound ;  the  child  was  perfectly  cured."  A  child,  a  fissure,  the  suture,  the 
making  raw,  the  approximation,  the  cure,  all,  notwithstanding  the  rather  vague 
expressions  of  Robert,  scarcely  permit  us  to  doubt  that  his  dentist  had  really 
recourse  to  staphyloraphy,  and  not  to  the  suture  of  a  simple  perforation  of 
the  palatine  vault.  This  operation  is  then  in  every  respect  a  discovery 
entirely  French.  It  is,  to  proceed,  so  frequently  indicated,  that  at  the  end  of 
1829,  M.  Rosa  had  himself  performed  it  forty -five  times.  M.  Jousselin  of 
Liege,  had  two  successful  cases,  and  M.Beaubien  a  third.  M.  Caillot,  of  Stras- 
burg,  has  published  a  fourth,  and  more  recently,  in  1823,  M.J.  Cloquet  a  fifth. 
M.  Morisseau  has  just  published  a  sixth  instance  of  success,  obtained  by  him 
at  Sable,  in  the  case  of  a  female  twenty  years  old ;  and  M.  Bonfils  has  com- 
municated another  of  about  the  same  time,  to  the  society  of  practical  medicine 
of  Paris.  It  appears,  moreover,  that  in  France  it  has  been  carried  from  its 
first  step  to  the  highest  degree  of  perfection  possible.  It  is  otherwise  in  Ger- 
many, where  they  are  constantly  attempting  to  improve  it.  Instead  of  the 
term  uranoraphy,  proposed  by  M.  Grsefe,  others  have  wished  to  substitute  the 
terms  velosynthesis,  kyonoraphy,  uraniskoraphy ,  &c.  MM.  Doniges,  Ebel, 
Hruby,  Dieffenbach,  Wernecke,  Lesenberg,  Schwerdt,  and  Krimer,  have  all 
endeavored  to  simplify  the  instrumental  apparatus;  and  in  England,  Mr. 
Alcock  has  not  adopted  in  every  particular  the  method  of  M.  Roux ;  its  every 
stage  has  been  discussed,  and  deserves  to  be  so. 


OPERATIVE   SURGERY.  429 

First  Stage. — Cauterization  with  muriatic  and  sulphuric  acids,  caustic, 
potash,  tried  by  M.  Graefe,  or  even  with  the  tinct.  cantharides,  lapis  infernalis, 
and  hot  iron  itself,  proposed  by  MM.  Ebel,  Wernecke,  and  Doniges,  is  not 
more  efficient  in  making  raw  the  fissure  of  the  velum  palati  than  that  of  the 
lips.  Excision  in  both  cases  is  indispensable.  With  dressing  forceps,  a  little 
concave  and  thin,  M.  Roux  seizes  successively  the  two  portions  of  the  palate 
or  division  near  their  free  extremity,  taking  care  to  include  but  a  very  small 
portion  of  their  edge ;  he  then  detaches,  proceeding  from  below  upwards  and 
from  behind  forwards,  a  strip  a  line  in  thickness,  which  he  prolongs  as  far  as 
their  angle  of  union,  and  even  beyond  it  if  the  osseous  vault  is  complete. 
For  this  purpose  a  straight  bistoury.^  probe-pointed  and  very  narrow,  con- 
ducted in  the  manner  of  a  little  saw,  appeared  to  him  preferable  to  the 
scissors  bent  upon  their  handle  near  their  heel,  which  he  at  first  devised,  and 
which  he  sometimes  uses  even  now  to  commence  this  excision.  In  the 
beginning  M.  Graefe,  to  fulfill  this  indication,  used  in  the  first  place  a  long 
forceps  resembling  in  other  respects  dissecting  forceps,  bent  laterally  near  the 
point  and  terminating  in  a  double  hook  or  two  small  bifurcations ;  secondly, 
an  uranotome,  too  complicated  for  me  to  describe  here,  which  is  in  its  body  some- 
thing analogous  to  the  syringe  of  Anel,  and  in  its  cutting  part  to  the  staphy- 
lotome  of  Raw.  At  present  M.  Graefe  acknowledges  the  inutility  of  this 
instrument,  and  substitutes  scissors  in  its  stead.  Doctor  Hruby  has  found 
that  forceps  curved  like  those  of  Museux,  terminating  in  the  form  of  a  crutch, 
bent  at  an  elbow  near  their  crossing  point,  one  of  the  bits  of  which  being 
wider  than  the  other  makes  it  resemble  in  this  respect  the  pincers  described 
by  Dionis,  fix  very  firmly  the  velum  palati  during  the  excision.  The  forceps 
of  M.  Grsefe,  with  or  without  hooks,  seemed  sufficient  to  M.  Dieftenbach, 
who  for  making  the  edges  raw  had  a  small  knife  constructed,  of  which  a 
lancet  narrowed  near  the  heel  and  mounted  on  a  very  long  handle  will  give  a 
very  good  idea.  In  fine,  Mr.  Schwerdt  does  not  differ  from  the  preceding 
authors,  except  in  having  his  forceps  not  bifurcated  at  the  extremity. 

Second  Stage. — The  interrupted  suture,  the  only  one  which  can  here  afford 
the  means  of  keeping  in  contact  the  two  cut  edges,  is  nevertheless  applied  in 
different  ways.  The  needles  of  M.  Roux,  short,  flat,  and  of  deep  curvature, 
are  not  narrower  than  elsewhere  at  the  heel,  which  has  a  large  square  opening. 
The  ligature  with  which  he  supplies  them  is  a  ribband  composed  of  from  four 
to  six  threads,  well  waxed  and  about  two  feet  long.  His  porte-aiguille,  already 
known  in  the  arts,  is  a  kind  of  forceps  with  a  groove  on  the  internal  face  of 
its  branches,  which  a  ring  tightens  or  loosens  at  will  as  it  is  pushed  forward 
or  drawn  back  by  a  stylet,  which  holds  it  and  which  slides  along  tlie  whole 
length  of  the  handle  of  the  instrument,  of  which  it  forms  in  some  sense 
an  axis.  The  needles  tried  by  M.  Grasfe,  in  1816,  represent  pretty  much  the 
half  of  an  elliptic  curve,  cut  at  the  ends  of  the  transverse  diameter.  They 
are  narrower  and  longer  than  those  of  M.  Roux,  but  their  eye  is  much  longer, 
and  perforates  them  laterally  as  in  the  old  suture  needles.  The  forceps 
intended  to  carry  them  is  not  pierced  by  any  wire.  Two  rings  two  inches 
apart,  supporting  two  lateral  rods,  open  or  close  it  by  sliding  towards  the 
extremity  or  on  the  side  of  its  handle.  Now  the  needles  of  M.  Graefe  are 
nearly  straight  and  lance-pointed.  He  has  moreover  bent  near  the  beak  his 
former  porte -aiguille,  so  that  being  fixed  by  their  edge  in  the  hollow  presented 


430  NEW  ELEMENTS  OF 

by  the  branches  of  this  instrument,  they  transform  it  into  a  real  hook.  In 
fine,  still  more  recently  M.  Grgefe  has  removed  the  rings  from  this  porte- 
aiguille,  which  at  present  is  nothing  more  than  a  jointed  forceps,  the  movable 
branch  of  which  works  on  a  centre  pivot  as  in  the  lithotome  cache.  The 
needles  of  M.  Ebel,  perfectly  straight,  very  sharp,  and  broader  in  the  middle 
tJian  near  the  eye,  like  those  of  M.  Roux,  have  a  square  perforation  to  receive 
the  thread.  Those  of  Mr.  Alcock  are  curved  into  an  oblong  arch,  and  are 
nearly  round;  M.  Dieifenbach  constructed  them  resembling  little  larding 
pins;  they  have  no  eye,  are  straight  or  very  slightly  concave,  hollowed 
in  their  posterior  half,  and  can  receive  a  leaden  wire,  which  their  inventor 
prefers  to  every  other  material,  and  which  he  easily  draws  through  after  them 
when  they  are  made  to  pass  from  the  fauces  into  the  mouth  and  through  the 
velum  palati.  His  porte-aiguille,  still  more  simple  than  that  of  M.  Graefe,  is 
in  reality  but  a  forceps  with  rings,  the  branches  of  which  are  one -fourth 
the  length  of  the  handles  and  are  bent  near  their  beak  almost  to  a  right  angle. 
The  needle  and  porte-aiguille  of  M.  Doniges  compose  but  one  instrument ;  it 
is  a  long  wire  in  an  ebony  handle,  bent  a  little  behind,  and  terminating 
in  front  by  a  hooked  needle,  pierced  near  its  point  and  hollowed  on  its 
convexity  to  receive  the  thread.  That  of  M.  Lesenberg  differs  from  it  by 
being  formed  of  two  parallel  branches,  which  open  and  close  by  the  same 
mechanism  as  tlie  first  porte-aiguille  of  M.  Graefe,  so  that  it  is  necessary  to 
open  it  after  perforating  the  parts,  in  order  that  the  thread  it  carries  may  be 
left  free,  and  itself  removed  without  acting  on  the  ligature.  In  adopting  this 
needle  M.  Schwerdt  proposed  to  apply  to  it  the  pivot  mechanism  of  the  last 
porte-aiguille  of  M.  Grsefe,  in  order  to  dispense  with  the  sliding  rings  of 
M.  Doniges. 

Tliird  Stage. — Placing  the  ligatures  does  not  finish  the  operation.  They 
3nust  also  be  tied  and  fastened.  In  France  it  can  scarcely  be  comprehended 
how  for  this  part  of  the  operation  it  is  necessary,  according  to  M.  Graefe, 
to  add  to  the  instruments  already  mentioned,  first,  a  little  hollow  cylinder 
pierced  on  its  sides ;  secondly,  a  pair  of  forceps  bent  at  an  angle  on  the 
back  near  the  handle,  similar  in  other  respects  to  the  second  porte-aiguille  of 
this  author,  and  grooved  with  two  hollows  on  the  external  face  and  on  each 
side  of  its  beak;  thirdly,  a  screw,  a  kind  of  stopper  fitted  to  the  preceding 
cylinder;  fourthly,  a  second  forceps  straight  and  mounted  like  the  common 
porte-crayon  of  the  lapis  infernalis ;  or,  fifthly,  along  steel  wire  mounted  upon 
a  handle,  swelling  and  cut  square  at  its  free  extremity,  where  are  two  openings 
to  receive  the  two  halves  of  the  ligature,  and  form  of  itself  an  actual  serre- 
noeud,  which  however  can  scarcely  act  except  on  metallic  wires.  Sliding  it 
with  one  hand  towards  the  palate  over  the  two  halves  of  the  thread  engaged 
in  its  openings,  it  soon  arrives  at  the  suture,  which  it  tightens  as  much  as  is 
.desired,  and  to  fix  which  firmly  it  is  only  necessary  to  twist  it  by  turning  it 
three  or  four  times  on  its  axis.  With  the  other  apparatus  the  ends  of  the 
ligature  are  first  passed  from  within  outwards  through  the  lateral  holes  of  the 
cylinder,  which  is  then  seized  with  bent  forceps.  It  is  then  puslied  on  the 
threads,  which  the  surgeon  draws  towards  him,  taking  care  on  the  other  part 
to  keep  them  engaged  in  the  external  grooves  of  the  beak  of  the  forceps  until 
it  touch  the  palatine  vault  and  the  ligature  becomes  sufficiently  tight.  Nothing 
now  remains  but  to  close  it  by  carrying  there  ^vith  the  other  forceps  the  screw 


OPERATIVE  SURGERY.  431 

designed  to  fill  it  and  arrest  the  threads,  and  then  leave  it  in  place.  This  array 
of  unnecessary  objects  exhibits  its  own  inconveniences  without  my  pointing 
them  out.  In  proposing  the  surgeon's  knot,  and  instead  of  the  instruments  of 
M.  Graefe,  a  kind  of  crutch  notched  at  the  ends  of  its  cross-piece  to  receive  the 
two  sides  of  the  thread,  which  are  drawn  with  one  hand  while  with  the  other 
the  crutch  is  made  to  slide  to  the  suture,  M.  Doniges  does  not  reflect  that  the 
fingers  will  answer  the  same  purpose  infinitely  better.  I  do  not  perceive, 
moreover,  what  real  advantage  M.  Krimer  could  find  in  the  use  of  a  gold 
screw  over  one  of  iron,  like  those  of  M.  Graefe,  and  of  black  thread  over 
white,  and  oiled  over  waxed.  The  method  of  M.  Roux  is  incomparably  more 
simple  and  more  natural.  After  passing  one  of  the  two  ends  of  each  ligature 
within  the  other,  he  makes  a  simple  knot,  which  the  index  fingers,  carried  to- 
gether to  the  bottom  of  the  mouth,  permit  him  to  tie  as  tightly  as  it  is  necessary. 
An  assistant  immediately  takes  hold  of  this  knot  with  the  ringed  forceps,  and 
holds  it  firmly  that  it  may  not  be  relaxed,  while  the  operator  fixes  it  by  a 
second  knot  formed  in  the  same  manner,  beyond  which  he  then  cuts  with 
scissors  each  of  the  superfluous  parts  of  the  ligature. 

B.  Manual. — Staphyloraphy  is  not,  properly  speaking,  a  difficult  or  painful 
operation,  but  it  is  long,  delicate,  and  fatiguing,  and  requires  great  patience  on 
the  part  of  both  patient  and  operator ;  so  that  it  cannot  be  performed  but 
on  those  who  desire  it,  who  feel  its  importance,  and  who  have  firmly  resolved 
to  submit  to  it.  It  is  rare,  therefore,  that  we  have  to  treat  children  under 
twelve  to  fifteen  years  of  age.  It  requires  no  precaution  in  regimen,  but  the  indi- 
vidual should  be  otherwise  in  good  health.  Diseases  of  the  gastro -pulmonary 
passages  particularly  endanger  its  success  in  consequence  of  cough,  sneezing, 
and  the  desire  of  spitting,  which  commonly  accompany  them. 

The  Apparatus,  prepared  beforehand,  consists  of,  first,  three  flat  ligatures 
very  regular  and  flexible ;  second,  of  six  needles,  one  at  each  end  of  the  liga- 
tures ;  third,  an  ordinary  porte -aiguille,  or  that  of  M.  Dieftenbach,  if  the  nearly 
straight  needles  of  M.  Ebel  are  preferred ;  fourth,  a  good  dressing  forceps, 
the  breaks  of  which,  a  little  concave,  should  not  exactly  touch  each  other 
when  closed,  except  at  their  point;  fifth,  a  straight  bistoury,  probe-pointed 
and  narrower  than  the  one  in  the  common  surgical  case ;  sixth,  scissors  for 
excision  and  straight  scissors  to  cut  the  threads ;  seventh,  corks  hollowed  into 
a  gutter  at  each  extremity,  to  accommodate  itself  to  the  form  of  the  dental 
ranges ;  eighth,  a  spoon  to  depress  the  tongue  in  case  of  need ;  ninth,  several 
napkins,  a  large  cloth,  cold  water  and  a  glass,  a  basin,  and  also  a  little 
vinegar. 

Position. — Covered  with  the  cloth,  with  a  napkin  wrapped  round  him,  his 
head  supported  by  an  assistant,  the  patient  is  to  be  placed  in  a  good  light,  as 
for  excision  of  the  tonsils.  A  second  assistant  stands  ready  to  hand  the  bason 
and  water  as  well  as  the  instruments,  when  wanted.  Seated  in  front,  on  a 
chair  of  proper  height,  the  operator  first  introduces  the  corks  between  the 
molar  teeth  of  each  side ;  then  with  the  forceps  in  his  left  hand,  he  seizes  the 
right  border  of  the  division,  conducts  with  his  right  hand  the  armed  porte- 
aiguille  into  the  pharynx,  brings  it  forwards,  and  endeavors  to  make  the  point 
of  the  needle  strike  from  three  to  four  lines  without  the  fissure  and  near  its 
inferior  part  to  pass  through  the  velum ;  he  then  seizes  it  with  the  forceps 
transversely  when  it  has  penetrated  as  far  as  possible  into  the  mouth ;  frees  its 


452  NEW   ELEMENTS  OF 

heel  at  the  moment  the  assistant  opens  the  porte -aiguille ;  without  the  slightest 
jerk  removes  this  last  instrument;  takes  the  forceps  in  his  right  hand,  and 
draws  the  needle  completely  forward  out  of  the  mouth,  the  ligature  following 
it.  The  patient  being  fatigued,  requires  to  spit  and  rest  a  moment.  His  jaws 
are  therefore  freed  from  what  keeps  tliem  separate  before  performing  on  the 
left,  with  the  second  needle  and  the  second  end  of  thread,  changing  hands, 
what  has  just  been  done  on  the  right.  In  order  not  to  confound  it  witli  those 
which  are  to  follow,  it  is  well  to  tie  the  free  extremities  of  this  first  ligature, 
and  depress  its  noose  a  little  into  the  tliroat  to  prevent  its  obstructing  the 
application  of  the  others.  The  two  ends  are  then  drawn  to  the  commissures, 
and  held  bj  an  assistant  on  the  sides  of  the  head.  The  surgeon  then  places 
the  second  and  the  third,  if  it  is  thought  necessary,  with  the  same  precautions 
and  in  the  same  manner,  leaving  between  each  two  about  an  equal  space. 
After  depressing  the  noose  an  inch  or  so,  and  pushing  it  back  in  order  not 
to  expose  it  to  be  cut  by  the  bistoury,  or  bent  scissors,  he  takes  hold  of  the 
left  lip  of  the  fissure  by  the  end  of  the  uvula ;  commences  with  the  scissors  the 
excision  of  the  small  lip  which  he  is  to  take  away,  and  which  the  forceps  is 
not  to  quit,  while  he  continues  its  separation  with  the  bistoury  as  far  as  the 
palatine  bone;  he  executes  the  same  manoeuvre  on  the  left  lip  with  the  right 
hand,  and  returns  to  the  use  of  the  scissors  to  smooth  the  edge,  if  the  action 
of  the  bistoury  has  not  been  equal  in  every  point  of  the  abnormal  division. 
The  blood  flows,  obstructs  the  pharynx,  and  often  collects  in  clots  about  the 
threads.  The  patient  is  to  be  rid  of  it,  to  gargle,  and  remain  quiet  for  several 
moments.  The  most  difficult  part  of  the  operation  is  now  over.  The  liga- 
tures are  distinguished,  and  put  in  order  so  as  easily  to  be  found  again,  and 
tied  one  after  the  other  beginning  with  the  lowest.  When  the  gape  is 
considerable  and  coaptation  seems  to  be  difficult,  M.  Roux  separates  each  of 
its  lips  from  the  posterior  edge  of  the  palate  bone  by  a  transverse  incision 
from  four  to  six  lines  deep.  The  two  halves  of  the  velum,  being  no  longer 
retained  by  the  hard  parts,  yield  and  approximate  with  surprising  facility. 
This  mode  prevents  all  dangerous  pulling  on  the  part  of  the  threads,  and  the 
new  wound  which  is  made  soon  closes  spontaneously  without  giving  any 
ground  for  apprehension.  To  obviate  the  same  difficulty  M.  DiefFenbach 
follows  another  method.  He  finds  that  a  longitudinal  incision  on  each  side 
about  four  lines  from  the  abnormal  fissure  is  infinitely  better  than  that  of. 
M.  Roux,  all  the  advantages  of  which  it  possesses  without  any  of  its  disadvan- 
tages ;  that  it,  too,  closes  of  itself  and  without  injury  to  relations  of  the  paUtine 
vault,  and  that  it  allows  a  very  marked  elongation  along  the  whole  extent  of 
the  flaps  which  are  to  be  brought  together.  These  two  modifications  are  not 
unimportant,  and  should  be  admitted  ;  the  first,  when  the  fissure  in  the  soft 
parts  is  complicated  with  a  separation  of  the  bones ;  the  second,  which  is  more 
natural,  when  it  is  intended  to  overcome  resistances  solely  of  these  latter, 
and  oppose  the  retraction  of  the  muscles  of  the  palate.  Both  prove  besides, 
that  in  proposing  incision  of  the  posterior  face  of  the  lips  in  hare-lip,  the 
ancients  were  not  so  wrong  as  moderns  have  imagined. 

Treatment. — The  ligatures  once  tied  the  operation  is  finished,  and  in  no 
case  is  any  further  dressing  necessary.  It  is  sufficient  that  the  patient  remain 
without  speaking,  and  take  particular  care  to  do  nothing  which  might  cause 
him  to  cough,  vomit,  spit,  or  sneeze  ;  that  he  take  notliing  but  broth  or  very 


OPERATIVE    SURGERY.  433 

liquid  soups  until  the  suture  has  acquired  some  degree  of  firmness.  On  the 
fourth  day  tiie  middle  thread  may  be  brought  away ;  the  next  day  the  highest 
may  be  removed  ;  the  third  is  to  be  left  until  the  sixth  day — understanding 
that  they  are  to  be  left  one  or  two  days  longer  if  agglutination  seems  still  incom- 
plete at  the  ordinary  period.  It  is  hardly  necessary  to  mention,  that  to  dis- 
engage them  from  the  tissues  they  are  to  be  cut  on  the  side  of  the  knot,  wliich 
is  held  and  withdrawn  with  the  forceps.  If  union  has  taken  place  only  on  the 
side  of  tlie  uvula,  which  frequently  occurs  when  the  fissure  is  prolonged  on 
the  median  line  of  the  jaw,  there  is  no  reason  to  be  alarmed.  Frequently  the 
opening  which  results  disappears  without  any  extraneous  aid  in  the  course  of 
time ;  but  the  union  may  be  promoted  by  making  the  edges  raw ;  by  producing 
inflammation  with  lapis  infernalis,  as  I  have  seen  done  by  M.  Roux ;  with  the 
nitrate  of  mercury,  as  M.  J.  Cloquet  tried  with  success  ;  or  indeed  with  any 
otiier  caustic.  After  all,  the  patient  would  be  freed  from  it  by  submitting  to 
wear  an  obturator  or  artificial  palate,  if  there  were  not  other  resources  against 
the  evil. 

C.  Modifications. — Fortunately  it  is  possible,  I  think,  to  remedy  it  in 
another  manner.    To  close  an  opening  of  this  kind,  M.  Krimer  made  an 
incision  several  lines  from  its  edges  on  each  side   from  behind  forwards, 
comprising  the  whole  thickness  of  the  palatine  membrane.     Having  thus 
marked  out  two  flaps  of  soft  parts,  he  dissected  them  up,  inverted  them  upon 
themselves,  brought  them  towards  the  median  line,  and  united  them  by  a  suf- 
ficient number  of  stitches,  which  he  was  able  to  remove  on  the  fourtli  day  ; 
agglutination  took  place  perfectly,  and  the  palatine  vault  was  wholly  restored. 
This  is  a  practice  assuredly  to  be  imitated ;  and  as  the  occasion  will  often 
present,  I  am  convinced  that  this  idea  is  a  real  improvement  of  staphyloraphy. 
Among  other  proposed  modifications,  I  scarcely  find  any  that  may  be  adopted 
with  advantage.     If  the  forceps  of  M.  Graefe,  improved  by  M.  Schwerdt, 
were  not  in  other  respects  a  superfluous  instrument,  perhaps  they  miglit  take 
hold  better  and  more  solidly  of  the  parts  to  be  excised  than  the  forceps  witli 
rings.     As  the  little  knife  of  M.  Dieffcnbach  might  in  reality  be  replaced  by 
a  ceratotome,  a  lancet  a  little  longer  than  usual,  fixed  by  a  band  of  linen,  or 
even  by  the  common  straight  bistoury,  and  which  has  no  other  disadvantage 
than  of  exposing  the  posterior  wall  of  the  pharynx  to  be  wounded,  I  see  no 
great  objection  to  using  it  instead  of  the  probe-pointed  bistoury.     Plunged 
from  the  mouth  towards  tlie  pharynx  through  the  velum  palati  very  near  the 
fissure ;  then  carried  parallel  with  this  fissure,  at  first  forwards  or  towards  the 
bones ;  then  in  the  direction  of  the  uvula,  it  would  easily  separate  a  slip,  the 
extremities  of  wkich,  detached  only  at  the  conclusion  of  the  stroke,  would 
evidently  render  the  excision  more  certain  and  easy,  by  furnishing,  what  is 
not  found  by  the  bistoury,  a  double  support  to  the  instrument  to  the  last.  The 
nearly  straight  needles  of  M.  Graefe  or  of  M.  Ebel,  introduced  by  means  of 
the  porte-aiguille  of  M.  Dieffenbach,  seem  also  to  present  some  advantages: 
first,  that  of  being  more  easily  loosened  than  with  the  ordinary  porte-aiguille 
when  they  have  passed  through  the  soft  parts;  then,  of  presenting  less  resist- 
ance than  curved  needles  to  the  forceps  which  is  to  draw  them  tln-ough  and 
bring  them  out  of  the  mouth.     As  to  the  wires  conveyed  by  the  lardoires  of 
M.Dieftenbach — for  as  far  as  experience  has  jet  proved  that  their  round  form 
and  smallness  of  size  are  not  too  favorable  to  cutting  the  tissues — I  will  not 
55 


434  NEW  ELEMENTS  OF 

venture  to  recommend  them.  The  hook-needles  with  single  or  double  shafts, 
of  Messrs.  Schwerdt,  Donigcs,  and  Lesenberg,  so  ingeniously  contrived,  at  the 
first  glance  seem  to  me,  however,  worthy  of  rejection,  because  it  will  always 
be  difficult  to  disengage  tlie  thread  from  them,  and  withdraw  them  without 
deranging  any  thing  after  passing  them  from  the  pharynx  into  the  mouth 
through  the  velum  palati.  Staphyloraphy,  which  has  been  practised  in  Boston 
by  Dr.  Warren,  and  in  New  York  by  Dr.  H.  H.  Stevens,  is  an  operation  which 
every  operator  should  be  allowed  to  modify  according  to  his  particular  ideas 
and  the  parts  to  be  approximated.  Staphyloplasm,  for  instance,  might  ,be 
substituteu  for  it,  as  was  done  by  M.  Bonfils,  when  instead  of  a  fissure  there 
is  a  real  loss  of  substance.  A  flap  sufficiently  large  cut  on  the  palatine  vault, 
dissected  and  inverted  from  before  backward,  could  be  easily  adapted  to  the 
form  of  the  opening,  and  kept  in  place  by  the  suture.  Although  incomplete, 
the  success  of  the  surgeon  of  Nancy  gives  us  a  glimpse  of  what  may  be 
expected  from  this  resource.  The  attempt  of  M.  Krimer  besides,  is  altogether 
in  its  favor.  If  there  is  an  opening  in  the  velum  palati  instead  of  a  fissure, 
hot  iron,  with  which  M.  Delpech  obtained  a  perfect  cure  on  a  child ;  the 
nitrate  of  silver,  which  succeeded  with  me  eventually  in  a  case  of  perforation 
in  consequence  of  syphilitic  ulcers ;  or  any  other  caustic,  should  first  be  tried. 


SECTION  IV. 

Olfactory  Apparatus. 
Art.  1. — Nasal  Fossae. 

§  1.  Hemorrhage — Plugging. 

Whether  the  flow  of  blood  from  the  nose  be  the  result  of  traumatic  lesion 
or  of  a  vital  congestion;  when  it  resists  revulsives,  cold  local  applications, 
styptics,  and  astringents ;  or  when  its  duration  and  its  abundance  render  it 
alarming,  the  surgeon  ought  to  have  recourse  to  plugging  of  the  nasal  fossae. 
This  operation,  which  is  both  simple  and  easy,  is  performed  as  follows :  a  roll 
of  lint  large  enough  to  fill  the  posterior  opening  of  the  nostril,  tied  round  its 
middle  with  a  waxed  thread,  to  the  circle  of  which  is  attached  a  long  single 
thread,  is  first  prepared  ;  other  rolls  of  less  volume,  or  simply  raw  charpie, 
are  also  prepared  beforehand.  The  operator  carries  into  the  pharynx  through 
the  bleeding  nostril  a  gum-elastic  sound,  a  piece  of  catgut,  a  lead  or  silver 
wire,  a  piece  of  whalebone,  or,  if  at  hand,  the  sound  called  Bellocq's;  brings 
through  the  mouth  the  extremity  of  one  of  these  instruments,  either  by  seek- 
ing for  it  with  one  or  two  fingers  in  the  back  part  of  the  throat  or  by  pushing 
the  spring  of  the  sound  if  this  be  used  ;  he  attaches  the  double  thread  to  this 
extremity,  and  then  withdraws  it  to  place  the  roll  of  Lint  in  the  posterior  part 
of  the  mouth,  carrying  with  it  the  single  thread ;  he  detaches  the  conducting 
instrument,  now  no  longer  necessary ;  draws  again  on  the  lint ;  engages  it  firmly 
in  the  affected  nostril,  wliich  is  thus  closed  from  behind ;  he  then  separates 
the  two  ends  of  the  ligature  which  come  through  the  nose ;  passes  between  them 
from  below  upwards  and  from  before  backwards  the  free  dossils  or  the  raw 
charpie  until  the  front  of  the  cavity  is  exactly  filled ;  then  crosses  them  as  if 


OPERATIVE    SURGERY.  435 

for  tying,  and  tightens  them  with  all  the  force  he  thinks  necessary  upon  this 
last  tampon  so  as  to  push  it  backwards,  at  the  same  time  that  it  acts  upon  the 
other  with  equal  energy  to  bring  it  forwards.  By  this  means  it  is  easy  to  fill 
the  nostril  completely  with  charpie,  or,  at  least,  to  seal  hermetically  the  two 
openings,  and  oppose  to  the  hemorrhage  an  insurmountable  barrier.  The  ends 
of  thread  which  come  out  of  the  mouth  and  nose,  are  to  be  kept  fastened 
against  the  cheek  or  the  cap  of  tlie  patient,  until  the  time  of  removing  the  appa- 
ratus. This  is  the  only  time  that  the  single  thread  proves  to  be  of  use,  unless 
the  surgeon  has  been  obliged  to  remove  and  replace  several  times  the  tampon 
in  the  posterior  nares  before  finally  removing  the  whole,  which  should  never 
take  place  before  the  complete  cessation  of  the  molimen  hemorrhagicum ; 
rarely,  at  the  least,  before  the  second  or  third  day.  He  then  cuts  or  unties 
the  anterior  knot,  removes  the  charpie  with  a  forceps,  and  leaves  in  the  nose 
but  the  first  dossil,  which  tractions,  exerted  on  the  buccal  thread,  are  to  draw 
down  into  the  pharynx  and  extract  by  the  mouth. 

§  2.  Polypi, 

Desiccation,  cauterization,  the  seton,  excision,  extraction,  and  the  ligature, 
may  all  cure  polypus  of  the  nose ;  but  these  several  therapeutic  methods  are 
far  from  being  equally  efficacious,  and  deserving  equal  confidence. 

1.  Desiccation,  for  example,  is  evidently  only  applicable  to  mucous  polypi  in 
their  early  stage ;  and  it  is  even  doubtful  if  its  result  be  then  very  satisfactory. 
Thus  it  is  not  used  at  the  present  day  but  as  subsequent  or  auxiliary  to  ex- 
cision or  extraction.  Notwithstanding  Aetius,  Alexander  of  Tralles,  Ac- 
tuarius,  and  a  host  of  ancient  authors,  the  appearance  of  success  obtained  by 
M.  Mayer  with  the  powder  of  Teucrium  marum  does  not  seem  to  me  calcu- 
lated to  reverse  that  sentence. 

2.  Cauterization  is  somewhat  more  worthy  of  attention ;  and  I  should  not  be 
surprised  if  the  future  appealed  from  the  unfavorable  judgment  pronounced 
against  it  by  the  moderns.  Hippocrates,  who  advocated  it,  performed  it 
sometimes  with  the  heated  iron,  at  others  with  caustics.  Arsenic,  the  acetate 
and  sulphate  of  copper,  according  to  Galen,  were  preferred  by  Philoxenes ; 
while  Antipater  and  Masa  employed  vermilion  of  Sinape.  Sandarac,  pimento, 
pomegranates,  oxyd  of  lead,  the  root  of  the  ranunculus,  quick  lime,  and  pot- 
ash, lauded  by  Archigenes,  S.  Largus,  and  P.  de  Bairo,  have  since  been  suc- 
ceeded by  the  butter  of  antimony,  which  Garengeot  used,  after  protecting  the 
sound  parts,  by  placing  a  plaster  between  the  polypus  and  the  corresponding 
wall  of  the  nose,  also  by  the  nitrate  of  mercury,  the  nitric  or  sulphuric  acids, 
or  the  nitrate  of  silver.  These  various  catheterics  were  applied  to  the  disease 
by  means  of  setons,  tents,  dossils  of  lint,  lead  wires,  metallic  tubes,  &c.,  so  as 
to  touch  the  projecting  portion  and  destroy  it  by  deorees.  They  were  after- 
wards superseded  by  injections  of  lime-water,  solutions  of  alum,  of  vitriol, 
astringent  or  styptic  decoctions,  in  a  word,  by  the  whole  catalogue  of  desic- 
cative  substances  ;  and  the  annals  of  medicine  prove,  that  radical  cures  of 
polypus  have  been  effected  in  this  manner.  Quite  recently,  too,  in  1827, 
M.  Wagmer  has  acquainted  the  academy  with  remarkable  observations,  very- 
worthy  of  exciting  attention  on  this  subject  if  correct.  He  succeeded  in 
discovering  the  secret  of  a  German  quack,  named  Jensch,  who  had  acquired 


436  NEW    ELEMENTS    OF 

in  his  province  the  reputation  of  overcoming  the  most  obstinate  polypi. 
Being  master  of  this  secret,  which  is  nothing  more  than  a  mixture  of  sulphuric 
acid,  butter  of  antimony,  and  nitrate  of  silver,  M.  Wagmer  was  desirous  of 
testing  its  efficacy,  following  exactly  the  rules  laid  down  by  the  empyric. 
According  to  him,  its  eftects  have  been  almost  miraculous.  The  fol- 
lowing is  the  process  indicated :  a  piece  of  metal  in  the  form  of  a  long  pin, 
with  a  head  of  the  size  of  a  large  pea,  is  the  only  instrument  necessary. 
Having  covered  the  head  with  a  coat  of  the  caustic,  it  is  applied  to  tlie  pro- 
jecting portion  of  the  polypus,  and  the  application  repeated  from  two  to  five 
times.  Every  day  the  operation  is  renewed,  until  the  iunwv  drops  off  or  is 
destroyed.  An  injection  with  a  solution  of  alum  is  made  an  hour  before,  and 
an  hour  after  each  cauterization.  After  the  principal  mass  has  been  detached, 
it  is  only  touched  with  the  lapis  infernalis.  The  injections  are  to  be  con- 
tinued for  two  months;  and  to  restore  the  sense  of  smelling,  the  powder  of 
napeta  (Teucrium  verum)  is  prescribed  in  the  form  of  snuff.  I  see  no  reason 
why  this  treatment  should  not  be  tried,  at  least  on  timid  subjects,  or  when 
the  polypus  is  broader  than  it  is  long,  and  equally  difficult  to  extract  or  to 
tie.  It  would  not  be  the  first  time,  moreover,  that  ignorance  and  gross  char- 
latantism  has  given  the  idea  of  a  prescription  of  service  in  the  methodical 
treatment  of  diseases. 

Jldiial  Cautery,  which  naturally  inspires  more  confidence  than  the  poten- 
tial, and  which,  according  to  the  Arabian  physicians,  it  is  sufficient  to  apply 
to  the  forehead  to  prevent  the  reproduction  of  polypi ;  so  highly  extolled  by 
Roger  of  Parma,  who  applied  it  to  the  disease  through  a  canula;  by  D. 
Scacchi  and  P.  de  Marchetti,  who  had  the  courage  to  repeat  its  application 
twenty  days  in  succession ;  by  Purmann,  who  succeeded  three  times  with 
an  iron  wire  heated  to  redness;  by  Richter  and  Acrel,  who  wrapped  the 
conducting  tube  with  a  moist  linen  the  better  to  protect  the  surrounding 
tissues,  is  nevertheless  almost  wholly  abandoned  at  the  present  day.  It  is 
sometimes  recurred  to  to  destroy  the  remains  of  polypi  left  behind,  after  other 
methods  to  arrest  hemorrhage  which  sometimes  follows  extraction,  or  for 
destroying  sensible  or  malignant  polypi;  but  neither  even  of  these  cases  abso- 
lutely require  it.  In  the  first,  escharotics,  which  are  less  alarming  to 
patients,  are  justly  preferred  to  it.  Plugging  may  easily  supply  its  place  in 
the  second.  In  the  third,  fire,  iron,  and  medicaments  are  equally  dangerous. 
This  species  of  polypus  which  bleeds  at  the  least  touch,  and  often  even 
without  being  touched,  which  alter  considerably  the  physiognomy  of  patients 
and  are  accompanied  with  sudden  shootings  of  pain,  yield  in  fact  to  no  remedy, 
and  constitute  the  real  noli  me  iangere. 

For  the  rest,  the  operation  is  easy  when  the  polypus  is  not  too  deeply  seated. 
The  anterior  (jrifice  of  the  nose  is  to  be  dilated  for  some  days,  if  the  cautery 
is  to  be  carried  through  that  passage.  A  speculum  nasi  permits  us  to  see  the 
exact  situation  of  the  tumor.  After  these  preliminaries,  the  surgeon  takes  a 
canula,  soldered  at  right  angles  at  its  base  upon  a  handle,  or  the  ends  of  a 
forceps,  unless  he  prefer  a  simple  tube  held  by  dressing  forceps,  wraps  it  with 
moist  cloth,  and  carries  it  to  the  polypus,  which  may  be  burnt  with  a  rose  or 
olivary  cautery  heated  to  whiteness.  It  would  be  most  frequently  impossible 
to  employ  this  means  through  the  mouth,  that  is,  for  polipi  of  the  posterior 
buces ;  and  even  in  the  other  case,  it  is  frequently  followed  with  intense 


OPERATIVE   SURGERY.  437 

cephalalgia,  and  very  serious  cerebral  affections,  as  Sabatier  has  several  times 
observed. 

Sd.  The  Seton  is  a  resource  of  another  description.  Three  distinct  indica- 
tions, strictly  speaking,  may  be  fulfilled  by  it.  The  knotted  string,  proposed 
at  first  by  Paul,  or  rather  by  Rhazes,  then  by  Avicenna,  and  most  particularly 
by  Brunus,  to  saw  the  polypi,  is  a  kind  of  seton  quite  ingeniously  devised, 
but  which,  to  say  the  least,  will  act  as  much  on  the  Schneiderian  membrane  as 
on  the  morbid  tumor.  The  silver  wire  wound  spirally  with  one  of  brass,  and  sup- 
ported by  two  handles,  one  fixed  and  the  other  n^ovable,  recommended  by 
Levret  instead  of  the  seton  of  the  ancients,  is  no  longer  used  in  practice.  Le 
Dran's  idea  was  more  natural :  passing  a  hook  through  the  nostrils  to  take 
hold  of  a  cotton  string  carried  into  the  pharynx  by  the  index  finger,  or,  which 
is  as  well,  passing  a  piece  of  catgut  which  was  brought  out  through  the  mouth 
and  drawn  back  through  the  nasal  fossa  after  a  seton  had  been  attached  to  it. 
This  surgeon  succeeded  in  destroying  a  polypus  of  which  several  roots  had 
escaped  him.  It  was  then  very  easy  to  pass  into  the  nose  every  day,  first  a 
dossil  of  dry  lint  to  remove  heterogeneous  matters,  and  afterwards  dossils 
spread  with  digestive  or  catheteric  ointment,  designed  to  favor  the  removal  of 
the  particle  of  the  polypus,  and  cleanse  the  sore.  With  this  view^  and  to  attain 
this  end,  Hippocrates  and  some  of  the  ancients,  have  extolled  the  seton ; 
while  intending  to  simplify  Le  Dran's  process,  Goulard  has  really  made  it 
more  complicated.  The  hook,  shaped  to  the  turnings  of  the  nasal  fossas,  which 
he  prescribes  in  place  of  the  catgut,  the  fork  which  he  used  instead  of  the  finger 
for  the  purpose  of  carrying  the  seton  behind  the  velum  palati,  are  evidently 
less  convenient.  After  all,  the  process  for  passing  a  seton  through  i^w^i  nostrils 
should  be  in  this  case  the  same  as  plugging  those  cavities.  It  is  a  method,  the 
advantagies  of  which  are  confined  to  conducting;  medicinal  substances  to  some 
point  within  the  nasal  fossae. 

4th.  Excision  may  be  referred  as  far  back  as  Celsus,  who  names  a  kind  of 
cutting  blade  (spatha)  to  be  used  in  performing  it.  Paul  cut  the  polypus  with 
his  spatha  polypica,  one  extremity  of  w^hich  was  furnished  with  scissors,  and 
tore  out  the  rest  with  a  polypoxiste.  Abul-Kasem  began  by  drawing  down 
the  tumor  with  a  hook,  and  then  cut  it  with  a  sharp  instrument.  Others,  Scacchi 
for  example,  operated  with  a  simple  bistoury,  or,  like  Hutten,  with  a  species  of 
syringotome,  or  again,  like  Nessi,  with  a  curved  probe-pointed  bistoury.  J. 
Fabricius  condemns  these  instruments,  and  emphatically  recommends  a  kind 
of  forceps  in  the  shape  of  a  double  cutting  spoon,  which  M.  A.  Severin  charges 
him  with  havino^  borrowed  from  Nicollini,  without  acknowledgment,  which 
Glandorp,  V.  Home,  and  Solingen,  have  successfully  modified,  and  which 
Dionis,  Percy,  and  B.  Bell,  have  thought  not  worthy  of  entire  rejection.  Le 
Dran,  Manne,  and  Levret,  who  under  some  circumstances  also  excised  polypi, 
used  no  other  instrument  than  the  ordinary  bistoury  or  curved  scissors.  But 
of  late  M.  Wathely  has  returned  to  the  use  of  the  syringotome;  that  is,  a  bis- 
toury lengthened  in  the  shape  of  the  point  of  a  probe,  concave  on  its  edge, 
enclosed  in  a  sheath  in  which  it  easily  glides  towards  either  the  point  or  the 
handle. 

When  the  polypus  has  solidity  and  is  very  near  the  exterior  of  the  pharynx, 
it  cannot  be  doubted  that  the  process  of  Abul-Kasem  with  a  bistoury,  or,  still 
better,  with  ordinary  scissors  or  those  curved  on  the  side,  will  often  succeed 


4S8 


NEW  ELEMENTS  OF 


ill  removing  it.  The  cutting  forceps  of  J.  Fabricius  may  also  perform  it  under 
certain  circumstances,  when  in  the  middle  of  the  nasal  fossae.  Nevertheless, 
excision  is  an  uncertain  method,  and  almost  always  requires  to  be  assisted  by 
one  of  the  preceding  methods,  if  we  would  not  wish  to  see  the  disease  sprout 
up  again,  and  consequently  it  ought  not  to  be  preferred  except  in  some  special 
cases. 

5.  Extraction,  which  has  for  a  long  time  been  generally  substituted  for 
excision,  is  a  method  not  less  ancient  and  on  other  accounts  very  important. 
From  having  confounded  the  cutting  forceps  with  the  ordinary  forceps,  the 
moderns  have  incorrectly  attributed  the  first  idea  of  this  method  to  A.  Pare, 
or  rather  to  Fabricius  ab  Aquapendente.  It  is  found  clearly  expressed  in  the 
books  attributed  by  Sprengel  to  Thessalus,  and  to  Draco,  the  son  of  Hippo- 
crates. Even  at  that  epoch  there  were  two  modes  of  executing  it.  In  one,  a 
piece  of  sponge  firmly  tied  and  fixed  by  four  threads  was  forced  into  the 
nose,  then  by  means  of  a  long  needle  it  was  attempted  to  carry  these  threads 
into  the  posterior  fauces,  to  draw  down  the  polypus  by  means  of  a  forked  instru- 
ment, and  extract  it.  The  other  consisted  in  first  tying  the  tumor  with 
catgut  wrapped  with  thread,  and  then  extracting  it  through  the  pharynx. 
Paul  and  Rhazes  speak  of  this  last  as  a  common  method.  Brunus  was  for 
removing  the  fleshy  excrescence  with  a  crotchet,  and  G.  de  Salicet  already 
recommended  the  forceps.  Aranzi,  who  devised  very  long  pincers,  found  a 
great  advantage  in  causing  the  light  which  was  to  fall  into  the  nose  to  pass 
through  a  hole  in  a  window,  or  a  glass  globe  filled  with  water.  Although  this 
instrument  was  lauded  by  Job  a  Meckren,  yet  to  Dionis  are  owing  the  first 
circumstantial  details  of  its  rational  employment.  Adopted  since  by  almost 
every  practitioner,  it  has  been  modified  by  Sharp,  who  sometimes  used  curved 
forceps ;  by  B.  Bell,  who  had  the  blades  pierced  with  an  opening,  and  by 
Richter,  who  for  voluminous  polypi  invented  an  instrument  with  branches  to 
be  separately  applied,  like  those  of  midwifery  forceps.  Straight  pincers  are  the 
best  when  the  situation  of  the  disease  allows  their  application.  By  turning 
them  on  their  axis,  they  act  on  the  polypus  with  a  force  not  to  be  attained 
with  the  curved  ones.  These  are  reserved  for  tumors  which  may  be  reached 
and  brought  through  the  mouth.  As  to  those  which  resemble  the  obstetrical 
forceps,  they  are  of  real  advantage  when  the  mass  to  be  extracted  is  t6o 
voluminous  for  the  ordinary  forceps  to  grasp  easily  midway  in  the  nasal 
fossa.  Whatever  in  other  respects  may  be  the  dimensions  or  general  form  of 
the  forceps,  it  is  best  that  their  blades  be  pierced  through,  or  concave  within 
like  a  spoon,  and  furnished  with  little  points  or  notches  called  deyits  de  loup,  to 
render  the  hold  more  secure.  They  should  also  be  as  stout  as  possible, 
otherwise  they  are  liable  to  be  bent.  Extraction  after  the  manner  of  the 
ancients  has  never  been  entirely  laid  aside.  Thelden,  for  example,  carried 
a  ligature  round  the  pedicle  of  the  polypus,  by  means  of  a  forceps  forming  by 
the  union  of  its  blades  a  ring  indented  on  its  convexity  and  pierced  with  an 
eye  at  each  of  its  free  extremities ;  after  which  he  used  this  thread  for  the 
extraction  of  the  tumor.  Though  Vogel  succeeded  with  the  forceps  of  The- 
den,  Sir  A.  Cooper,  who,  when  he  can,  also  extracts  polypi  with  the  ligature, 
thinks  proper  to  reject  its  use,  the  actual  necessity  of  which  no  one  will  pre- 
tend to  maintain.  Admitting  that  this  mode  of  extraction,  as  Sir  A.  Cooper 
asserts,  has  the  advantage^of  being  less  liable  to  hemorrhage,  and  of  bringing 


OPERATIVE   SURGERY.  439 

away  at  once  the  whole  root  of  the  polypus  and  the  fibro-mucous  mem- 
brane which  gives  it  origin,  it  is  yet  subject  to  the  serious  disadvantage  cf 
requiring  two  operations  instead  of  one,  of  not  being  applicable  to  hard  and 
pedunculous  polypi,  and  of  being  with  difficulty  employed  in  the  depth  of  the 
nostrils.  When  the  tumor  is  not  larger  than  a  walnut,  when  it  is  firm  without 
too  thick  a  pedicle,  the  following  manoeuvre  may  be  practised,  as  it  was  done 
by  Morand,  with  success.  The  two  index  fingers  are  introduced  into  the  nose, 
one  in  front  the  other  from  behind,  as  far  as  the  polypus,  which  is  moved 
alternately  towards  the  pharynx  and  the  face  until  finally  detached,  when  it 
is  brought  out  through  the  passage  that  offers  the  least  resistance.  This  is  a 
process  which,  in  imitation  of  M.  Dupuytren,  it  would  be  well  to  combine  with 
the  use  of  the  forceps.  Undoubtedly,  by  pressing  on  the  tumor  with  the  finger 
through  the  pharyngeal  opening  of  the  nasal  fossa,  extraction  with  the  forceps, 
which  draws  it  in  the  opposite  direction,  is  more  certain  and  easy. 

Operation. — Extraction  requires  no  preparation,  unless  it  has  been  thought 
fit  to  imitate  G.  de  Salicet  in  enlarging  gradually  the  anterior  opening  of  the 
nostrils  with  a  sponge,  or  any  other  dilatory  means.  Cold  water,  vinegar  and 
water,  one  or  more  basins,  a  cloth  and  napkins,  charpie,  and  all  the  apparatus 
directed  for  plugging  the  nasal  fossae,  a  hook,  scissors,  a  probe-pointed 
bistoury,  an  ordinary  bistoury,  Museux's  forceps,  and  several  polypus  forceps, 
as  they  may  become  necessary,  should  be  arranged  on  a  table  or  large  salver. 
It  would  also  be  well  to  have  ready  dossils  of  lint  sprinkled  with  rosin,  and 
even  one  or  two  cauteries,  in  case  of  obstinate  hemorrhage.  The  patient  is  to 
be  covered  with  a  cloth  with  his  face  towards  a  window  in  a  good  light,  and 
his  head  held  by  an  assistant.  If  an  adult,  he  may  have  his  hands  free, 
in  order  to  be  able  to  gargle  at  pleasure ;  but  wrapped  round  and  concealed 
by  the  cloth,  if  a  child.  Standing  in  front,  the  operator  introduces  his  forceps 
into  the  orifice  of  the  nose;  ascertains  with  this  instrument  the  precise  seat  of 
the  polypus  which  he  grasps  as  near  its  pedicle  as  possible,  taking  care 
also  to  embrace  it  very  extensively ;  he  then  draws  it  gently  towards  him ;  takes 
hold  again  a  little  higher  up,  if  it  elongates,  with  a  second  forceps  without 
loosino;  the  first,  and  still  with  a  third,  if  he  is  fearful  of  not  removino;  its  root, 
and  then  tries  to  extract  it  entire  at  a  single  jerk.  When  the  tumor  is  too 
deeply  situated,  and  not  extensible  enough  to  protrude  outwards  before  being 
torn,  it  would  be  better  as  soon  as  it  is  grasped  to  turn  the  forceps  steadily  on 
itself,  continuing  to  draw  until  the  polypus  yields  and  is  detached.  During 
these  efforts  the  instrument  is  held  by  its  ring  in  the  right  hand  and  near  its 
crossing  with  the  left,  in  order  the  better  to  direct  its  movements,  and  in 
some  cases  to  make  it  act  as  a  lever  of  the  first  kind,  by  inclining  its  blades 
with  all  necessary  force  above,  inwards,  and  outwards.  If  the  whole  tumor  is 
not  at  first  extirpated,  or  if  several  exist,  the  operation  is  recommenced  imme- 
diately and  always  in  the  'same  manner,  until  there  is  a  certainty  that  no 
foreign  body  is  left  in  the  nasal  fossa.  On  this  point  when  we  wish  to 
discover  if  such  exist,  when  the  eye  discovers  nothing  more,  it  is  sufficient  to 
make  the  patient  breathe  strongly  through  the  diseased  nostril,  the  sound  one 
being  kept  closed.  As  long  as  there  is  difficulty  in  the  passage  of  the  air,  we 
may  be  sure  thai  some  portion  of  the  polypus  has  escaped  the  action  of 
the  forceps.  But  if  nothing  arrest  it;  if  it  arrive  freely  at  the  respi- 
ratory passage,  it  is  unnecessary  to  examine  further:  the  operation  is 
finished. 


440  NEW  ELEMITNTS  OF       ' 

Remarks. — Mucous  polypi  are  too  soft,  and  too  easily  adapt  themselves 
to  the  parts  which  surround  them  for  the  narrowness  of  the  opening,  to  offer 
any  serious  obstruction  to  their  extraction.  With  hard  polypi  it  is  otherwise. 
The  irregularities  with  which  they  are  covered,  to  adapt  them  to  the  form  of 
the  meatus ;  the  elongations  which  they  sometimes  send  out  behind,  before,  or 
in  the  maxillary  sinus;  or,  as  I  once  saw  with  the  zygomatic  fossa,  throu«>;h  the 
spheno-palatine  foramina,  of  which  also  M,  Blandin  gives  an  example,  render 
it  very  difficult  to  draw  them  out.  As  in  the  body  of  the  nostril  the  bones  do 
not  oppose  to  them  a  very  powerful  resistance,  they  depress  them,  push  the 
septum  to  one  side,  and  the  spongy  bones  and  the  ethmoid  to  tlie  other, 
and  depress  the  palatine  vault  without  much  difficulty,  while  posteriorly  the 
pterygoid  apophysis,  the  body  of  the  sphenoid  and  the  thick  edge  of  the 
vomer,  oppose  a  much  more  considerable  obstacle,  and  in  front  the  nasal 
process  of  the  maxillary  bone  retains  them  also  for  a  longer  or  shorter  time. 
They  are  especially  restrained  by  the  ring  or  fibro-cartilaginous  collar  of  the 
facial  orifice  of  the  nostril.  In  consequence  of  its  great  elasticity,  this  circle 
tends  continually  to  return  within  its  natural  limits,  and  resists  infinitely 
better  than  bone  the  efforts  made  against  it.  If  it  seem  too  laborious  to 
extract  a  large  polypus,  rather  than  employ  the  dilatation  of  G.  de  Salicet,  we 
should  make  an  incision  from  the  free  edge  of  the  ala  of  the  nose  to  the  trian- 
gular cartilage,  as  advised  by  M.  Dupuytren.  When  the  tumor  protrudes 
from  the  posterior  aperture  of  the  nasal  fossae,  it  is  rarely  possible  to  extract 
it  entire  through  the  nose.  In  this  case  the  curved  forceps  become  indis- 
pensable for  seizing  it  through  the  pharynx  above  the  velum  palati.  If  in  this 
position  it  has  acquired  a  large  size,  or  if  in  consequence  of  a  particular  dis- 
position it  forces  downwards  and  forwards  the  posterior  half  of  the  palatine 
vault  to  the  point  of  contracting  the  isthmus  of  the  fauces,  the  method  of 
Manne  or  of  Nessi,  which  consists  in  dividing  the  velum  palati  with  a  curved 
bistoury  from  above  downwards,  'should  not  be  rejected.  Heuermann  and 
Morand  have  given  it  their  approbation,  and  I  have  myself  tested  it  in  a  simi- 
lar case;  and  its  condemnation  by  Schumacher  only  proves  that  it  was  not 
indispensable  in  the  case  he  mentions.  It  is  a  true  unbridling,  which  is 
performed  without  danger  of  wounding  any  artery  of  considerable  size.  The 
polypus,  which  may  then  be  grasped  and  extracted,  if  not  entire  at  least  piece-, 
meal,  with  the  forceps  or  the  fingers,  may  also  be  excised  with  curved  scissors, 
or  the  cutting  forceps  of  M.  A.  Severin.  There  are  cases,  moreover,  in  which 
these  several  operations  are  to  be  united  and  skilfully  combined;  in  which, 
after  extracting  a  great  portion  of  the  tumor  through  the  nose,  and  another 
through  the  pharynx,  as  in  a  case  reported  by  M.Chaumet,  in  1821,  whether 
unbridled  or  not  anteriorly  and  posteriorly,  enough  of  it  remains  for  the  appli- 
cation of  the  process  of  Morand.  In  every  case  the  patient  should  be 
permitted  from  time  to  time  to  wash  his  mouth  and  nose  with  cold  water,  pure 
or  acidulated.  If  hemorrhage  should  become  too  abundant,  the  operation 
should  cease,  and  further  attempt  delayed  for  several  days.  When  it  does  not 
cease  spontaneously  plugging  should  be  resorted  to,  which  almost  always 
renders  the  application  of  caustics  or  the  hot  iron  unnecessary.  Tiiese  should 
only  be  had  recourse  to  after  vainly  trying  inspirations  of  I'eau  de  Rabel,  a 
solution  of  alum,  or  some  other  styptic. 

Reaidts. — The  extraction  of  polypi  is  rarely  followed  by  serious  accidents. 
Scarcely  any  fever  supervenes  if  the  patient  follows  a  strict  course  of  diet  for 


OPERATIVE    SURGERY.  441 

several  days.  It  is  a  method,  however,  which  is  far  from  succeeding  always, 
or  from  being  employed  with  advantage  under  all  circumstances.  It  is  parti- 
cularly proper  for  mucous  and  fibrous  polypi  with  a  single  root,  and  for  all, 
the  base  of  which  is  not  extended  over  too  large  a  surface;  in  a  word,  for 
those  tliat  may  be  extracted  entire.  Sarcomatous  polypi,  in  v/hich  the  can- 
cerous degeneracy  commences  at  the  projecting  part,  will  admit  of  it,  if,  as 
M.  Dupuytren  maintains,  they  can  be  distinguished  from  others  before  pro- 
ceeding to  the  operation ;  but,  in  other  cases,  says  M.  Boyer,  it  will  only 
hasten  tlie  march  of  symptoms,  and  conduce  to  formidable  changes.  Here,  more 
than  in  any  other  case,  the  operator  should  call  to  mind  the  anatomical  dispo- 
sition of  the  nasal  cavities,  so  as  not  to  grasp  and  tear  out,  instead  of  polypi, 
the  turbinated  bones  which  are  on  the  outer  side,  nor  bruise  the  septum  which 
is  within,  nor  the  cribriform  plate  of  the  ethmoid  which  is  above,  nor  to  mis- 
take a  simple  swelling  of  the  mucous  membrane,  or  any  deviation  of  the 
bones  for  an  abnormal  production,  so  as  to  go  astray  in  any  stage  of  the 
operation ;  but  to  carry  his  forceps  in  the  proper  direction,  so  as  to  know  that 
tumors  may  exist  in  the  nose  which  have  their  rise  in  the  frontul  sinus,  as  on 
the  patient  operated  upon  by  M.  Hoffmann ;  in  the  maxillary  sinus,  and  even, 
in  the  interior  of  the  cranium,  or  in  the  pterygo-maxillary  fossa,  for  example, 
as  in  the  subject  mentioned  by  M.  Del  Greco,  who  had  the  superior  maxillary 
nerve  transformed  into  five  enormous  polypoid  masses. 

6.  Ligature. — Like  most  of  tlie  preceding  methods,  tlie  ligature  may  be 
referred  to  the  highest  antiquity.  Nevertheless,  the  Greeks  and  the  Arabians 
hardly  proposed  it  but  as  accessary  to  excision  or  extraction.  We  must 
come  down  to  the  sixteenth  and  seventeenth  centuries,  to  find  it  clearly 
described  and  formally  indicated.  Fallopius  performed  it  with  a  brass  wire, 
the  noose  of  which  he  carried  round  the  polypus  wdth  a  silver  canula.  F.  de 
Hilden  says  nothing  of  his  process.  Glandorp,  who  particularly  mentions  it, 
practised  it  with  a  kind  of  needle  in  the  form  of  a  hook,  having  an  eye  near 
its  point  which  carried  a  silk  cord.  In  the  course  of  the  last  century,  it 
became  the  subject  of  numerous  researches  and  modifications. 

a.  First  Process  of  Levret. — Levret  proposed  to  carry  a  silver  wire  by 
means  of  a  probe  around  the  root  of  the  tumor,  and  then  pass  its  two  ends 
through  a  double  canula,  so  as  to  be  able  to  twist  them  by  turning  it  on  its 
axis,  after  fixing  them  to  the  rings  at  its  free  extremity.  Instead  of  two  tubes, 
soldered  side  by  side  in  the  form  of  a  double  sound,  Palucci  is  said  to  have 
invented  a  single  canula  like  that  of  Fallopius,  but  divided  by  a  small  trans- 
verse piece  at  its  nasal  extremity.  Levret  himself  used  this  instrument,  and 
had  made  it  known  before  it  was  mentioned  by  Palucci.  It  is  neither  more 
nor  less  convenient  than  the  preceding,  of  which  it  may  be  considered  a  simple 
varietv.  The  same  may  be  said  of  the  instruments  of  Nessi,  Hunter,  and 
King; 

b.  Second  Process. — Unable  to  reach  polypi  of  the  posterior  nares  with  his 
double  canula,  Levret  had  constructed  for  this  purpose  a  kind  of  forceps  with 
rings,  a  porte-ligature  forceps  with  long  branches,  curved  inwards  a  little  and 
swelling  into  a  bulb  at  the  extremity  and  hollow^  which  surgeons  have  not 
adopted  more  than  that  of  Theden,  which,  without  doubt  suo;gested  the  idea. 

c.  Process  of  Bras  dor. — The  difficult  point  in  the  first  process  of  Levret  is 
to  engage  the  polypus  within  the  noose  carried  by  the  metallic  tube.    Brasdor 

5Q 


442  NEW   ELEMENTS   OF 

thought  to  remedy  this  inconvenience  by  drawing  through  a  silver.wire  doubled 
to  form  a  noose,  as  the  dossils  of  lint  are  drawn  forwards  from  behind  in 
plugging  the  nasal  fossae.  The  two  extremities  being  brought  through  the  nose, 
the  surgeon  with  one  hand  draws  them  gently  forwards,  while,  with  two  fingers 
of  the  other  carried  in  the  pharynx,  he  endeavors  to  direct  the  noose  over  the 
root  of  the  polypus,  then  introduces  them  into  a  serre-nceudy  and  immediately 
proceeds  to  the  strangulation  of  the  tumor.  A  simple  thread  is,  besides,  fixed 
to  the  middle  portion  of  the  silver  wire,  and  left  free  in  the  mouth  in  order  to 
draw  back  the  ligature,  to  replace  it  if  not  properly  applied  at  first.  This  is 
an  improvement,  it  must  be  confessed ;  but  as  metallic  ligatures  cannot  be 
tightened  but  by  twisting  them  upon  themselves,  and  as,  consequently,  they 
often  break  before  cutting  through  the  pedicle  of  the  tumor,  many  prefer  a 
hempen,  flaxen,  or  silken  ligature.  The  sole  advantage  not  to  be  denied  them 
is  that  of  forming  a  noose,  which  is  easily  kept  open  without  twisting. 

d.  Process  of  Desault. — Reasoning  from  this  hypothesis,  Desault  at  first 
used  a  ligature  of  thread  instead  of  the  silver  wire  of  Brasdor.  Afterwards, 
to  obviate  the  difficulty  of  forcing  the  tumor  within  so  flexible  a  ligature,  he 
employed  another  method.  His  last  process  is  performed  by  means  of  three 
separate  instruments ;  first,  a  canula  slightly  curved,  terminating  in  a  bulb 
and  furnished  with  a  lateral  ring  at  the  other  extremity ;  second,  a  wire  of 
iron  or  steel,  a  kind  of  porte-nceiid  which  slides  easily  in  a  second  canula, 
and  when  open  represents  a  forceps,  but  when  shut  its  beak  forms  a  ring ; 
third,  a  serre-noeud,  another  metallic  shaft,  one  extremity  of  which  being  bent 
at  a  right  angle  with  its  axis,  has  a  circular  opening,  while  the  other  is  bifur- 
cated .  One  half  of  the  thread  is  fastened  to  the  ring  of  the  canula  after  passing 
through  it ;  the  other  is  passed  through  the  ring  of  the  porte-fil-forceps  which 
is  then  closed  by  drawing  it  within  the  sheath.  The  surgeon  then  introduces 
both  instruments  together  as  far  as  the  polypus,  and  even  a  little  beyond, 
guided  by  the  floor  or  septum  of  the  nasal  fossae,  that  is,  the  part  of  those 
cavities  which  is  the  least  embarrassed,  and  endeavors  to  place  them  above  or 
below,  at  the  right  or  the  left  of  the  pedicle  of  the  tumor ;  holds  the  porte- 
nocud  at  this  point  with  the  left  hand,  while  with  the  other  he  causes  the  canula 
to  glide  over  the  whole  circumference  of  the  tumor,  and  brings  it  to  a  point 
diametrically  opposite,  so  as  exactly  to  embrace  its  pedicle ;  passes  the  canula^ 
and  the  porte-noeud  once  or  twice  about  each  other,  in  order  to  form  a  circle 
of  the  noose  of  thread,  and  withdraws  the  instruments,  leaving  the  ligature 
in  its  place;  passes  its  ends  through  the  ring  of  the  serre-noeud,  which  he 
pushes  backwards  with  more  or  less  force  for  the  purpose  of  strangulating  the 
morbid  mass ;  then  fixes  the  extremity  of  the  thread  upon  the  bifurcation,  and 
attaches  it  to  the  cap  of  the  patient  to  keep  the  whole  within  the  nasal  fossae. 
Constriction  is  increased  gradually  by  drawing  each  time  with  greater  force  upon 
the  serre-noeud,  and  in  a  few  days  the  extrication  of  the  polypus  is  complete. 
Anotlier  process  of  Desault,  less  embarrassing  than  the  preceding,  consists  in 
carrying  the  loop  of  a  long  thread  through  the  nostril,  as  far  as  the  pharynx,  by 
means  of  a  gum-elastic  sound  or  a  bougie.  The  operator  seizes  this  loop  with 
his  finger  as  soon  as  it  appears  behind  the  velum  palati ;  brings  it  through  the 
mouth ;  detaches  from  it  the  conducting  sound,  which  he  withdraws  through 
the  nose ;  fixes  to  it  a  common  thread  designed  for  the  same  use  as  in  the  pro- 
cess of  Brasdor;  draws  it  back  through  the  back  part  of  the  mouth,  supporting 


OPERATIVE    SURGERY.  44S 

it  with  two  fingers,  while  an  assistant  draws  its  two  extremities  through  the 
anterior  aperture  of  the  nose;  after  which  they  are  engaged  in  the  serra-nocud, 
as  before.  If  the  fingers  are  not  long  enough  to  follow  the  noose  to  the  poste- 
rior opening  of  the  nares,  two  threads  instead  of  one,  fastened  to  the  ligature 
an  inch  apart  and  then  passed  each  through  a  canula,  will  supply  their  place 
very  advantageously.  This  process  was  further  modified  by  Desault  himself, 
for  the  special  purpose  of  applying  it  more  easily  to  polypi  of  the  pharynx. 
Having  introduced  the  extremity  of  a  ligature,  and  the  two  ends  of  a  loop  of 
thread  of  a  different  color  from  the  mouth  and  throat,  and  brought  tliem  out 
by  the  nasal  fossae,  he  engaged  in  his  slightly  curved  canula  the  extremity 
remaining  in  the  mouth,  penetrated  with  this  canula  to  the  bottom  of  the  pha- 
rynx, and  employed  it  for  passing  the  ligature  around  the  polypus;  then 
slipped  over  it  the  noose  of  the  accessory  thread  which  an  assistant  was  charged 
with  drawing  through  the  nostril,  for  the  purpose  of  bringing  through  this 
passage  the  second  end  of  the  ligature,  which  is  then  passed  with  the  first 
through  the  ordinary  serre-noeud. 

e.  Process  of  M.  Boyer. — M.  Boyer,  who  approves  of  these  different  methods 
and  has  tried  the  greater  part  of  them  with  success,  has  found  it  best  under 
some  circumstances  to  substitute  a  catgut  for  the  lio;ature  of  thread  recom- 
mended  by  Desault. 

/.  Process  of  M.  Dubois. — With  the  view  of  preventing  a  collapse  of  the 
noose  of  the  ligature  before  reaching  the  root  of  the  polypus,  M.  Dubois  for- 
merly recommended  it  to  be  enclosed  in  a  piece  of  elastic  sound  about  three 
inches  long,  which  may  be  afterwards  drawn  through  the  nose  by  tractions 
made  as  if  for  turning  the  ligature  over  a  pulley,  by  acting  for  a  moment  on 
one  of  its  extremities  only.  This  little  tube  being  removed,  the  other  end  is 
drawn  so  as  to  bring  them  even,  and  both  are  then  passed  into  the  serre-noeud. 
Unfortunately  this  piece  of  sound  does  not  always  follow  the  direction  in- 
tended to  be  given  to  it.  It  slips  sometimes  to  one  side  and  sometimes  to  the 
other,  and  often  is  of  more  hindrance  than  service,  so  that  means  are  still  to 
be  sought  for,  to  keep  open  the  loop  of  thread  as  far  as  the  top  of  the  pharynx. 

g.  Process  of  M.  Rigaud. — In  the  month  of  January,  1829,  two  new  in- 
struments were  proposed  for  this  purpose.  One  named  by  its  inventor,  M, 
Rigaud,  a  polyodome,  is  composed  of  three  branches  of  steel,  capable  of 
moving,  of  advancing,  and  retiring  separately  or  together,  in  a  strong  canula. 
Bent  into  an  arch  at  their  extremities,  they  form  a  kind  of  forceps  with  three 
branches,  which  are  opened  and  closed  at  pleasure.  The  extremity  of  each 
has  a  bird's-eye  or  opening  continuous  with  a  small  fissure  which  seems  to 
bifurcate  them.  The  middle  of  the  thread  is  fixed  in  these  openings,  and  the 
ends  are  carried  through  the  nose  by  the  sound  of  Bellocq.  The  forceps, 
with  its  three  branches  closed,  is  then  carried  into  the  back  part  of  the  mouth, 
and  are  there  separated  more  or  less  according  to  the  size  it  is  necessary  to 
give  the  noose.  Then  the  end  of  the  instrument  is  elevated  as  much  as  pos- 
sible by  inclining  it  towards  the  nasal  fossae,  and  sometimes  a  little  to  one  side, 
as  in  using  the  polypus  forceps.  To  disengage  the  thread  it  is  sufficient  to 
draw  with  some  force  upon  the  ends  which  hang  out  of  the  nose.  The  two 
halves  of  their  terminal  fissure  being;  elastic  enough  to  hold  the  thread  when 
not  drawn  upon,  easily  let  them  escape  upon  the  pedicle  of  the  tumor.  What 
remains  has  nothing  peculiar. 


444  NEW  ELEMENTS  OF 

h.  Process  of  M.  Felix  Hatin. — The  other,  that  of  M.  Felix  Hatin,  is  a  plate 
of  polished  metal  bent  almost  to  a  right  angle  near  its  pharyngeal  extremity, 
arched  and  rounded  on  its  convex  surface  and  chiefly  at  its  vertical  portion, 
and  may  serve  two  purposes  and  answer  two  indications.  Its  horizontal 
portion  depresses  the  tongue  very  well,  while  the  other  obliges  the  ligature  to 
glide  over  it  until  it  reach  the  polypus.  It  is  a  very  simple  instrument  wliich 
might  be  supplied  in  reality  by  a  table-spoon  bent  forwards  near  the  base  of 
its  handle.  But  the  polyodome  of  M.  Rigaud  is  incontestibly  preferable,  as 
it  occupies  less  space,  conceals  the  parts  less,,  and  carries  the  ligature  more, 
surely  where,  and  as  we  wish;  and  besides  it  can  conduct  it  with  advantage 
without  passing  through  the  mouth  upon  polypi  of  the  anterior  portion  of  the 
nasal  cavities. 

JRemarks. — The  serre-noeud  has  attracted  the  attention  of  a  great  number 
of  practitioners.  Bichat  directed  it  to  be  divided  so  that  withoijt  being  dis- 
placed it  might  be  made  longer  or  shorter  as  occasion  required.  That  of  M. 
Graefe  is  composed  of  two  pieces,  which  slide  one  on  the  other  by  means  of  a 
lateral  button,  which  permits  powerful  strangulation  of  the  polypus  without 
deranging  the  extremity  of  the  threads.  But  the  most  ingenious  of  all  is  that 
which  Roderick,  a  wealthy  individual  of  Cologne,  had  constructed  to  cure 
himself  of  a  polypus  which  had  defied  all  the  eftbrts  of  the  surgeons  of  Brus- 
sels. It  consists  in  passing  the  two  extremities  of  the  thread  brought  through 
the  nose  through  a  series  of  small  ivory  balls,  and  then  fixing  them  on  a  tour- 
niquet or  little  roller.  The  chaplet  which  is  thus  formed  adapts  itself  per- 
fectly to  the  different  curvatures  of  the  nasal  fossie,  and  causes  incomparably 
less  inconvenience  by  its  presence  than  any  other.  To  increase  the  constric- 
tion of  the  polypus,  it  was  only  necessary  to  shorten  this  little  chain  by  turn- 
ing the  roller  or  tourniquet.  The  balls  may  be  made  of  wood,  bone,  or  metal. 
M.  Sauter  had  them  made  of  the  tips  of  ox-horns.  M.  Mayor,  of  Lausanne, 
ordered  them  of  silver,  tin,  &c.,  and  employed  them  upon  polypi,  as  has  been 
said  above  in  the  article  Tongue.  In  fine,  instead  of  the  axle,  M.  Bouchet, 
of  Lyons,  used  a  little  barrel,  while  M.  Levanier  employed  only  a  simple 
catch.  M.  Braun  has  also  thought  proper  to  modify  this  instrument,  previously- 
hinted  at  by  Girault  or  Riolan,  which  the  serre-noeud  of  Desault  most  fre- 
quently renders  useless,  but  which  in  some  cases  may  become  valuable. 

The  process  described  by  Dionis  is  reduced  to  carrying  with  a  crow-bill 
forceps  a  sliding  knot  over  the  pedicle  of  the  tumor,  one  of  the  ends  of  which 
is  then  passed  through  the  nostril  with  a  long  needle  of  lead  or  brass,  and 
brought  through  the  mouth,  while  the  other  remains  at  the  extremity  of  the 
nose.  It  is  scarcely  ever  practicable.  That  of  Glandorp,  modified  by  Gorter, 
renewed  by  Heister,  who  used  with  success  for  applying  the  ligature  in  a 
woman  seventy  years  old  a  bent  needle  fixed  in  a  handle,  with  an  eye  near  its 
point  (very  similar  to  the  needle  invented  by  Goulard  for  tying  the  intercostal 
artery),  cannot  be  reasonably  tried  except  in  cases  where  the  polypus  is  very 
near  the  aperture  of  the  nostril.  Admitting  for  a  moment  that  it  may  be  pro- 
perly fixed  over  the  tumor,  this  species  of  ligature  presents  still  an  incon- 
venience which  the  ancients  seem  not  to  have  noticed.  As  the  anterior  nasal 
opening  descends  below  the  palatine  floor  of  the  nostrils,  the  cord  necessarily 
presses  with  force  on  the  facial  edge  of  this  floor  when  it  is  drawn  through  the 
nose,  and  continually  tends  to  cut  or  at  least  to  excoriate  it.    To  remedy  this 


OPERATIVE    SURGERY.  445 

Levret  proposed  to  add  a  handle  to  the  two  ends  of  the  seton,  which  he  some- 
times advised  to  be  used.    For  the  same  end  M.  Felix  Hatin  recently  proposed 
a  small  plate  to  be  held  vertically  behind  the  lobe  of  the  nose,  where  it  is  to 
act  as  a  return  pulley  and  may  be  made  indifferently  of  metal,  ivory,  horn,  &c., 
and  for  which  a  staff  of  steel,  pierced  superiorly  with  an  eye  for  the  passage  of 
the  thread,  will  be  a  perfect  substitute.  On  the  whole,  the  ligature  is  not  proper 
for  polypi  with  a  large  base,  nor  vesicular  polypi.    In  whatever  manner  it  may 
be  applied,  it  should  be  tightened  every  day  until  the  body  it  embraces  shall 
fall  off.     The  avowed  intention  is  to  produce  mortification  of  the  polypus  by 
intercepting  the  course  of  the  fluids  in  its  pedicle,  which  it  should  at  last 
completely  divide.     Consequently  we  must  expect  to  see  the  tumor  swell 
immediately  after  the  operation,  and  then  to  become  shrivelled  or  decomposed, 
and  require  the  use  of  forceps  or  hooks  when  its  root  is  detached.     On  the 
other  hand,  injections  of  acetated  or  alum  water,  or  some  styptic  or  antiseptic 
solution,  forms  in  this  case  an  accessary  not  to  be  neglected.     Prudence  also 
requires  that  the  patient  should  keep  himself  inclined  forwards,  so  that  the 
putrid  matters  may  not  descend  into  the  digestive  passages.     If  the  polypus 
is  to  fall  into  the  pharynx,  it  will  be  important  previously  to  pass  a  thread 
through  it  by  means  of  a  needle;  otherwise  it  might  be  directed  towardsthe 
opening  of  the  larynx  after  being  detached,  and  cause  danger  of  suffocation, 
x^fter  it  comes  away  it  is  well  to  continue  the  use  of  detersive,  astringent,  or 
styptic  injections  for  a  week  or  two,  if  the  nostril  has  not  entirely  ceased  to 
suppurate.    Having  pointed  out,  in  discussing  these  several  methods,  the  merit 
of  each  in  particular,  it  is  unnecessary  here  to  bring  them  in  comparison  to 
determine 'their  relative  value.     As  no  single  one  can  obtain  an  absolute  pre- 
ference, the  choice  of  the  process  to  be  used  in  each  individual  case  must  be 
left  to  the  sagacity  of  the  surgeon. 

Art,  ^,-^Maxillary  Sirms^ 

§  1.  Perforation. 

The  maxillary  sinus  or  antrum  highmorianum,  is  often  the  seat  of  diseases 
for  which  perforation  has  frequently  been  performed.  Worms,  which  Borde- 
nave,  Fortassin,  Heysham,  &c.,  say  have  been  found  there,  would  without  doubt 
require  it,  if  it  were  possible  to  recognize  their  existence  during  the  life  of 
the  patient :  so  also  with  the  small  bodies  of  adipocire  which  it  has  been 
remarked  are  sometimes  formed  in  it ;  but  recourse  is  especially  to  be  had  to 
perforation,  to  remedy  abscess,  dropsy,  ulcerations,  fungus,  fibrous  and  car- 
cinomatous tumors,  polypus,  necrosis,  and  caries  of  this  cavity.  Jourdain,  who 
about  the  middle  of  the  last  century  insisted  so  much  on  the  advantages  of 
medicinal  injections  through  the  natural  opening  of  the  sinus,  and  on  the  use- 
lessness  of  its  perforation  in  almost  all  its  affections,  has  not  succeeded,  not- 
withstanding the  numerous  reasons  he  advances  in  convincing  practitioners ; 
and  at  the  present  day  his  doctrine  has  no  defenders.  On  the  one  hand,  it  is 
most  frequently  found  to  be  very  difficult,  whatever  may  be  said,  to  discover 
with  a  probe  the  enti-ance  to  the  sinus  in  the  centre  of  the  middle  meatus  of 
the  nasal  fossae ;  on  the  other,  this  opening,  more  frequently  obliterated  by 
disease  than  in  any  other  manner,  would  afford  no  relief  even  should  it  be 


446  NEW  ELEMENTS  OF 

re-established ;  and  taking  every  thing  into  consideration,  artificial  perfora- 
tion, being  less  difficult  and  more  certain,  ought  to  be  preferred. 

1st.  Method  of  Meibomius. — Of  the  various  modes  of  effecting  this  perfora- 
tion, the  most  ancient  is  not,  as  generally  believed,  that  which  consists  in 
penetrating  into  the  cavity  of  the  maxillary  bone  through  the  sockets  of  the 
molar  teeth.  Molinetti,  who  wrote  in  1675,  says,  that  in  a  patient  who  was 
a  prey  to  horrible  pains,  a  crucial  incision  was  made  in  the  cheek,  and  the 
antrum  highmorianum,  which  was  the  seat  of  an  abscess,  was  penetrated  with 
the  crown  of  a  trephine.  It  is  wrong,  morover,  to  give  the  honor  of  it  to  Mei- 
bomius, Zwinger  a  long  time  previously,  after  the  extraction  of  several 
loose,  necrosed  teeth,  healed  a  caries  of  the  maxillary  bone,  by  dilating  the 
diseased  socket  with  prepared  sponge.  Ruysch  remarks,  that  Vanuessen 
destroyed  a  polypus  only  after  extracting  several  molar  teeth  and  cauterizing 
their  sockets  with  red-hot  iron,  so  as  to  admit  the  finger  into  the  maxillary 
sinus.  Some  years  afterwards,  in  1697,  W.  Cowper,  according  to  Drake, 
who  formally  consulted  him,  preferred  the  socket  of  the  first  molar  tooth, 
and  penetrated  the  sinus  with  a  kind  of  punch,  so  as  to  be  able  to  inject 
liquids.  Meibomius,  whose  researches  were  published  in  1718,  so  far  from 
having  invented  this  method,  confined  himself  to  the  extraction  of  a  single 
tooth,  to  give  issue  to  matter  accumulated  in  the  sinus,  the  perforation  of 
which  appeared  to  him  to  be  altogether  dangerous.  This  was  also  the  prac- 
tice followed  by  Saint  Yves  with  success  upon  a  patient  who  had  an  old 
fistula,  attended  with  destruction  of  the  floor  of  the  orbit ;  so  that  it  was 
necessary  for  Cheselden  to  introduce  it  again,  to  attract  the  attention  of  prac- 
titioners^ This  surgeon  preferred  the  extraction  of  the  third,  and  even  of  the 
fourth  tooth  to  that  of  the  first  or  second,  as  laid  down  by  Junker;  and  in  case 
of  an  osseous  fistula,  to  enlarge  it  instead  of  piercing  the  bottom  of  the  socket. 
Since  that  period,  it  has  been  modified  by  different  authors.  Heuerman,  who 
also  prefers  the  socket  of  one  of  the  last  teeth,  recommends,  if  the  pus  does 
not  immediately  escape,  to  perforate  the  sinus  with  a  stylet,  and  to  place  a 
little  canula  in  the  opening,  in  order  to  prevent  its  too  speedy  obliteration. 
Bordenave  judiciously  remarks,  that  with  the  exception  of  the  first,  all  the 
molar  teeth  correspond  to  the  maxillary  sinus ;  and  consequently,  if  one  be 
carious  or  more  painful  than  the  rest,  that  should  be  removed  in  preference, 
but  that  the  third  should  be  extracted  if  all  be  equally  sound.  He  prescribes, 
on  the  other  hand,  the  extraction  of  all  that  are  decayed,  provided  they  are 
nx>  longer  of  service.  A  canula  of  lead,  in  his  opinion,  is  more  proper  than 
sounds  and  bougies  to  keep  the  orifice  open  for  some  length  of  time  ;  and  he 
does  not  think,  after  all,  that  the  process  should  be  the  same  in  every  case. 
Desault,  who  adopted  the  principles  of  Bordenave,  commenced  the  operation 
with  a  trepan  mounted  on  a  swelling  handle,  and  terminated  it  with  another 
instrument  of  the  same  kind  but  with  a  blunt  end,  so  as  not  to  wound  the 
opposite  wall  of  the  sinus.  According  to  B.  Bell,  if  there  is  a  choice,  one  of 
the  posterior  teeth  should  be  extracted,  and  in  the  interval  between  the  dress- 
ings the  orifice  should  be  kept  closed  with  a  plug  of  wood.  Richter  perforates 
the  socket  with  a  trocar.  He  forbids  the  canula  which  is  placed  in  it  to  be 
left  open,  because  particles  of  food  might  be  introduced  through  it  into  the 
sinus.  Deschamps  prescribes  a  permanent  canula  to  be  fastened  to  one  of 
the  teeth  by  a  thread.    The  method  of  Meibomius,  which  offers  the  advantage 


OPERATIVE    SURGERY.  447 

of  placing  the  opening  in  the  most  depending  point  of  the  sinus  and  of  leaving 
no  external  cicatrix,  the  execution  of  which  is  besides  simple  and  easy,  and 
preferable  to  all  others  when  there  is  a  carious  tooth,  should  yet  be  rejected 
in  the  contrary  case,  and  also  when  the  alveoli,  having  long  been  deprived  of 
their  processes,  are  entirely  closed. 

2.  Method  of  Lamorier. — In  this  case,  Lamorier,  a  surgeon  of  Montpellier, 
recommends  the  penetration  of  the  maxillary  sinus  immediately  below  the 
zygomatic  process,  between  the  malar  bone  and  the  third  molar  tooth.  This 
point  corresponds  with  the  summit  of  the  cavity,  and  its  parietes  there  present 
the  least  thickness,  and  it  is  there  more  easily  reached.  An  assistant  with  a 
blunt  hook  draws  the  labial  angle  outwards  and  upwards.  The  operator 
incises  the  fibro-mucous  membrane  which  covers  the  bone  at  the  bottom  of 
the  maxillo-labial  sulcus,  and  on  the  designated  point,  with  a  scalpel  or  good 
bistoury,  traverses  the  osseous  wall  with  a  strong  punch,  enlarges  the  opening 
as  much  as  he  judges  necessary,  and  concludes  by  inserting  into  it  a  tent  of 
charpie. 

3.  Method  of  Molinetti. — Others,  returning  to  the  operation  of  Molinetti, 
have  advised  the  division  of  the  cheek  first  between  the  malar  bone  and  the 
infra-orbitary  foramen,  and  then  penetrating  from  this  wound  into  the  interior 
of  the  sinus;  but  unless  imperatively  demanded  by  the  circumstances,  the 
division  of  the  external  soft  parts  ought  to  be  avoided. 

4.  Method  of  Desault. — Here  Desault  prescribes  entrance  into  the  maxil- 
lary sinus  through  the  canine  fossa,  piercing  beneath  the  superior  lip.  Instead 
of  the  perforators,  one  sharp  and  triangular  and  the  other  blunt,  invented  by 
Desault  for  this  species  of  operation,  Runge,who  practised  in  1740,  employed 
simply  a  scalpel,  which  he  turned  four  or  five  times  on  its  axis  to  enlarge  its 
first  opening.  The  trephine,  which  Charles  Bell  designed  for  the  same  purpose, 
has  neither  greater  nor  less  disadvantages  than  the  scalpel  of  Runge,  or  the 
perforating  trepan  of  Desault. 

5.  Method  of  Gooch. — Upon  a  patient  who  had  no  molar  teeth,  Gooch  con- 
ceived the  idea  of  perforating  the  antrum  highmorianum  through  its  nasal 
surface,  and  fixing  there  a  leaden  canula.  01.  Acrel  had  already  followed 
a  process  nearly  similar ;  that  is,  after  operating  in  the  manner  of  Cowper,  he 
placed  a  second  canula  in  the  sinus  through  the  nose,  which  presented  there  a 
fistulous  opening. 

6.  Method  of  RuffeL — A  buccal  fistula  of  the  maxillary  sinus  suggested  to 
Ruifel  the  idea  of  inserting  there  a  trocar,  and  bringing  it  out  above  the  gum 
to  establish  a  counter- opening.  A  seton  was  then  passed  and  kept  in  this 
passage  for  six  weeks,  when  success  crowned  the  efforts  of  the  surgeon. 

7.  Method  of  Callisen. — Callisen,  who  adopted  the  seton  of  Ruffel,  and  was 
followed  in  tliis  particular  by  Zang,  thinks,  with  reason,  if  fluctuation  is  per- 
ceived at  the  palate  vault,  that  the  artificial  opening  ought  to  be  there 
established.  Busch  and  Henkel  have  fully  succeeded  by  means  of  a  seton 
introduced  through  a  fistula  of  the  floor  of  the  orbit,  and  brought  into  the 
mouth  through  an  opening  in  the  alveoli.  Bertrandi  did  the  same,  except  that 
he  omitted  the  use  of  the  seton  with  a  patient  who  could  not  open  his  mouth, 
and  who  had  also  a  fistula  at  the  orbitary  wall  of  the  sinus. 

8.  Method  of  Weinhold. — In  the  process   which  the   Germans  attribute 
to  Weinhold,  the  surgeon  first  carries  his  instrument  to  the  superior  and 


448  NEW   ELEMENTS  OF 

external  part  of  the  canine  fossa,  and  directs  it  obliquely  downwards  and 
outwards,  avoiding  carefully  the  branches  of  the  infra-orbital  nerve ;  per- 
forates the  sinus,  and  then  fixes  a  dossil  of  lint  in  the  wound.  If  the  sinus 
has  no  other  issue,  Weinhold  directs  it  to  be  perforated  through  and  through, 
either  by  pushing  his  first  instrument  into  the  mouth  through  the  palate  vault, 
or  by  a  curved  needle  when  he  means  to  place  the  counter-opening  without 
the  gum  and  above  the  alveoli.  An  eye,  which  is  found  in  both  instruments, 
permits  a  thread  to  be  drawn  at  the  same  time  through  the  sinus,  conducting 
a  roll  of  lint  designed  to  perform  the  oflice  of  a  seton,  which  is  covered  with 
some  appropriate  medicament.  This  method  approaches  nearly  that  of  Ruffel 
or  of  Henkel,  and  may  be  tried  as  well  as  that  of  Desault  or  Lamorier.  It 
resembles  also  that  of  Nessi,  who,  after  having  largely  opened  the  sinus 
through  the  mouth,  inserts  a  trocar  and  destroys  as  much  as  possible  of  the 
anterior  wall  below  the  malar  bone  or  the  canine  fossa. 

Remarks, — On  the  whole,  perforation  into  the  maxillary  sinus  is  performed 
in  the  point  of  election  or  of  necessity.  The  first  may  vary  according  to  the 
ideas  of  the  operator.  The  circumstances,  on  the  contrary,  determine  the 
second.  In  case  of  abscess,  dropsy,  fistulas,  and  ulcerations,  the  operation  is 
almost  always  performed  in  the  place  of  election.  Then,  provided  one  of  the 
molar  teeth  be  unsound,  it  must  be  extracted,  together  with  the  adjoining 
tooth ;  the  gum  is  then  to  be  cut  down  to  the  bone,  externally,  internally, 
behind,  and  before,  forming  a  kind  of  square  flap,  and  to  be  completely  de- 
tached from  the  surrounding  tissues ;  after  this,  the  alveoli  are  to  be  perforated 
with  the  instruments  of  Desault,  and  an  opening  made  large  enough  to  admit 
the  finger  into  the  sinus.  M.  Boyer,  who  follows  this  process,  insists  with 
reason  on  the  necessity  of  giving  this  opening  considerable  dimensions.  If 
all  the  teeth  are  perfectly  sound,  or  if  the  patient  has  lost  them  a  long  time 
before,  and  the  alveolar  margin  is  round  and  full,  preserving  its  natural 
firmness,  the  method  of  Desault  or  Lamorier,  in  my  opinion,  deserves  the 
preference.  Supposing  that  it  does  not  succeed,  there  will  always  be  time 
to  have  recourse  to  that  of  Meibomius,  which,  it  cannot  be  denied,  is  incom- 
parably more  painful  and  terrifying  to  the  patient. 

§  2.  Foreign  Bodies ;  Polypi, 

Simple  extraction  of  a  foreign  body,  a  ball,  shot,  or  splinters  of  bone,  for 
example,  must  be  effected  through  the  anterior  wall  of  the  sinus.  When  a 
polypus,  a  fungus,  or  a  necrosis,  on  the  contrary,  is  to  be  removed,  reason 
requires  that  we  should  attack  it  at  the  point  to  which  it  seems  naturally 
to  tend,  or  which  has  sustained  the  greatest  alteration.  Thus  it  sufiiced 
Dubertrand,  in  extirpating  a  polypus  of  this  description,  to  unite  the  two 
alveoli  by  breaking  down  the  division  between  them,  and  removing  the  frag- 
ments of  carious  bone ;  while  Caumont  was  obliged,  in  a  patient  who  had 
fruitlessly  submitted  to  a  similar  operation,  to  reach  the  tumor  through  the 
canine  fossa  where  it  showed  itself;  and  again,  it  was  necessary  in  the  case 
cited  by  Chastenet,  to  destroy  nearly  half  of  the  maxillary  bone  with  its  pala- 
tine process  to  accomplish  the  same  purpose.  When  the  antrum  highmorianum 
is  opened  for  the  sole  intention  of  giving  free  issue  to  the  matters  it  secretes 
or  exhales,  the  sequel  of  the  operation  is  reduced  to  simply  detersive,  astrin- 


OPERATIVE  SURGERY.  449 

gent,  antiseptic,  or  dessiccative  injections,  until  the  bottom  of  the  wound  is 
covered  with  cellular  granulations  of  a  good  red  color.  If,  at  the  same  time 
any  necrosed  osseous  portions  exist,  they  are  to  be  removed.  In  this  case  it 
is  often  necessary  to  prolong  the  incisions,  enlarge  the  opening,  and  have 
recourse  to  the  saw,  scissors,  cutting  nippers,  or  the  gouge  and  mallet.  The 
same  occurs  in  case  of  exostosis,  and  every  other  alteration  of  the  osseous 
tissue.  When  the  sinus  contains  a  polypus,  the  tumor  is  treated  as  if  it  were 
in  the  nose ;  with  this  difference,  that  extraction,  which  is  generally  applicable, 
rarely  fails  of  being  sufficient,  and  it  cannot  be  seen  at  least  what  advantage 
is  here  presented  by  the  ligature.  After  its  periphery  has  been  isolated,  and 
its  pedicle  or  base  displayed,  it  is  grasped  with  polypus  forceps,  or,  if  found 
more  convenient,  with  the  forceps  of  Museux,  which  has  been  frequently  used 
by  Dupuytren.  It  is  then  extracted  by  pulling,  or  rather  by  twisting  it  upon 
itself.  If  it  has  not  sufficient  density  to  resist  the  grasp  of  the  forceps,  it  is 
removed  by  incision  after  making  it  yield  as  much  as  possible ;  and  if  any 
osseous  bands  or  lamellae  prevent  its  extraction,  they  are  to  be  divided  with- 
out hesitation,  at  least  whenever  there  is  no  danger  in  touching  them.  When 
it  has  more  breadth  than  prominence,  or  when  instead  of  polypus  we  meet 
with  fungi  or  any  other  degeneration,  we  are  sometimes  obliged  to  remove 
piece  by  piece  w^ith  the  common  or  probe-pointed  bistoury,  or  a  scalpel  with  a 
truncated  point,  short,  wide,  a  little  bent  on  the  side  like  the  knife  of  F.  de 
Hilden,  devised  by  Pelletan,  and  approved  by  M.  Boyer ;  or,  in  fine,  with  any 
other  appropriate  instrument ;  a  kind  of  cutting  spoon,  like  that  of  Bartisch,  for 
instance,  which  is  sometimes  employed  by  M.  Dupuytren.  On  the  other 
hand,  if  the  tumor  be  too  voluminous  for  easy  extraction  through  the  maxillo- 
labial  fissure,  we  must  incise  boldly  the  whole  depth  of  the  lip  or  one  of  its 
commissures,  in  the  most  suitable  direction.  The  twisted  suture  renders 
union  of  this  wound  so  easy,  that  it  would  be  truly  culpable  to  neglect  it 
whenever  the  operation  would  be  simplified  by  its  use.  Caustics  may  be 
applied  to  destroy  what  could  not  be  removed  by  extraction  and  excision. 
Mineral  acids,  butter  of  antimony,  and  better  than  all,  the  acid  nitrate  of 
mercury  applied  by  means  of  fdrceps,  and  retained  by  dossils  of  lint,  have  the 
advantage  of  not  transmitting  far  their  action,  as  does  the  actual  cautery, 
which  in  this  point  in  particular  is  to  be  dreaded  on  account  of  the  vicinity  of 
the  eye.  However,  it  is  to  be  remembered,  that  Garengeot  only  succeeded  in 
destroying  a  fungous  mass  of  the  antrum  maxillare,  by  consuming  it  with  red- 
hot  iron,  after  it  had  resisted  repeated  excision,  extraction,  and  chemical 
escharotics.  The  nitrate  of  silver,  alum,  sulphate  of  iron  or  copper,  and  every 
substance  rather  styptic  than  really  caustic,  are  not  adapted  in  truth  but  to 
vegetations,  small  ulcers,  and  swellings;  in  a  word,  to  alterations  uncon- 
nected with  the  bones  and  exhibiting  none  of  the  character  of  malignity.  It 
need  not  be  said  that  if  a  misplaced  tooth  be  the  cause  of  the  disorder,  it 
should  be  sought  for  and  immediately  extracted.  The  records  of  the  art 
contain  facts  extremely  curious  on  this  point;  for  example,  the  one  pub- 
lished by  M.  Dubois.  Expecting  to  find  a  fungous  tumor,  this  practitioner 
saw  only  a  turbid  liquid  matter  flow  from  the  maxillary  sinus,  into  which  he 
had  just  made  a  large  opening  above  the  dental  range.  The  wound  soon 
closed,  but  the  tumor  remained.  With  the  assent  of  Messrs.  Pelletan  and 
Boyer,  &c.,  M.  Dubois  extracted  three  teeth,  removed  a  large  portion  of  the 
57 


450  NEW    ELEMENTS    OF 

alveolar  margin,  and  thus  entirely  brought  to  view  the  antrum ;  he  found  no 
fungus,  but  perceived  at  the  top  of  the  cavity  in  the  substance  of  its  anterior 
wall  a  whitish  projection,  which  was  nothing  but  a  tooth,  an  incisor,  whose 
root  was  found  rivetted  as  it  were  in  the  sinus.  As  to  hemorrhage,  these 
several  manoeuvres  sometimes  render  it  so  abundant,  as  to  require  the  opera- 
tion to  be  temporarily  suspended.  If  it  does  not  stop  spontaneously,  eau- 
de-Rabel,  vinegar  and  water,  or  plugging  with  balls  of  charpie  springled  with 
rosin,  and  even  on  emergency  heated  iron,  are  at  the  disposal  of  the  surgeon, 
and  always  aiford  an  efficacious  remedy. 

Art.  3. — Frontal  Sinus;  Perforation, 

The  direct  communication  of  the  frontal  sinus  with  the  middle  meatus  of 
the  nasal  fossae,  renders  the  perforation  of  them  rarely  indispensable.  The 
polj'pi  which  are  sometimes  developed  there,  soon  extend  into  the  nose,  where 
they  may  be  reached  with  the  forceps  as  well  as  if  they  sprung  from  any  other 
point  of  the  nostril.  Heister  is  said  to  have  extracted  them  by  this  passage. 
Pus,  glaiy  mucus,  sebaceous  and  fibrinous  concretions,  and  worms,  have  all 
been  found  in  them,  but  less  frequently  than  in  the  maxillary  sinus ;  yet  it  is 
rare  that  these  substances  accumulate  there  in  any  quantity,  and  do  not  find 
issue  through  the  nose.  The  perforation  of  the  frontal  sinus  is  therefore 
really  indicated  but  under  very  few  circumstances.  Without  being  difficult 
or  delicate,  its  execution  nevertheless  requires  some  important  precautions 
which  are  not  to  be  neglected.  Thus,  in  order  to  strike  as  low  as  possible 
upon  the  frontal  cavity,  it  will  be  proper,  in  my  opinion,  to  lay  bare  the  bone 
between  the  supra-orbitary  foramen  and  the  root  of  the  nose.  Then  the 
small  crown  of  the  trepan,  or  Desault's  instrument  for  the  maxillary  sinus,  is 
to  be  directed  obliquely  backwards,  upwards,  and  inwards.  Through  this 
opening,  more  or  less  enlarged  with  forceps,  a  hook,  crotchet,  or  scissors,  we 
are  to  seek  for  the  tumor  or  the  foreign  bodies  to  be  extracted  ;  apply  a  tent 
simple  or  medicated  to  the  disease ;  make  injections  and  introduce  caustics,  or 
even  the  hot  iron  if  necessary.  The  air  which  penetrates  freely  from  the 
opening  of  the  frontal  sinus  through  the  nose,  and  vice  versa,  seems  at  first 
view  to  become  an  insurmountable  obstacle  to  artificial  cicatrization,  and  to 
convert  it  almost  necessarily  into  a  fistula.  This  has  been  observed  more 
tlian  once;  and  M.  Dupu}'tren  and  some  other  practitiojiers  look  upon  it  as 
tiie  constant  result.  But  we  have  at  present  sufficient  proof  of  the  contrary, 
so  that  we  need  not  hesitate  on  account  of  this  opinion.  Wounds  of  the 
frontal  sinus  close  quite  as  well  as  those  of  the  antrum  highmorianum,  and 
their  chief  inconvenience  consists  in  leaving  indelible  cicatrices  on  one  of  the 
most  striking  parts  of  the  countenance 

Section  v. 

The  P'ace. 
Art.  1. — Osseous  Cysts. 

Tumors  filled  with  turbid  serosity,  as  in  ranula;  or  of  a  fibrous,  fatty,  or 
fungous  nature;  or  even  composed  of  several  of  these  elements  at  once,  have 
often  been  observed  without  the  maxillary  sinus,  and  in  the  very  substance  of 


OPERATIVE    SURGERY.  451 

the  bones  of  the  face.  Rurige,  who  appears  to  be  one  of  the  first  to  notice 
them,  sajs  that  his  father  and  himself  had  met  with  them  in  either  jaw,  and 
that  their  point  qJ[  departure  is  often  from  the  summit  of  a  dental  root.  It  is 
probable  also,  that  those  pretended  lymphatic  congestions,  the  parietes  of 
which  were  as  thin  as  parchment,  which  Kirkland  locates  in  the  antrum  high- 
morianum,  belonged  to  the  same  kind  of  affection.  Did  notCallisen  fall  into 
the  same  error  when  speaking  of  tumors  with  separate  compartments,  which 
according  to  him  required  the  extraction  of  several  teeth  ?  Siebold,  who  saw 
an  osteo-sarcoma  between  the  laminae  of  the  sinus,  made  section  of  it  without 
causing  pain,  and  cured  his  patient;  and  has  distinguished  better  than  his 
predecessors  the  special  position  of  the  disease.  Runge,  who  besides  de- 
scribes it  very  well,  did  not  let  the  fact  escape  that  upon  pressure  with  the 
finger  it  recedes  returning  immediately  afterwards  to  its  place  tvith  iioise, 
ranks  it  among  the  affections  of  the  sinus.  Sprengel  accuses  him  of  using 
several  times  in  his  dissertation,  inadvertently,  no  doubt,  the  inferior  jaw  for 
the  superior  jaw.  In  this  the  learned  historiographer  is  evidently  mistaken. 
It  is  certainly  the  inferior  jaw  that  Runge  means  when  he  speaks  of  it.  Only 
he  uses  improperly  the  term  sinus,  in  designating  tumors  which  have  their  seat 
without  the  cavities.  These  isolated  facts  had  fixed  no  attention,  and  to  M. 
Dupuytren  is  the  honor  due  of  giving  in  his  clinical  lectures  detailed  notions 
of  the  disorder  here  treated  of.  I  have  met  with  four  cases.  The  two 
patients  from  the  vicinity  of  Tours,  given  by  M.  Fabre  in  La  Clinique  had 
been  submitted  to  my  examination  before  being  operated  upon  by  M,  Dupuy- 
tren. Although  without  the  sinuses,  and  observed  more  frequently  on  the 
inferior  than  the  superior  jaw,  and  on  the  ramus  as  well  as  the  body  of  the 
bone,  the  tumor  nevertheless  nearly  ahvays  bears  some  relation  to  a  diseased 
state  of  the  teeth.  Similar  in  form  and  external  appearance  to  carcinomatous 
or  fungous  tumors,  it  differs  from  them  essentially,  in  being  more  easily  over- 
come by  art.  Analogy  leads  to  the  opinion,  that  the  various  treatments 
approved  of  in  lesions  of  the  maxillary  sinus,  would  be  usually  applicable  to 
these ;  and  that  by  opening  them  on  the  internal  face  of  the  lips  or  cheeks, 
when  they  are  situated  so  as  to  admit  of  this  operation,  many  of  them  would 
disappear,  so  that  it  would  be  no  great  disadvantage  to  confound  them  with 
polypus  or  other  tumors  developed  in  the  antrum  highmorianum,  as  happened 
to  the  father  of  Runge,  and,  quite  recently,  to  M.  Dupuytren  himself.  But 
until  the  present,  at  least,  M.  Dupuytren  has  found  it  sufficient  to  cut  exten- 
sively through  the  cheek,  then  make  injections,  and  place  every  day  a  tent  of 
charpie  in  the  wound,  to  produce  its  diminution  and  revolution. 

Art,  2. — Section  of  the  Facial  Nerves., 

Neuralgia  of  the  face,  a  cruel  disorder,  and  characterized  by  the  severest 
pains,  has  often  been  subdued  by  division,  cauterization,  and  excision  of  the 
affected  nervous  trunk.  It  was  natural  to  suppose,  that  by  destroying  tlie  con- 
tinuity of  the  sensitive  cords,  transmission  of  pain  to  the  cerebrum  would  be 
prevented,  and  the  disease  be  thus  completely  removed.  But  as  the  nerves 
are  possessed  of  no  power  of  retraction,  it  was  to  be  feared  on  the  other  hand, 
that  after  being  divided  they  might  immediately  reunite,  and  therefore  that 
«imple  division  would  not  be  followed  by  a  lasting  relief.    Experience  has 


452  XEW  ELEMENtS  OF 

unfortunately  but  too  well  confirmed  these  apprehensions.  Hence  the  idea  of 
destroying  enough  of  the  nerves  to  render  impossible  the  re-establishment  of 
their  continuity,  presented  itself.  Caustics  or  fire,  proposed  to  fulfill  this  indi- 
cation, have  the  serious  disadvantage  of  producing  large  cicatrices,  and  horribly 
disfiguring  the  patient.  In  our  times  the  cutting  instrument  has  been  gene- 
rally substituted  in  their  place.  By  means  of  an  incision  in  a  line  vi^ith  the 
corrugations  of  the  skin,  of  the  muscular  fibres,  or  the  principal  vessels,  they 
may  be  exposed  at  their  exit  from  the  bones  and  cut,  before  sending  oft*  any 
branches,  and  a  portion  two  or  three  lines  long  removed.  The  wound,  uniting 
by  the  first  intention,  is  unperceived  after  healing  among  the  lines  of  the  facCj 
and  the  continuity  of  the  nerve  being  forever  destroyed,  it  seems  impossible 
that  neuralgia  should  not  be  arrested  by  such  powerful  means.  Nothing  is 
wanting  on  this  point,  but  that  clinical  observation  should  never  have  contra- 
dicted the  theory.  Often,  too  often,  the  disorder  resists  the  best  performed 
excision  as  well  as  mere  incision,  and  many  patients  have  not  been  more 
relieved  by  one  of  these  operations  than  by  the  other,  nor  by  the  deepest 
cauterization.  At  the  hospital  St.  Antoine,  in  1829,  there  was  a  man  of  about 
forty-five  years  of  age,  who  for  fifteen  years  was  afflicted  with  a  tic  douloureux, 
and  who  submitted  successively  to  section  and  excision  of  all  the  nerves  of 
the  face,  without  any  kind  of  benefit.  However,  as  more  fortunate  results 
have  been  published,  when  all  other  modes  of  treatment  have  been  vainly 
tried,  especially  when  the  suffering  is  extremely  severe,  it  is  a  last  resource  to 
propose  to  the  patient,  and  of  which  perhaps  it  would  be  inhuman  to  deprive 
him.  The  cords  which  may  be  subjected  to  it  are  four  in  number ;  the  frontal, 
the  infra -orbital,  the  inferior  dental  and  the  facial. 

Frontal. — To  derive  all  possible  advantage  from  excision  of  the  supra-orbital 
nerve,  it  should  be  taken  at  the  point,  where,  issuing  from  the  supra- orbitary 
foramen,  it  is  reflected  and  passes  over  i\\Q  bone  before  the  origin  of  the 
anastomosing  branches  which  part  from  it  to  be  united  with  the  neighboring 
nerves.  Here  it  is  only  covered  by  the  skin,  a  thin  layer  of  cellular  tissue,  and 
some  pale  fibres  of  the  orbicularis  muscle.  The  artery  that  accompa- 
nies it  is  not  of  sufficient  size  to  cause  fear  if  wounded,  and  in  the  vicinity 
no  other  organ  is  seen  which  can  be  exposed  to  the  touch  of  the  instrument* 
If  not  distinguished  at  first  sight  through  the  integuments,  it  is  only  neces- 
sary, for  determining  its  location,  to  recollect  that  the  fissure  or  canal  which 
gives  it  passage,  is  found  at  the  union  of  the  internal  third  with  the  external 
two-thirds  of  the  superior  orbitary  arch,  or  about  an  inch  from  the  root  of  the 
nose ;  and  by  running  the  finger  along  the  edge  of  the  orbit  from  the  nasal 
apophysis  to  the  temporal  apophysis  of  the  frontal  bone,  it  is  almost  always 
possible  to  determine  its  exact  position. 

The  operator,  placed  behind  the  head  of  the  patient,  lifts  the  eyebrow  with 
his  left  hand,  while  the  lids  are  depressed  by  an  assistant;  assures  himself 
anew  of  the  place  occupied  by  the  diseased  nerve ;  takes  a  bistoury  in  his 
right  hand,  holding  it  as  a  pen;  applies  its  point  upon  the  intenial  orbitary 
apophysis;  brings  it  upwards,  then  outwards,  and  divides  all  the  tissues  down 
to  the  bone  to  tlie  extent  of  an  inch,  a  little  above  and  in  the  direction  of  the 
adherent  edge  of  the  eye-lid  ;  separates  gently  the  edges  of  this  crescentic 
wound;  finishes  the  section  of  the  nerve,  if  not  already  complete;  takes  hold 
of  ilA  anterior  end  with  a  good  dissecting  forceps ;  insulates  it;  and  excises  a 


OPEIUTIVE    SURGERY,  453 

sufficient  portion  to  prevent  the  subsequent  re-establishment  of  continuity  of  its 
two  extremities.  The  immediate  union  of  the  integuments  may  be  permitted 
to  take  place.  The  loss  of  substance  in  the  nerve  gives,  as  far  as  that  organ 
is  concerned,  all  security  on  this  point.  Yet,  as  the  least  infiltration  of  hete- 
rogeneous fluid  in  the  midst  of  lamellae  so  flexible,  and  tissues  so  easy  of 
separation  as  those  of  the  eye-lids,  the  orbit,  and  the  forehead,  might  induce 
purulent  collections  and  dangerous  inflammation,  it  seems  to  me  prudent,  as  a 
general  rule,  to  permit  the  wound  to  suppurate.  It  is  therefore  dressed  lightly 
with  a  pledget  of  lint  spread  with  cerate ;  or,  if  there  be  hemorrhage  (but  only 
for  the  first  time),  with  a  little  soft  linen  and  rolls  of  charpie.  No  other  care 
is  demanded  than  in  simple  wounds,  and  cicatrization  soon  takes  place. 

2d.  Infra-orbital  Nerve. — More  deeply  situated,  surrounded  by  parts  more 
important,  and  spreading  at  its  exit  from  the  bone,  the  infra-orbital  nerve, 
is  much  less  easy  of  excision  than  the  preceding;  but  on  the  other  hand, 
it  is  much  less  subject  to  neuralgia.  Two  courses  may  be  followed  to  reach 
it.  The  first  is  through  the  mouth.  Prolonging  an  inch  upwards  the  furrow 
in  which  the  lip  meets  the  jaw,  we  traverse  the  whole  depth  of  the  canine 
fossa,  and  arrive  at  the  root  of  the  nerve,  which  is  found  in  the  direction  of 
the  first  molar  tooth,  three  or  four  lines  below  the  orbit.  The  bistoury,  which 
were  necessary  in  the  first,  is  to  give  place  to  straight  scissors  in  the  last 
stage  of  the  operation.  Followed  by  M.  Richerand,  who  even  impinges  on 
the  bone  with  his  instrument,  this  method,  the  principal  advantage  of  which 
is  to  leave  no  traces  on  the  countenance,  only  admits  of  simple  division  of  the 
cord,  which  should  be  excised.  In  the  other,  the  instrument  traverses  from 
the  skin  to  the  bone  all  the  soft  parts  that  compose  the  cheek,  and  hence  it  is 
much  more  dreadful,  at  least  to  the  fair  sex.  Fortunately,  by  following  the 
natural  lines  of  the  face  instead  of  being  governed  exclusively  by  the  direc- 
tion of  the  fleshy  fibres,  it  is  possible  to  obtain  a  cicatrix  scarcely  perceptible. 

Process. — The  patient  should  be  seated,  dressed,  and  held  as  in  all  other 
operations  on  the  face.  Armed  with  a  straight  bistoury,  and  placed  in  front, 
the  surgeon  makes  an  incision  at  the  bottom  of  the  naso-jugal  line,  that  is,  of 
the  depression  or  line  extending  obliquely  from  the  ala  of  the  nose  towards 
the  middle  of  the  space  which  separates  the  prominence  of  the  cheek  from  the 
corresponding  labial  angle;  in  this  direction  then  he  makes  an  incision  from 
an  inch  to  an  inch  and  a  half  long,  beginning  at  the  external  face  of  the 
perpendicular  apophysis  of  the  maxillary  bone,  dividing  at  first  but  the  skin  ; 
he  then  soon  meets  with  the  facial  vein,  which  he  pushes  outwards,  some  fat, 
and  the  proper  elevator  of  the  lips,  which  he  pushes  inwards,  and  the  canine 
muscle,  which  often  conceals  the  nerve  by  its  internal  border ;  he  then  uses  a 
steel  director  to  put  aside  all  these  objects,  tears  the  filaments  and  layers 
which  still  conceal  or  may  conceal  the  aflected  nerve,  cuts  the  nerve  close  to 
the  infra-orbitary  foramen,  removes  a  portion  of  it,  and  the  operation  is  done. 
3d.  Inferior  Dental  Nerve. — ^The  inferior  maxillary  nerve  issues  from  the 
jaw  through  the  mental  foramen  below  the  osseous  furrow,  which  separates 
the  alveoli  of  the  canine  and  first  molar  tooth.  This  point  is  very  easily  reached . 
While  with  one  hand  he  inverts  the  lip  outwards  and  downwards,  the  surgeon 
with  the  other  cuts  through,  layer  by  layer,  from  above  downwards,  with  a 
straight  bistoury,  the  tissues  at  the  bottom  of  the  maxillo -labial  sulcus.  The 
above  mentioned  teeth  are  his  guides.    At  the  depth  of  several  lines  he  meets 


454 


Nr.W    ELEMENTS    OF 


with  the  nerve ;  insulates  it  to  the  extent  of  a  quarter  of  an  inch,  bj  separating 
from  the  jaw  the  posterior  face  of  the  soft  parts  wliich  cover  it,  and  excises  it, 
following  the  course  laid  down  for  the  frontal,  and  using  no  dressing. 

An  American  surgeon.  Dr.  Warren,  has  been  bold  enough  to  seek  for  the 
trunk  of  the  maxillary  nerve,  and  perform  its  excision  in  front  of  the  pterygoid 
muscles.  A  crucial  incision  of  the  skin,  of  the  parotid  gland,  and  masseter 
muscle,  allowed  him  to  apply  the  crown  of  a  trepan  upon  the  coronoid  pro- 
cess, and  seize  the  nerve  with  a  stylet  above  the  dental  canal,  and  remove 
about  three  lines  of  it  with  the  scissors.  The  artery  was  woUnded,  and 
tied  without  difficulty.  The  patient,  whom  other  excisions  had  temporarily 
relieved  but  not  cured,  and  who  still  experienced  horrible  pain,  ceased  to 
suffer  after  the  operation,  and  has  continued  well  ever  since.  Ze  vraipeut 
71* ef  re  pas  vraisemblabte. 

4th.  T7ie  Facial. — Spread  over  almost  every  point  of  the  face,  the  portio  dura 
of  the  seventh  pair  would  at  first  seem  to  be  more  subject  to  facial  neuralgia, 
and  therefore  has  been  frequently  excised.  Its  temporo-genal  branch,  the 
only  one  which  has  been  ventured  upon,  crosses  the  neck  of  the  condyle  of 
tlie  jaw  at  the  place  where  the  lobe  of  the  ear  is  continuous  with  the  integu- 
ments of  tlie  face.  At  this  point  it  is  proper  to  expose  it.  An  incision  is  made 
a  little  oblique  from  before  backwards  or  nearly  Vertically,  which,  beginning 
from  the  zygomatic  process,  terminates  on  the  posterior  edge  of  the  jaw  above 
its  angle.  We  must  divide  successively  the  cellulo-adipose  layer,  an  aponeu- 
rotic expansion,  and  several  small  prolongations  of  the  parotid  gland,  before 
finding  the  nerve,  which  is  separated  from  the  bone  only  by  lamellated  and 
filamentous  cellular  tissue.  In  this  way  the  temporal  artery  is  avoided  with 
certainty;  and  if  the  transversalis  faciei  be  wounded,  it  will  be  very  easy  to 
compress  it  if  the  hemorrhage  should  prove  troublesome.  The  other,  the 
cervico-facial  branch,  lost  as  it  were  in  the  parotid,  presents  too  much  anomaly 
of  position,  and  the  trunk  itself  of  the  facial  runs  too  deep  and  is  surrounded  by 
too  important  parts,  to  let  us  think  of  its  excision.  An  appeal  ought  to  be 
taken  from  this  judgment,  without  rashness.  I  have  assured  myself  frequently 
on  the  dead  subject,  that  the  nerve  now  spoken  of  may  be  exposed  without 
danger  at  its  exit  from  the  cranium,  before  it  has  given  off  any  other  branches 
tlian  the  mastoid,  digastric,  and  stylo-hyoid  filaments.  For  this  purpose  the 
operator  has  but  to  make  a  vertical  incision  an  inch  and  a  half  in  length  between 
the  mastoid  process  and  the  lobe  of  the  ear,  and  keeping  close  to  the  anterior 
face  of  the  bony  process  and  the  corresponding  margin  of  the  sterno-mas- 
toid  muscle,  to  divide  to  the  depth  of  from  six  to  ten  lines,  the  integuments, 
the  cellular  expansion,  and  the  parotid,  which  is  to  be  drawn  forwards.  The 
lips  of  the  wound  being  separated,  the  nerve  is  to  be  see;i  at  the  bottom,  near 
the  middle  of  the  space  which  separates  the  temporo -maxillary  articulation 
from  the  summit  of  the  mastoid  process,  where  it  appears  to  direct  itself  to- 
wards the  edge  of  the  inferior  maxillary.  The  division  and  even  the  excision 
of  this  nerve,  is  then  as  simple  and  as  easy  as  that  of  the  frontal ;  and  it  is  at 
once  evident,  that  this  alone  can  offer  all  desirable  guaranty  in  this  case,  pro- 
vided these  several  excisions  of  the  nerves  be  the  temedy  for  facial  neuralgia.  I 
raise  purposely  here  some  doubts  of  their  value,  because  facts  have  not  yet  pro- 
nounced conclusively  in  their  favor.  If  in  some  cases  they  have  been  followed 
by  a  marked  diminution,  or  even  a  complete  cessation  of  pain,  they  have 


OJ»ERATIVE    SURGERY.  455 

been  seen  much  more  frequently  to  produce  no  relief  or  but  a  momentary 
ease.  I  have  already  mentioned  a  man  who  had  submitted  to  them  all  on  both 
sides  of  the  face,  without  any  appreciable  advantage ;  and  M.  Boyer  has  im- 
parted to  me  a  similar  observation.  The  patient  upon  whom  he  excised,  one 
after  the  other,  the  four  principal  nerves  of  the  face  was  at  first  slightly  re- 
lieved, but  was  not  more  Completely  cured  than  he  whom  I  have  mentioned. 
Moreover,  if  the  opinions  of  Ch.  Bell  are  correct ;  if  it  is  true  that  the  frontal 
infra-orbital  mental ;  in  a  word,  all  the  branches  of  the  fifth  pair  are  exclusively 
sensitive,  while  the  seventh  pair  presides  over  only  the  muscular  actions  of 
the  face,  it  is  evident  that  the  division  of  the  latter  will  only  produce  paralysis 
of  the  muscles  of  the  face,  and  it  is  only  to  that  of  the  three  others  that  we 
are  to  look  for  what  concerns  neuralgia. 


SECTION    VI. 

Auditory  Apparatus. 

^Srt.  1. — External  Ear. 

§  1.  Otoraphy. 

Pibrac,  and  those  who,  like  him,  in  the  last  century  declaimed  against  the 
abuse  of  sutures,  were  wrong  in  proscribing  that  of  the  ear.  If  it  be  true 
that  in  wounds  of  the  pavilion  of  this  organ,  adhesive  strips,  position,  and  a 
bandage  sometimes  suffice  to  produce  a  good  cicatrization,  it  is  also  true  that 
these  means  often  fail,  and  are  altogether  inferior  to  the  suture.  When  it  is 
performed,  in  whatever  manner,  I  see  no  reason  for  including  only  the  skin 
and  placing  as  many  stitches  behind  as  before,  in  order  to  avoid  the  cartilage, 
according  to  directions  given  by  the  ancients.  Leschevin,  and  quite  recently 
M.  H.  Larrey,  have  siiown  that  there  is  no  inconvenience  in  including  the 
whole  thickness  of  the  ear  in  the  loop  of  the  stitch.  Every  w^ound  by  a  cut- 
ting instrument  which  completely  divides  the  external  ear,  should  be  imme- 
diately closed  by  the  suture.  Old  divisions  are  to  be  treated  in  the  same  way 
after  making  a  fresh  wound  of  their  edges,  conforming  in  other  respects  to 
the  principles  laid  down  under  the  article  Hare-lip.  However  slender  may 
be  the  pedicle  of  the  flap,  the  division  of  it  should  never  be  completed  before 
attempting  to  restore  it  to  its  place  and  procure  its  coaptation  by  the  suture. 
If  it  mortify  we  are  but  where  we  were,  and  may  remove  it  and  leave  the 
wound  to  heal  by  the  second  intention.  The  facts  observed  at  Heidelberg, 
by  M.  Hoftaker,  show,  moreover,  that  we  should  not  lose  all  hope  of  seeing 
on  the  ear  as  on  the  nose,  the  adoption  of  a  flap  which  had  been  completely 
separated  from  the  living  tissues  by  the  wound. 

§  2.  Otoplasm, 

The  art  of  patching  the  ear  is  as  ancient  as  that  of  replacing  the  nose. 
Galen,  Paulus  Egineta,  and  Celsus,  mention  both.  There  is  every  reason  to 
believe  that  the  Brancas,  and  several  other  surgeons  of  Italy,  caused  it  to  make 
new  progress  in  the  course  of  the  fifteenth  and  sixteenth  century.  In  the 
case  he  relates,  Tagliacozzi  says,  that  after  the  cure  the  resemblance  between 


456  NEW   ELEMENTS   OF 

the  two  ears  was  so  exact,  that  they  might  easily  be  mistaken  for  each  other. 
Since  then,  however,  there  has  not  been  much  notice  taken  of  otoplasm ;  so 
that  M.  Dieft'enbach,  of  Berlin,  who  performed  it  with  success,  may  in  some 
measure  be  considered  as  its  inventor.  Doubtless  if  the  whole  external  ear 
was  removed,  we  could  not  think  of  reconstructing  it,  but  would  decide  on 
replacing  it  by  a  metallic  one ;  but  when  it  is  only  partially  destroyed,  and 
at  least  one  half  yet  remains,  we  may  attempt  to  restore  it  to  its  natural 
dimensions.  The  lobe  especially  is  very  easily  reproduced.  When  the  loss 
of  substance  does  not  extend  beyond  the  ante-helix,  or  even  when  it  comprises 
nearly  the  whole  of  the  helix,  we  should  not  despair  of  success.  Without 
even  acquiring  the  firmness  of  the  destroyed  cartilage,  the  new  tissues  which 
are  put  in  its  place  become  sufficiently  firm  to  render  the  deformity  much  less 
siiocking.  As  in  the  case  of  the  nose,  the  skin  of  the  neighboring  parts  is  to 
supply  materials  for  the  repairs.  We  begin  by  excising,  smoothing,  making 
raw,  the  affected  edge  of  the  ear.  We  then  incise  above,  below,  or  at  the 
posterior  part  of  the  concha,  the  integuments  covering  the  temple,  the  mastoid 
process,  or  the  subauricular  depression  of  the  neck,  a  little  nearer  the  meatus 
auditorius  than  the  level  of  the  raw  border,  and  in  a  direction  parallel  to  this 
border.  Another  incision,  of  more  or  less  length,  carried  from  each  extremity 
of  the  first,  gives  a  flap  of  the  form  and  extent  desired,  which  is  to  be  at  least 
one  half  larger  than  the  loss  of  substance  seems  to  indicate.  In  dissecting  this 
flap  from  the  first  wound  towards  its  adherent  edge,  it  is  necessary  to  raise 
with  it  a  considerable  thickness  of  cellular  tissue,  which  lines  its  posterior 
face  and  affords  it  nutrition  and  life.  The  surgeon  then  fits  its  free  edge 
to  the  bleeding  wound  of  the  external  ear,  and  effects  its  union  by  means 
of  fine  short  needles,  and  a  sufficient  number  of  points  of  the  twisted  suture 
delicately  adjusted.  To  conclude,  he  has  but  to  pass  behind  the  kind 
of  bridge  which  results  from  this  arrangement  a  bandage  of  linen  spread 
with  cerate,  for  the  purpose  of  preventing  readhesion  of  the  dissected  skin. 
After  enveloping  the  whole  with  compresses  steeped  in  a  tepid  infusion  of  mal- 
lows, the  patient  is  put  to  bed.  At  the  end  of  three,  foiir,  or  five  days,  if  union 
is  well  advanced,  the  needles  may  be  removed  ;  at  least  those  near  the  most 
solid  points.  In  a  contrary  case,  it  is  to  be  seen  if  it  would  not  be  useful  to 
replace  some  of  the  first  needles  with  others.  When  the  cicatrix  is  firm,  that 
is,  from  the  fifteenth  to  the  thirtieth  day,  the  tegumentary  flap  is  to  be  sepa- 
rated from  the  cranium,  which,  becoming  free,  requires  new  attention.  First, 
its  inequalities  are  to  be  removed  by  rounding  its  angles;  in  a  word,  its  ex- 
ternal edge  is  to  be  shaped.  For  fear  of  its  mortifying,  it  is  to  be  dressed  for 
some  days  with  emollient  dressing,  when  it  is  treated,  together  with  the  wound 
left  on  the  head,  as  any  other  solution  of  continuity.  In  retracting  it  becomes 
thicker,  hardens,  takes  the  form  of  a  cushion,  reddens  after  being  at  first  pale, 
and  remains  a  longtime  more  highly  colored  than  the  nei!.';]iboring  parts  of  the 
external  ear.  Such  at  least  was  the  state  of  things  in  the  case  related  by  M. 
Dieffenbach. 

§  3.  Perforation  and  Dilatation  of  the  Auditory  Canal. 

Wlien  imperforation  of  the  canal  of  the  ear  is  complete,  and  when  it  has  its 
source  in  the  temporal  bone  itself,  as  of  which  I  have  observed  a  double  ex- 
ample on  the  body  of  a  child  four  years  old ;  and  a  second,  on  one  side  only, 


OPERATIVE  SURGERY.  457 

in  another  child  ten  or  twelve  years  old,  it  is  incurable  and  requires  no  kind 
of  treatment.  On  the  contrary,  to  whatever  degree  the  contraction  maybe 
carried,  if  there  is  barely  room  to  admit  the  passage  of  a  needle,  as  seen  by 
Lametrie,  or  if  the  coarctation  is  trifling  and  the  obstruction  occupies  but  a 
point  in  length,  or  has  invaded  the  whole  extent  of  the  canal,  an  attempt 
should  be  made  to  remedy  it  by  dilatation.  Caustics  were  preferred  by  some 
ancient  authors,  and  Hippocrates  himself  might  here  become  dangerous,  and 
would  very  rarely  attain  the  end  proposed.  Canulae,  sounds,  or  tents  in- 
creasing gradually  in  size,  should  be  continued  for  a  long  time  after  the  cure, 
and  even  sometimes  during  life,  for  the  wall  of  the  canal  preserves  almost 
always  a  great  tendency  to  recover  its  former  dimensions.  In  certain  cases 
the  walls  of  the  auditory  passage  are  directly  applied  to  each  other,  and  cannot 
be  efficaciously  separated  but  by  a  metal  canula  of  a  diameter  equal  to  that  of 
the  auditory  canal  in  its  normal  state.  If  deafness  depend  evidently  upon  an 
anomaly  in  the  curvature  of  the  cartilaginous  prolongation  of  the  ear,  it  may 
be  remedied  by  a  permanent  gold  canula  placed  in  this  canal,  of  which  M. 
Boyer  gives  an  example  taken  from  his  own  practice.  More  frequently  the 
external  ear  is  closed  by  a  membrane  or  kind  of  diaphragm.  If  it  be  not  too 
far  from  the  pavilion,  it  should  be  incised  crucially  with  a  bistoury  wrapped 
with  linen  to  within  two  lines  of  its  point.  Its  flaps  are  then  cut  away  with 
the  same  instrument,  or  small  scissors,  each  being  held  by  a  hook.  Others 
have  advised  perforation  with  a  trocar,  and  absorption  to  be  determined  by  a 
dilating  body ;  but  this  method  is  not  so  good  as  the  first.  The  incision  which 
Paulus  Egineta  adopts  when  the  accidental  diaphragm  is  deeply  seated,  as  in 
the  preceding  case,  is  rejected  by  Fabricius  ab  Aquapendente,  under  the  pre- 
text that  it  exposes  the  internal  ear  to  be  penetrated,  is  practised  at  the  pre- 
sent by  the  greatest  practitioners  in  all  cases,  except  where  it  seems  likely  to 
touch  the  membrane  of  the  tympanum.  In  this  case  they  follow  the  precepts 
of  J.  Fabricius,  having  recourse  to  caustics,  the  best  of  which  without  doubt 
is  the  lapis  infernalis.  Leschevin  directs  it  to  be  fixed  in  the  barrel  of  a  quill, 
and  carried  to  the  bottom  of  the  canal  through  a  silver  canula.  Three  or  four 
cauterizations,  with  two  or  three  days'  interval  between  each,  generally  suffice, 
and  the  operation,  which  gives  hardly  any  pain,  is  not  in  the  least  degree  dan- 
gerous. In  the  same  manner  every  other  atresia,  complete  or  incomplete,  is 
to  be  attacked,  when  it  depends  upon  a  fault  of  conformation  of  the  soft  parts, 
and  is  not  purely  membranous.  When  the  instrument  has  passed  beyond  the 
obstacle,  which  is  indicated  by  the  sudden  want  of  resistance,  the  trocar  only 
is  withdrawn  so  that  its  canula  may  be  used  to  conduct  a  bougie  to  the  bottom 
of  the  auditory  canal,  which  is  renewed  every  day  with  gradually  increasing 
size. 


§  4.  Foreign  Bodies, 

A  thousand  different  kinds  of  foreign  bodies  may  be  engaged  in  the  auditory 
canal,  and  a  thousand  different  means  have  been  proposed  for  their  extraction. 
In  obliging  the  patient  to  hop  on  one  foot,  and  making  him  use  sternutatories, 
Archigenes  had  the  same  intention  as  Celsus,  who  recommended  the  head  to 
be  rested  on  a  table  and  violently  jarred  by  raising  the  patient  by  the  feet,  or 
by  striking  the  sound  ear,  or  letting  fall  suddenly  after  lifting  it  the  body  on 
58 


458  NEW   ELEMENTS   OF 

which  it  rests.  Alexander,  of  Tralles,  has  given  the  idea  of  drawing  them  out 
with  a  tube ;  and  Mesne,  who  reproduced  it,  has,  like  J.  Arculanus,  con- 
structed for  this  purpose  another  instrument  designed  solely  to  pump  out 
liquids.  The  sucking  pump,  an  instrument  recently  invented  by  M.  Deleau, 
which  may  be  used  for  drawing  out  air,  serosity,  pus,  &:c.,  as  well  as  for  in- 
jections into  the  ear,  is  made  upon  the  same  principle.  Leschevin,  who  con- 
tends that  air  entering  the  canal  of  the  pavilion  is  the  ordinary  cause  of  the 
buzzing  and  tingling  in  the  ears,  had  been  anticipated  by  Reusner,  who  to 
remedy  this  inconvenience  proposed  a  small  silver  cahula  to  be  left  perma- 
nently in  the  auditory  canal.  The  hardened  cerumen  dissolves  very  well  in 
the  oil  of  sweet  almonds,  as  remarked  by  Avicenna,  but  still  better  in  warm 
soap-suds,  or  even  pure  water,  if  we  trust  to  the  experiments  of  Haygarth,  who 
rejects  the  oils  as  less  advantageous.  A  solution  of  sea-salt  dilutes  it  equally 
well,  according  to  J.  E.  Trempel.  Consequently  when  deafness  is  produced, 
as  is  often  the  case  with  persons  of  a  certain  age  by  the  accumulation  of  this 
substance,  one  of  these  liquids  is  to  be  introduced  daily  into  the  ear  by  a  sy- 
ringe or  by  cotton  soaked  with  it,  and  when  softened  or  detached  the  mass  is 
to  be  removed  by  a  curette.  If  fleas,  earwigs,  or  other  insects,  which  some- 
times insinuate  themselves  into  the  bottom  of  the  auditory  canal,  are  not  caught 
in  the  cotton  and  pitch,  already  prescribed  by  Hippocrates,  or  the  pencil  of 
lint  covered  with  turpentine  which  is  presented  to  them  for  the  purpose  of 
entangling  tliem,  we  may  attempt,  like  Hameck,  to  kill  them  by  pouring  in 
upon  them  oil  of  bitter  almonds,  or,  like  Rhazes,  a  decoction  of  peach  leaves. 
A  decoction  of  the  sedum  palustre,  used  by  Acrel,  produces  the  same  effect. 
But  it  is  unnecessary  at  the  present  day  to  combat  Verduc,  who  maintains 
that  the  rennet  apple  has  the  property  of  extracting  them ;  or  Leschevin,  who 
boasts  that  a  small  piece  of  potatoe  is  a  special  antidote  against  the  earwig. 
It  is  proper  at  first  to  attempt  their  extraction,  whether  living  or  dead,  with 
tlie  forceps. 

As  to  foreign  bodies  of  a  considerable  volume,  which  Paulus  Egineta  has 
correctly  ranged  in  two  distinct  classes,  the  first,  those  which  absorb  humidity 
and  may  become  swelled  in  the  parts,  and  the  second  those  which  are  imper- 
meable, they  deserve  all  the  attention  of  the  surgeon.  Violent  inflammation, 
abscess,  caries  of  the  bone,  cerebral  symptoms,  and  severe  pains  of  the  head, 
may  be  caused  by  their  presence.  On  opening  the  body  of  a  patient  who  had 
died  in  this  manner,  Sabatier  found  the  petrous  portion  of  the  bone  perforated, 
the  dura  mater  inflamed,  an  abscess,  and  a  ball  of  paper  in  the  substance  of 
the  bone  itself.  In  the  case  of  a  girl,  who  had  been  long  subject  to  convulsive 
tits  and  nervous  symptoms  of  every  description,  F.de  Hilden  obtained  a  com- 
plete cure  by  extracting  from  the  ear  a  foreign  substance,  which  had  been 
introduced  into  it  seven  years  before.  An  analogous  observation  is  related 
in  1829,  and  scientific  compilations  are  crowded  with  similar  examples.  M. 
Larrey,  however,  remarks,  that  in  a  soldier  whom  he  attended,  the  foreign 
body  remained  in  place  for  ten  years  without  producing  any  unpleasant  symp- 
tom. It  should  not  be  forgotten  that  these  several  substances,  which  are 
sometimes  a  bean,  a  pea,  a  cherry-stone,  a  shot,  a  piece  of  glass  or  corn,  a 
pebble,  &.c.,  sometimes  come  out  of  themselves  after  the  first  symptoms  pass 
off,  and  after  producing  suppuration  more  or  less  profuse.  It  is  important  to 
r?,raember,  especially  in  practice,  that  the  patients  and  their  relatives  often 


•  OPERATIVE  SURGERY.  459 

insist  strongly  that  the  ear  contains  a  foreign  body,  when  in  fact  it  is  com- 
pletely clear.  A  terrified  mother  brought  her  child,  of  about  five  years  of  age, 
to  one  of  the  public  consultations  in  the  capitol,  to  have  a  cherry-stone  re- 
moved which  had  been  twenty-four  hours  in  the  ear.  Attempts  of  every  kind, 
uselessly  renewed  every  morning  for  three  days,  caused  excessive  pain,  inflam- 
mation, and  fever;  and  when,  not  daring  to  do  anything  furtlier,  the  surgeons 
thought  to  ascertain  whether  if  the  organ  of  the  little  patient  really  contained 
a  cherry  stone,  they  found  nothing  of  it.  Such  instances  of  inattention  have 
often  given  rise  to  the  most  serious  consequences.  M.  Boyer  gives  two  ex- 
amples, and  there  are  few  surgeons  who  have  not  had  occasion  to  observe 
similar  cases. 

If  inclining  the  ear  be  insufficient  to  extract  the  foreign  body,  we  must  en- 
deavor to  reach  it  with  forceps  when  its  form  is  long  and  flattened.  A  small 
hook  is  sometimes  best  for  extracting  those  which  are  somewhat  soft.  To 
such  as  these  relates  the  advice  of  dividing  them,  and  reducing  them  to  small 
pieces  with  a  long  and  narrow  blade  of  wood  so  as  to  remove  them  piecemeal. 
Brittle  bodies  require  much  more  precaution.  A  false  pearl,  says  M.  Boyer, 
being  broken  in  the  auditory  canal  by  a  surgeon  in  attempting  to  extract  it, 
put  the  life  of  the  patient  in  danger,  and  actually  produced  suppuration  of 
the  tympanum  and  loss  of  hearing.  In  such  a  case  a  small  but  solid  curette 
should  be  used  to  look  for  it,  following  the  inferior  wall  of  the  canal  so  as  to 
conduct  it  beneath  the  body  to  be  removed,  to  be  then  used  as  a  lever  of  the 
first  kind  by  depressing  the  handle  at  the  moment  of  extraction.  A  cherry- 
stone, which  had  resisted  these  manosuvers,  at  length  terminated  in  the  ear, 
so  that  if  \ye  are  to  credit  M.  Donatus,  it  was  extracted  by  the  sprout ;  but  I 
need  not  expose  the  improbability  of  such  a  fact.  The  process  of  F.  de  Hilden, 
adopted  by  C.  de  Solingen,  has  been  justly  put  aside;  it  consists  in  carrying 
first  a  canula  upon  the  foreign  body,  and  then  through  this  a  second  one 
designed  to  fix  it  by  means  of  teeth  at  its  extremity,  while  a  kind  of  gimlet 
is  inserted,  and  the  whole  withdrawn  together.  What  cannot  be  done  with 
the  curette,  will  not  be  attained  by  this  apparatus,  which  is  better  adapted  for 
pushing  the  body  into  the  cavity  of  the  tympanum  than  for  extracting  it.  In 
difficult  cases,  Paulus  made  a  crescentic  incision  behind  the  concha,  in  order  to 
penetrate  to  the  bottom  of  the  canal,  opening  the  cartilage  from  without  in- 
wards, so  as  to  be  able  to  push  the  foreign  body  from  within  outwards  with  an 
appropriate  instrument.  This  operation,  which  was  also  proposed  by  Dionis 
and  Verduc,  is  now  totally  abandoned.  Perhaps,  however,  it  should  not  be 
rejected  entirely,  when  danger  presses  and  all  other  means  have  been  fruitless. 
For  the  rest,  whether  this  or  that  instrument  be  used,  it  is  always  proper,  be- 
fore commencing  the  operation,  to  drop  a  little  oil  into  the  ear  to  lubricate  the 
parts  and  render  them  less  irritable.  Afterwards  nothing  more  is  necessary 
than  emollient  injections  for  some  days,  at  least  whenever  the  manoeuvres 
employed  excite  no  fear  for  the  future  development  of  formidable  symptoms. 
Otherwise,  antiphlogistic,  hypnotic,  and  soothing  medicines  become  indis- 
pensable. 

§5.  Polypi. 

The  several  kinds  of  treatment  to  which  polypi  of  the  nasal  fossae  have 
been  subjected,  have  also  been  presented  for  those  of  the  ear.    Aranzi  con- 


460  NEW   ELEMENTS   OF  , 

tends  that  they  are  to  be  cured  with  caustics,  especially  with  an  ointment  of 
red  precipitate.     De  Vigo  employed  against  them  by  turns,  hot  iron,  caustics, 
the  liguture,  and  tlie  forceps.     Paul  removed  them  with  a  bistoury  made 
expressly  for  the  purpose,  or  rather  with  his  pterygotome.     G.  de  Salicet 
cauterized  the  root  after  tying  them  with  a  horse-hair  or  silken  thread.    At 
the  present  day  the  ligature  and  extraction  are  almost  the  only  methods  used. 
The  ligature,  which  F.  de  Hilden,  and  after  him  Marchetti  and  Purmann 
applied  by  means  of  a  silver  plate  bent  to  the  form  of  a  forceps,  is  rendered 
easier  of  application,  says  C.  de  Solingen,  by  piercing  the  base  of  the  tumor 
as  a  preliminary  with  a  thread  in  the  manner  of  a  hook.     It  is  really  ap- 
plicable but  in  a  small  number  of  cases,  when  the  polypus  is  redunculous  and 
narrow,  and  near  the  external  opening.     It  is  performed  with  a  hempen  thread, 
and  the  canula  of  Desault,  or  rather  after  the  process  of  F.  de  Hilden,  modified 
by  Solingen,  or  again  by  carrying  with  forceps  a  slip-knot  or  noose  of  thread, 
making  it  glide  over  a  stylet  to  the  root  of  the  polypus.     When  the  thread  is 
placed  in  any  manner  whatever,  its  two  ends  are  passed  through  a  serre-noeud, 
and  after  this  there  is  nothing  particular  in  the  operation.     Excision  is  prac- 
ticable under  the  same  circumstances,  and  in  almost  every  case  in  which  tlie 
ligature  can  be  tried.     The  polypus  bei*ng  engaged  on  a  hook,  it  is  drawn 
forM'ard,  turning  it  back  a  little  to  expose  its  root,  which  is  divided  with  a 
single   stroke  of  the  bistoury.     As  to  extraction,  the   only  method,  in  my 
opinion,  which  can  be  usefully  applied  to  polypi  whose  root  is  deeply  seated, 
and  which  may  also  be  considered  applicable  to  the  others,  is  effected  with 
ordinary  forceps  with  pierced  blades,  being  concave,  thin,  and  furnished  with 
teeth. 

The  speculum  auris  of  G.  Fabricius,  and  that  of  Cleland,  as  well  as  all  that 
have  been  proposed  before  or  since,  are  unnecessary  if  not  prejudicial.  The 
forceps  supersedes  them.  The  surgeon  opens  them  moderately,  and  engages 
them  between  the  tumor  and  the  parietes  of  the  canal,  which  he  gently  sepa- 
rates, thus  entering  them  as  deeply  as  possible,  and  after  securing  a  grasp  of 
the  polypus,  turns  them  upon  their  axis  and  extracts  the  whole,  half  drawing, 
half  twisting  them.  The  blood  which  immediately  escapes  conceals  the  parts 
in  such  a  way,  that  most  frequently  the  exploration  necessary  to  render  it 
certain  if  any  thing  more  exists  or  not  in  the  auditory  canal,  has  to  be 
deferred  until  the  next  day.  This  hemorrhage  is  never  dangerous.  A  tent 
of  charpie  smeared  with  cerate,  or  a  dossil  of  lint,  to  prevent  the  bleeding 
surfaces  from  being  irritated  by  contact  witli  the  air,  form  all  the  dressing 
required,  and  that  which  is  always  employed  after  extraction  of  polypus  of  the 
ear.  In  case  some  heterogeneous  tissue  remains  after  th«  operation,  before  it 
increases  we  should  attempt  to  destroy  it  either  with  hot  iron,  as  prescribed 
by  G.  de  Salicet,  F.  de  Hilden,  &c.,  or  with  caustics,  which  are  generally 
preferred  at  present.  The  canula  of  J.  de  Vigo,  open  on  the  side,  permits,  it 
is  true,  the  fire  to  be  carried  on  the  diseased  point ;  but  as  we  have  sometimes 
to  act  upon  large  surfaces,  or  very  near  the  membrane  of  the  tympanum,  actual 
cautery  in  this  place  is  not  without  danger.  Nothing  is  more  simple,  on  the 
contrary,  than  to  reach  tlie  polypus  through  the  same  canula,  with  a  pencil 
charged  with  butter  of  antimony,  the  nitrate  of  mercury,  or  any  other  caustic, 
supposing  even  that  the  lapis  infernalis  might  not  take  the  place  of  these 
several  means.    Polypi  of  the  ear  are  developed  so  slowly,  and  produce  so 


OPERATIVE    SURGERY.  461 

little  derangement  of  function,  that  many  patients  carry  them  for  years  before 
requiring  the  assistance  of  art.  At  this  very  moment  (February,  1830)  I  have 
just  extracted  one  at  the  liospital  St.  Antoine,  from  an  adult  who  had  carried 
it  for  fourteen  years.  Extraction  in  this  case  is  not  without  danger.  The 
tympanum,  deprived  for  a  considerable  time  of  tlie  action  of  its  natural  stimu- 
lants, becomes  irritated  by  their  presence,  if  suddenly  restored  without 
precaution.  It  is  the  same  as  with  an  eye  just  operated  on  for  cataract; 
it  must  at  first  be  kept  in  darkness ;  and  exposed  to  the  light  but  by  insensible 
degrees. 


Art.  ^. — Internal  Ear. 

§  1.  Perforation  of  the  Membrane  of  the  Tympanum. 

Plemp  is  the  first,  I  believe,  who  maintained  that  the  hearing  might  be 
preserved  although  the  membrane  of  the  tympanum  were  perforated.  The 
fact  which  he  adduces  in  support  of  his  assertion,  appeared  at  the  time  so 
extraordinary,  that  Verduc  refused  to  give  it  credence ;  and  Valsalva,  who 
mentions  experiments  tried  upon  animals,  also  rejected  its  possibility,  notwith- 
standing the  authority  of  Riolan,  supported  by  the  case  of  a  deaf  and  dumb 
person,  who  having  plunged  an  ear- pick  through  the  membrane  of  the  tym- 
panum, was  suddenly  restored  to  hearing.  But  J.  Munnicks,  and  more  par- 
ticularly Cheselden,  having  again  brought  it  forward,  sustaining  it  by  new 
observations,  it  must  be  received  as  a  demonstrated  truth.  Cheselden  did 
more ;  since,  says  he,  the  loss  of  the  membrana  tympani  does  not  bring  on 
deafness,  one  might  perhaps,  by  perforating  it  when  thickened  or  degenerated, 
in  some  cases  restore  the  faculty  of  hearing.  Unfortunately  the  criminal  in 
whom  he  made  the  application  of  this  idea,  was  deaf  from  another  cause,  and 
his  operation  was  without  success.  Although  taught  again  of  late  by  M.  Por- 
tal, and  formally  proposed  by  Busson,  as  a  means  of  evacuating  abscess  of  the 
tympanum,  perforation  of  the  membrane  could  only  be  revived  effectually 
by  Sir  A.  Cooper,  who  first  practised  it  with  success  in  1800  and  1802. 
Attempted  since  with  various  results  by  a  number  of  surgeons,  it  has  yet 
to  take  rank  among  the  useful  and  regular  operations  of  the  healing  art.  A 
small  trocar  slightly  curved  is  the  only  instrument  used  by  Sir  A.  Cooper, 
who,  to  avoid  the  malleus  and  the  chorda  tympani,  correctly  advises  the  mem- 
brane to  be  pierced  in  its  anterior  and  inferior  fourth.  Himly,  who  pretends 
to  have  publicly  described  this  perforation  in  the  year  iZOr,  says  that  the 
opening  made  with  the  trocar  soon  closes,  and  to  prevent  this,  it  should  be  per- 
formed with  a  hollow  punch,  which  M.  Fabrizi,  of  Modena,  intending  io 
modify,  has  singularly  complicated.  According  to  this  remark,  the  cataract 
needle,  preferred  by  Arneman ;  the  little  square  knife  like  Key's  needle,  with 
which  Buchanan  thought  to  divide  the  fibres  transversely  and  favor  the  retrac- 
tion of  the  lips  of  the  wound ;  the  triangular  sound  of  Paroisse,  and  the  kysti- 
tome  cache  of  Fusch,  should  all  be  proscribed ;  as  also  the  little  punch  with 
ciroidar  shoulder  to  prevent  its  passing  too  deeply,  invented  by  Rust;  a  knitting 
needle,  which  according  to  Michaelis  might  also  be  adopted;  the  simple  st3^1et 
of  M.  Itard ;  the  needle  which  M.  Saissy  encloses  in  a  small  tube  of  gum- 
elastic  ;  and  the  kystitome  of  la  Faye,  which  seems  at  least  to  me  more  con- 


462  NEW   ELEMENTS   OF  *■ 

venient  than  any  other  instrument.  For  the  purpose  of  securing  a  permanent 
opening,  M.  Richerand  thought  it  would  be  better  to  perforate  the  membrane 
of  the  tympanum,  by  cauterizing  it  with  a  pencil  of  lapis  infernalis,  and  Zang 
suggested  the  idea  of  leaving  a  piece  of  catgut  in  the  wound.  To  tiie  three 
successful  cases  of  Sir  A.  Cooper,  may  now  be  added  a  great  number  of  others. 
That  of  Saunders,  for  instance,  who  cured  by  this  operation  a  deafness  of  three 
years'  standing ;  another,  of  Paroisse,  in  a  patient  who  had  been  deaf  for  eight 
years ;  those  of  Michaelis,  Rust,  Itard,  Saissy,  Maunoir ;  and  those  of  Henrald, 
who  declares  that  he  succeeded  twice  in  three  attempts ;  but  it  must  not  be 
dissembled,  that  the  most  of  these  practitioners,  Celliez  and  M.  Itard,  among 
others,  and  M.  Dubois,  at  four  different  attempts,  have  also  performed  it  with- 
out deriving  the  least  advantage  from  it.  Trury  and  Kauerzhave  not,  I  believe, 
been  more  fortunate,  and  besides,  it  is  only  proper  in  very  few  circumstances. 
It  would  be  wrong  to  expect  any  thing  from  it,  for  example,  when  the  deafness 
is  caused  by  a  lesion  of  the  labyrinth  or  of  the  middle  ear,  the  nerves,  the 
small  bones,  or  their  muscles ;  in  a  word,  whenever  the  disease  does  not  arise 
from  pure  and  simple  obliteration  of  the  Eustachian  tube.  Its  design,  in  fact, 
is  to  allow  an  entrance  into  the  cavity  of  the  tympanum  and  the  mastoid  cells, 
and  no  other  indication  can  be  fulfilled  by  it.  Pus,  serosity,  mucus,  and  other 
liquid  matters,  the  discharge  of  which  it  might  favor,  would  find  a  more  natu- 
ral route  by  the  pharynx,  if  the  trumpet  were  not  closed ;  and  the  perforation 
of  the  tympanum  should  be  rejected  as  long  as  it  is  not  indispensable,  or  when 
it  is  possible  to  penetrate  to  the  middle  ear  by  any  other  way.  This  is  not 
because  it  is  dangerous,  or  that  it  may  occasion  very  serious  accidents.  As  it 
is  scarcely  painful  and  rarely  followed  by  general  reaction,  nothing  forbids  its 
being  tried  when  nothing  further  is  to  be  expected  from  other  means ;  but  we 
must  not  promise  ourselves  too  brilliant  results  from  it,  or  found  upon  it  too 
sanguine  hopes.  Simple  puncture  is  of  no  value ;  the  opening  is  often  closed 
in  a  day.  Excision  itself  does  not  place  it  beyond  risk  of  this  ill  result,  for 
the  lack  of  a  proper  instrument.  The  hollow  punch  of  M.  Deleau,  a  kind  of 
sheathed  spring  which  expands  at  the  will  of  the  operator,  and  which  suddenly 
pushes  against  each  other  two  small  cutting  circles  so  as  to  detach  neatly  a 
disk  of  the  tympanum^  although  one  of  the  most  perfect,  is  far  from  being 
always  successful. 

§  2.  Perforation  of  the  Mastoid  Cells, 

When  in  consequence  of  violent  or  even  chronic  inflammation,  lively,  dull,  or 
tensive  pains  are  experienced  in  the  ear;  when  there  are  strong  reasons  to 
believe  that  an  abscess  is  formed  in  this  part,  or  that  injections  into  the  cavity 
of  the  tympanum  would  be  advantageous,  or  that  caries  exist,  or  some  splin- 
ters of  bone  which  should  be  removed,  perforation  of  the  mastoid  apophysis 
seems  to  be  clearly  indicated.  The  passage  in  which  Galen  says,  that  if  ulcers 
of  the  auditory  canal  have  affected  any  of  the  hard  parts,  it  is  necessary 
to  mak-e  an  incision  behind  the  ear,  to  scrape  the  bone,  or  remove  the  exfolia- 
tions, is  all  that  appears  to  relate  to  this  subject  in  the  ancient  authors.  But 
Valsalva  has  already  made  the  remark,  that  injections  through  the  mastoid 
cells  return  by  the  mouth.  Riolan  and  Rolfinck  expressly  assert  it.  Heuer- 
ifiann,  who  saw  an  abscess  of  tlie  ear  point  at  the  mastoid  apophysis,  and  there 


,  OPERATIVE    SURGERY.  463 

leave  a  fistula,  concludes  from  it,  that  it  would  be  best  in  such  a  case  to  apply 
the  crown  of  a  trepan  behind  the  concha,  without  giving  time  to  the  pus  to 
affect  too  deeply  the  spongy  tissue  of  the  apophysis.  A  patient  was  advised 
by  J.  L.  Petit,  but  could  not  be  induced  to  submit  to  this  operation,  while  by 
this  means  the  same  author  has  saved  a  number  of  others  who  were  at  least  as 
seriously  affected.  Observations  of  the  same  kind  have  been  published  by 
Morand,  Martin,  &c.  It  was  chiefly  on  these  that  Jasser  relied  in  operating  on 
the  soldier,  in  whom  he  opened  the  mastoid  process  of  one  side  containing  an 
abscess  with  caries,  and  that  of  the  opposite  side  for  simple  deafness.  Fiedlitz 
performed  it  with  success  on  both  sides,  for  a  woman  whom  a  quartan  fever 
had  deprived  of  hearing.  This  author,  quoted  by  Richter,  relates  two  other 
cases  not  less  remarkable,  Loefier,  who  boasts  of  it,  recommends  the  use  of  a 
perforating  trepan,  furnished  with  a  ledge  to  prevent  its  penetrating  too  far,  and 
that  the  soft  parts  be  incised  twenty-four  hours  before  perforating  the  bone,  so 
as  not  to  have  an  effusion  of  the  blood  into  the  mastoid  cells ;  and  lastly,  that 
there  be  daily  injections  through  the  opening,  which  is  to  be  kept  dilated  with 
a  leaden  sound.  Hagstroem,  who  however  has  nothing  to  boast  of  from  it,  enters 
into  more  minute  details  on  the  mode  of  performing  it  than  Loeffler,  whose  ideas 
he  principally  adopts.  If  a  fistula  exist,  says  he,  we  must  confine  ourselves  to 
dilating  it.  Otherwise  the  bone  is  to  be  denuded,  avoiding  the  auricular  artery, 
which  is  usually  very  near  the  concha,  after  which  it  only  remains  to  open  the 
apophysis  from  behind  forwards,  with  a  gimlet,  a  punch,  or  trocar,  rather  than 
with  a  trepan.  Acrel  thinks  it  useless  when  the  bones  are  sound ;  and  Murray  has 
well  remarked  that  before  puberty  the  mastoid  cells,  being  scarcely  developed, 
it  would  in  reality  be  to  no  purpose.  The  case  of  Doctor  Berger,  who  died  after 
being  operated  upon  by  Callisenand  Koelpin,  and  in  whose  cranium  no  mastoid 
cells  were  found,  proves  that  they  may  also  be  wanting  in  adults.  Similar  facts 
related  by  Morgagni,  did  not  deter  Prost  or  Arnemann,  who  declare  they  have 
resorted  to  it  several  times  with  success.  Dropsy  of  the  cavity  of  the  tym- 
panum and  simple  abscess,  do  not  absolutely  require  it.  They  are  evacuated 
as  easily  by  perforating  the  membrane  of  the  tympanum,  which  is  a  far  less 
painful  and  less  serious  operation.  After  all  it  is  only  in  phlegmasias,  which 
are  accompanied  with  necrosis  or  caries,  and  are  inclined  to  point  behind  the 
ear,  that  we  are  in  any  way  obliged  to  have  recourse  to  it, 

Manual,-^A  crucial  or  T  incision,  lays  bare  the  whole  external  face  of  the 
mastoid  apophysis.  After  the  bone  has  been  scraped,  there  is  applied  to 
it  either  a  perforator,  the  small  crown  of  a  trepan,  a  gimlet,  or  a  trocar.  Care 
is  to  be  taken  to  incline  the  instrument  a  little  forwards  and  upwards 
as  it  penetrates.  When  it  has  reached  the  auditory  cells,  it  is  to  be  withdrawn 
to  permit  the  operator  to  enlarge  the  opening  immediately  if  necessary.  Injec- 
tions are  tlien  to  be  cautiously  thrown  in.  Tents,  dossils  of  lint,  or  a  sound 
of  lead,  should  be  daily  placed  in  the  perforation  until  the  cavity  of  the  tym- 
panum have  returned  to  its  natural  state.  The  scissors,  or  the  gouge  and 
mallet,  used  by  J.  L.  Petit  are  to  be  preferred  if  the  bone  is  widely  necrosed, 
and  if  it  is  necessary  to  separate  large  fragments.  If  nothing  indicate  before- 
hand where  the  instrument  is  to  be  applied,  it  is  from  six  to  eight  lines  above 
the  summit  of  the  apophysis.  The  largest  cells  correspond  to  this  point. 
The  auricular  artery,  which  is  found  in  front,  and  the  sub-mastoid,  which  is 
below,  may  be  easily  avoided. 


464  NEW   ELEMENTS   OF  ♦ 

§  3.  Cathcterism  of  the  Eustachian  Tube, 

The  idea  of  penetrating  into  the  cavity  of  the  tympanum  through  the 
pharynx  is  already  very  ancient.  Archigenes,  Vasalva,  Munnicks,  and  Busson, 
without  doubt  had  it  in  mind,  when  they  advised  the  vapor  of  water,  tobacco, 
&c.,  to  be  inhaled,  and  the  nose  and  the  mouth  to  be  tightly  closed  to  force 
them  towards  the  ear  during  expiration.  In  1724,  Guyot,  postmaster  at 
Versailles,  and  Cleland,  in  1741,  invented  each  an  instrument  for  injecting  the 
tubes,  one  by  the  mouth,  the  other  through  the  nose.  The  slightly  curved 
sound  of  J.  L.  Petit,  rendered  the  operation  still  more  easy.  Douglas  and 
Wathen  decided  in  favor  of  the  process  of  Cleland.  Heuermann  and  Ten 
Haaf,  adopting  that  of  Guyot,  introduced  a  female  catheter  into  the  tube 
through  the  mouth,  above  the  velum  palati,  and  then  screwed  a  small  syringe 
to  the  other  extremity  of  the  tube.  It  is  further  recommended  by  Falken- 
berg,  Sims,  Chopart,  and  Desault;  by  Callisen,  who  performed  it  sometimes 
through  the  nose  and  sometimes  through  the  mouth,  and  describes  very  well 
its  mechanism ;  by  Buchanan,  Itard,  Boyer,  Richerand,  &c.  Proscribed  as 
inapplicable  to  the  living  subject  by  B.  Bell,  and  as  dangerous  by  Trempel, 
these  injections  have  been  brought  into  vogue  again  and  highly  recommended 
by  M.  Deleau,  who  appears  to  have  effectually  obtained  from  them  the  happiest 
results.  As  a  mechanical  means  they  remove  obstructions  of  the  tube;  as 
medicinal,  they  act  with  efficacy  upon  inflammations,  engorgements  of  all 
kinds,  thickened  matters,  and  fluid  collections  in  the  cavity  or  guttural  canal 
of  the  tympanum.  It  is  therefore  perceived  of  v/hat  benefit  they  may  be  in 
deafness,  which  depends  on  any  of  these  causes. 

No  doubt  we  may,  and  that  very  easily,  penetrate  the  tube  by  carrying  a 
bent  sound  through  the  mouth  above,  behind,  and  on  one  side  of  the  velum 
palati,  as  it  was  done  by  Heuermann  ;  but  the  operation  being  still  more  easy, 
and  especially  more  certain  through  the  nasal  fossse,  this  is  the  way  generally 
followed  at  the  present  day.  The  instrument  of  Saissy,  Itard's  sound,  shaped 
like  an  Italic  S  cr  rather  an  algalie,  which  differs  from  a  female  catheter  only 
in  being  open  at  both  extremities  without  any  holes  on  its  sides,  and  a  small 
syringe  to  force  up  liquids  are  all  that  it  is  necessary  to  procure  in  this  case. 
A  gum-elastic  sound,  supplied  with  its  stylet  and  suitably  curved;  a  buttoned 
stylet,  in  case  the  obstacles  are  removed  by  a  solid  body,  may,  strictly  speak- 
ing, take  place  of  other  catheters.  The  surgeon,  placed  on  the  side  and  in 
front  of  the  patient,  bends  back  the  head  with  one  hand,  takes  in  the  other  the 
sound  smeared  with  some  unctuous  substance,  presents  its  beak  to  the  orifice 
of  the  nose,  and  causes  it  to  glide  over  the  floor  of  the  nasal  fossse  through  the 
inferior  meatus,  taking  care  to  keep  its  convexity  towards  the  septum,  and  a 
little  inclined  upwards.  Arrived  at  the  superior  face  of  the  velum,  he  raises 
a  little  the  extremity  of  the  instrument  without  letting  it  quit  the  external 
wall  of  the  nostril,  which  carries  it  insensibly  upon  the  superior  part  of  the 
maxillary  meatus ;  he  continues  it  in  this  direction,  and  infallibly  enters  it  into 
the  mouth  of  the  tube,  which  from  thence  looks  obliquely  outwards,  back- 
wards, and  upwards.  As  soon  as  the  sound  is  sufliciently  engaged,  the  syringe 
is  fitted  on  as  for  injecting  a  hydrocele,  and  every  body  knows  what  then 
remains  to  be  done.    The  operation  is  renewed  once  or  twice  a  day,  and,  as 


OPERATIVE    SURGERY.  465 

it  is  plainly  seen,  nothing  prevents  the  entrance  of  any  medicated  fluid  that 
may  be  deemed  necessary  into  the  middle  ear.  If  the  injection  be  arrested 
in  the  tube,  and  from  some  cause  cannot  be  made  to  advance,  it  will  be  a 
case  for  removing  the  syringe  and  passing  up  the  stylet  as  far  as  the  obstacle, 
so  as  to  remove  or  destroy  it.  But  in  this  place  force  is  not  to  be  used  but 
with  great  caution ;  and  before  having  recourse  to  it,  we  should  be  well  assured 
that  it  is  indispensable — that  the  best  directed  manoeuvre  cannot  supersede 
it.  M.  Deleau,  who  obtained  the  happiest  results  from  this  kind  of  medi- 
cation, finding  that  the  beak  of  the  metallic  sound  would  not  fail  of  soon 
striking  against  the  parietes  of  the  tube  when  an  attempt  is  made  to  advance 
it  some  lines,  that  its  inflexibility  creates  pain,  and  that  aqueous  injections 
penetrate  thus  with  great  difficulty  into  the  auricular  cavity,  thought  to  sub- 
stitute for  it  a  flexible  sound  and  to  force  in  atmospheric  air.  Y/ith  the  pro- 
cesses of  this  surgeon' the  operation  is  possible  at  every  age.  He  even 
succeeded  in  passing  his  sound  by  the  nostril  opposite  the  diseased  ear ;  which 
is  an  extremely  happy  thing  when  any  alteration  or  deviation  prevents  its 
being  carried  through«the  corresponding  nostril.  I  have  seen  two  boys,  one 
four,  the  other  seven  years  old,  submit  with  a  very  good  grace  to  the 
manoeuvres  of  his  method,  and  without  giving  the  least  sign  of  pain.  By  means 
of  a  silver  stylet  from  four  to  six  inches  long,  with  a  strong  curve  near  one 
extremity,  carrying  a  ring  at  the  other,  the  diameter  of  wliich  varies  from  a 
line  to  a  line  and  a  half,  he  conducts  a  gum-elastic  sound  to  the  tube.  The 
patient  seated  on  a  chair  leans  his  head  a  little  backward,  supporting  it  on 
the  back  of  his  seat  or  against  a  cushion  made  for  the  purpose,  and  supported 
by  a  staff  which  may  be  lowered  or  raised  at  pleasure.  The  operator  takes 
his  instrument,  previously  oiled ;  presents  it  to  the  nostril,  holding  it  like  a 
pen  in  his  right  hand,  with  its  concavity  turned  downwards  and  outwards; 
enters  it,  rapidly  following  the  floor  of  this  cavity  soon  touches  tlie  palatine 
vault  (vvhicii  is  known  by  an  involuntary  movement  of  deglutition,  and  by 
the  instrument's  having  arrived  at  the  depth  of  two  or  two  and  a  half  inches); 
raises  its  beak  outwards  and  upw^ards  by  a  circular  or  rotatory  motion  to  bring 
it  into  the  tube ;  then  seizes  above,  with  the  thumb  and  index  finger  of  the 
left  hand,  the  free  extremity  of  the  catheter,  if  it  is  engaged  within  the  tube  ; 
attempts  to  make  it  advance  while  the  stylet  is  kept  immovable  by  the  right 
hand ;  moves  it  tims  as  far  as  the  obstacle,  which  it  removes  as  a  coarctation 
of  the  urethra  is  removed,  and  withdraws  the  conducting  stylet  when  he 
thinks  he  has  entered  sufficiently  far ;  screws  a  silver  pavilion  to  the  external 
orifice  of  the  canula,  which  he  retains  in  place  with  a  wire  twisted  in  the 
shape  of  forceps,  which  embraces  at  the  same  time  the  corresponding  ala  of 
the  nose  ;  fits  to  this  pavilion  the  beak  of  a  syringe,  a  bottle,  or  bellows  of  gum- 
elastic;  uses  it  to  force  the  air  beyond  the  obstacle,  not  exceeding  a  degree  of 
pressure  which  habit  alone  teaches  to  proportion;  discovers  by  the  noise 
which  is  heard  in  applying  the  ear  to  that  of  the  patient  whether  the  cavity  is 
sound  or  diseased,  empty  or  full,  whether  the  gas  which  is  forced  in  can  or 
cannot  return  between  the  sound  and  the  parietes  of  the  tube ;  substitutes  the 
tunnel  of  a  reservoir  furnished  with  a  manometer,  in  which  there  is  a  pump 
to  compress  the  air ;  turns  the  stopcock  of  this  apparatus,  and  establishes  a 
double  atmospheric  current  in  the  ear,  one  entering  by  the  sound,  the  other 
59 


466 


NEW   ELEMENTS   OF 


issuing  between  it  and  the  guttural  canal,  augmenting  or  diminishing  the  force 
of  this  injection,  and  stops  in  the  course  of  one  or  several  minutes. 

JRemarks. — In  penetrating  through  the  opposite  nostril  the  instrument  is  a 
little  more  curved,  and  its  beak  is  slightly  bent  again  in  the  direction  of  its 
main  convexity.     Held  in  the  same  hand,  its  concavity  turned  downwards  and 
inwards,  it  is  made  to  pass  along  the  inferior  margin  of  the  septum.    When  at 
the  velum  palati,  the  hand  is  elevated  by  carrying  it  outwards,  to  incline  its 
extremity  behind  the  vomar  and  reach  the  tube;  the  rest  is  performed  ac- 
cording to  the  directions  already  laid  down.     In  the  one  case  as  in  the  other, 
if  the  sound  is  not  well  placed,  the  patient  himself  makes  it  known  after  he  has 
once  undergone  the  operation.  Its  direction  and  position  otherwise  sufficiently 
announce  it  to  the  surgeon.     For  positive  assurance,  however,  there  is  an  easy 
means.     The  stylet  being  withdrawn,  air  or  a  liquid  is  to  be  thrown  through 
thecanula;  the  injection  will  fall  into  the  pharynx  if  the  position  is  wrong, 
and  in  the  contrary  case  will  either  not  pass  or  will  enter  th€  cavity  of  the 
tympanum.     M.  Deleau  is  of  opinion,  that  by  passing  the  sound  briskly  though 
gently  forwards,  there  will  be  less  hindrance  and  fatigue  than  by  the  common 
method.     Experience  has  demonstrated  to  him  that  there  is  less  inconvenience 
in  beginning  again  once  or  oftener,  and  turning  the  beak  rapidly  towards  the 
tube,  than  in  feeling  slowly  about  it  to  find  its  entrance.     His  flexible  canula 
has  a  very  great  advantage.   Pushed  forwards  by  the  fingers  of  the  left  hand 
while  the  stylet  is  held  without,  it  enters  and  adapts  itself  to  the  direction  and 
bendings  of  the  canal  to  be  traversed.     From  the  pressure  it  meets  with  in 
advancing,  we  perceive  at  what  distance  the  contraction  exists ;  what  is  its 
degree,  and  even  its  density.     If  the  first  instrument  used  appear  too  large,  it 
is  replaced  by  a  smaller,  and  vice  versa.     The  curvature  of  the  inflexible 
sound  allows  nothing  of  this ;  with  it  the  injection  is  thrown  more  or  less 
obliquely  against  one  of  the  walls  of  the  canal ;  the  other  directs  it,  on  the 
contrary,  in  the  axis  of  the  tube.     If  after  the  removal  of  the  obstacle  the  air 
makes  a  hissing  noise  in  the  cavity  of  the  tympanum  upon  the  membrane,  or 
a  dry  sound,  the  conclusion  is  that  the  middle  ear  is  not  aftVcted ;  if  it  seem 
rather  to  agitate  a  liquid,  if  it  is  mucous,  we  are  authorized  to  infer  that  there 
exists  pus,  blood,  serosity,  or  at  least  an  engorgement  of  the  internal  mem- 
brane of  the  middle  ear.     In  both  cases,  if  the  tube  is  evidently  obstructed  or 
contracted,  and  the  patient  has  better  perception  of  sounds  immediately  after 
than  before  the  catheterism,  the  deafness  depends  on  the  condition  of  the  tube, 
and  there  is  every  reason  to  believe  that  it  may  be  removed.     When  no  change 
results,  the  evil  probably  lies  elsewhere ;  and  we  may  be  pretty  certain  that  in 
the  end  there  will  be  no  advantage  derived  from  this  operation.     Sharp  pain 
produced  by  the  injection  announces  an  acute  phlegmasia,  or  too  great  nervous 
irritability,  which  is  to  be  overcome  by  the  usual  treatment.     In  simple  ob- 
struction or  purely  chronic  phlegmasiae,  there  is  scarcely  any  pain  during  the 
operation.     M.  Deleau  explains  the  action  of  the  air  in  a  manner  altogether 
mechanical ;  it  sweeps  out,  blows,  and  cleanses  by  degrees  the  cavity  of  the 
tympanum  and  the  mastoid  cells.     In  returning  between  the  sound  and  the 
tube  it  necessarily  makes  an  effort,  and  becomes  a  dilating  and  resolving  body 
by  the  compression  it  exercises  on  the  engorged  tissues.     Water  and  other 
liquids  produce  no  other  medical  effects  than  gases,  and  are  much  more  apt 


« 


OPERATIVE    SURGERY.  467 

to  wound  and  rupture  the  membrane  of  the  tympanum.  Every  professional 
man  will,  however,  understand  that  each  case  may  require  special  modifications, 
and  that  it  is  the  same  as  far  as  relates  to  the  operative  process  in  contractions 
of  the  Eustachian  tube,  as  in  coarctations  of  the  urethra;  and  that  on  this  point 
dexterity  and  frequent  practice,  joined  with  great  prudence,  will  alone  give 
sufficient  skill  to  him  who  wishes  to  reap  any  fruit  from  catheterism  of  the 
guttural  auditory  canal.  It  would  consequently  be  vain  to  expect  to  attain 
the  knowledge  and  tact  possessed  by  M.  Deleau,  without  long  practice.  Thus 
does  it  become  a  very  simple  matter  how  this  practitioner  has  succeeded  in 
affording  relief  or  cures  to  a  host  of  deaf  and  dumb,  who  had  fruitlessly  sought 
elsewhere  the  amelioration  procured  in  his  establishment. 

It  remains  for  me  to  offer  a  suggestion.  As  engorgement,  thickening,  or  a 
phlegmasiac  condition  of  the  mucous  lining  of  the  tube  is  admitted  as  a  cause 
of  deafness,  might  it  not  be  allowed  to  try  against  this  affection  what  is  em- 
ployed with  so  much  advantage  in  the  radical  cure  of  it  in  the  urethra,  viz., 
the  nitrate  of  silver  ?  Having  no  authority  in  support  of  this  suggestion,  I 
merely  throw  it  out  in  passing,  without  forgetting  the  fear  naturally  inspired 
by  the  introduction  of  caustics  through  the  pharynx  into  the  ear. 


TITLE  n.— OPERATIONS  ON  THE  TRUNK. 

CHAPTER    I. 

Nech. 

SECTION  I. 

Lateral  and  Superior  Regions. 

Art.  1. — Parotid  Gland, 

To  take  literally  what  has  been  said  by  the  authors  of  the  last  century, 
nothing  should  be  so  simple  as  the  total  eradication  of  the  parotid  gland.  In 
our  days,  on  the  contrary,  nothing  seems  more  difficult ;  so  that  many  great 
masters,  M.  Boyer  among  the  rest,  deny  even  its  possibility.  It  is  true  that 
the  greater  part  of  reported  cases  are  far  from  being  conclusive.  Thus,  as 
Richter  has  already  remarked,  and  Burns  demonstrated,  the  assertions  of 
Heister,  who  is  said  to  have  extirpated  the  parotid  several  times ;  those  of 
Scultetus,  Yerdier,  Palfyn,  Van  Swieten,  Gooch,  Berh,  Roonhuysen,  Gotte- 
fried,  Errhart,  &c.;  of  Garengeot,  who  maintains  that  the  operation  never 
causes  hemorrhage ;  of  Kaltschmidt,  who  avers  that  he  performed  it  a  number 
of  times  with  success,  among  others  for  a  tumor  which  weighed  three  pounds ; 
of  Acrel,  who  arrested  the  hemorrhage  by  simple  tamponnement ;  of  Bur- 
graw,  of  Hezel,  of  Alix,  who  removed  a  mass  ^  weighing  four  pounds  from 


468  NEW    ELEMENTS    OF 

beneath  the  ear  without  producing  the  least  effusion  of  blood ;  of  Kauw, 
Boerrhaave,  and  some  others ;  evidently  relate  to  the  removal  of  lymphatic 
tumors  developed  in  the  depth  of  the  parotid  space,  and  not  to  the  parotid 
itself.  Mightnotthe  same  be  said  of  the  following  observations?  In  1781,  J.  B. 
Siebold  thought  that  he  had  entirely  removed  the  parotid,  because  after  the 
operation  it  was  easy  to  discern  the  digastric  and  stylo-hyoid  muscles,  as  well 
as  the  carotid  artery.  In  the  case  of  a  student,  mentioned  by  Heister,  it  was 
necessary  to  go  so  deep  that  the  carotid  gave  rise  to  a  fatal  hemorrhage. 
Thinking  to  remove  a  wen,  Soucrampe  perceived  that  he  was  extirpating  the 
parotid  and  continued  his  operation,  dissecting  out  the  gland  with  a  bistoury. 
**  I  guided  the  instrument,"  says  he,  *'  with  the  index  finger  of  the  left  hand, 
to  distinguish  the  pulsation  of  the  arteries  and  especially  of  the  carotid." 
Less  blood  was  lost  than  the  surgeon  expected,  and  the  patient  was  perfectly 
restored.  In  1796,  Ch.  G.  Siebold,  who  removed  an  enormous  tumor  from 
the  side  of  a  young  lady's  neck,  says,  that  there  resulted  so  deep  an  excava- 
tion that  all  the  assistants  were  obliged  to  admit  that  the  parotid  gland  hatl 
been  extracted  entire.  In  an  operation  by  Klein,  in  1820,  the  facial  nerve 
was  cut.  It  was  necessary  to  lay  bare  the  carotid  artery  and  the  pneumo- 
gastj'ic  nerve,  to  turn  aside  the  temporal,  external  maxillary,  auricular,  and 
transversalis  faciei  arteries,  and  tie  several  of  these  vessels.  At  the  end  of 
eigriteen  days  the  cure  was  complete.  In  the  case  which  occurred  to  M.  Idrac, 
of  Toulouse,  there  was  no  artery  to  tie,  but  the  wound  presented  the  same 
aspect  as  in  the  patient  of  the  elder  Siebold,  and  the  diseased  portion,  as 
large  as  the  fist,  was  round  and  rugose ;  inwards  w^as  a  projection  moulded  in 
the  space  bounded  by  the  mastoid  process,  the  auditory  canal,  and  tlie  margin 
of  the  jaw.  It  was  of  the  same  nature  throughout,  and  presented  exactly  the 
form  of  the  parotid.  The  patient  was  cured  without  the  occurrence  of  pa- 
ralysis. The  observation  of  M.  Lacoste  difters  from  that  of  M.  Idrac  only  in 
having  an  abundant  hemorrhage,  twice  renewed,  and  which  placed  the  life  of 
the  patient  in  danger.  The  tumor  j-emoved  by  M.  Prieger  weighed  nearly 
three  pounds.  The  external  maxillary,  temporal,  and  auricular  arteries,  but 
not  thfe  carotid,  were  divided  and  tied.  The  woman  survived.  If  we  are  to 
believe  Mr.  Kirby,  we  may  be  assured  that  after  his  operation  the  interval  of 
the  pterygoid  muscles  was  empty,  the  auditory  canal  displayed  as  well  as  the 
temporo -maxillary  articulation  and  the  whole  length  of  the  styloid  process. 
Nevertheless,  plugging  with  sponges  sufticed  to  arrest  the  hemorrhage ;  and 
notwithstanding  an  erysipelas  of  the  face  which  supervened,  the  patient  was 
cured.  As  to  the  case  related  by  M.  Pamard,  the  author  himself  admits  that 
the  parotid  was  not  entirely  extirpated.  M.  Nasgele  maintains  that  tlie  gland 
may  be  removed  from  the  dead  subject  without  lesion  of  the  facial  nerve,  and 
declares  that  he  has  performed  it  successfully  in  his  hospital  without  producing 
paralysis.  If  in  these  various  observations  the  authors  are  far  from  giving 
all  the  details,  and  all  the  proofs  capable  of  carrying  their  ow^n  conviction  to 
the  minds  of  their  readers ;  if  in  several  instances  the  little  they  do  say  tends  to 
prove  the  contrary  of  what  they  have  advanced,  it  is  not,  therefore,  the  less 
probable  that  some  among  them  refer  really  to  the  eradication  of  tlic  principal 
secretory  organ  of  the  saliva.  Besides,  there  actually  exist  irrefragible  proofs 
of  such  an  operation.  Althougli  M.  Goodlad  reports  a  case  quite  circum- 
stantially, yet  to  Beclard  is  due  its  first  demonstration.    His  patient,  operated 


OPERATIVE    SURGERY.  469 

upon  in  1823,  at  the  hospital  La  Pitie,  had  the  muscles  of  the  whole  of  one 
side  of  the  face  paralysed,  and,  as  he  died  some  months  after  of  chronic 
meningitis,  it  was  iii  the  power  of  the  operator  to  prove  on  the  dead  body  that 
all  the  gland  had  been  positively  extirpated.     A  patient,  who  was  operated 
on  by  M.  Gensoul,  in  September,  1824,  and  died  in  the  courseof  the  year  1825, 
if  we  admit  without  reserve  the  assertion  of  the  author,  proved  also  that  the 
removal  of  the  parotid  gland  had  been  complete.     With  better  fortune  than 
at  first,  M.  Gensoul  repeated  the  operation  in  1826,  and  with  full  success, 
but  the  patient  remained  with  paralysis  of  one  half  of  the  face.     M.  Car- 
michael  met  with  the  same  good  fortune  some  time  previously,  that  is,  in  1818, 
and  mentions  the  same  peculiarity  as  M.  Gensoul  as  the  consequence  of  the 
operation.      In  1826,  also,  M.  Lisfranc  had  occasion  to  remove  the  whole  of 
the  parotid,  and  exhibited  the  patient  and  the  morbid  portion  to  the  academy, 
and  proved  satisfactorily  after  death,  which  happened  after  the  lapse  of  some 
weeks,  that  there  was  no  portion  of  the  gland  remaining  in  the  parotid  space. 
In  the  operation  performed  by  M.  Heyfelder,  of  Treves,  in  the  month  of 
June,  1825,  the  patient  lost  but  three  or  four  ounces  of  blood,  but  a  very 
small  lobe  of  the  gland  was  left  in  front,  and  the  paralysis  of  the  face  in  the 
end  spontaneously  disappeared.  In  the  operation  by  Dr.  G.  M'Clellan,  in  1826, 
the  success,  says  the  author,  was  complete,  although  the  gland  was  entirely 
removed.     That  of  M.  Cordes,  of  Hirschetrg,  who  declares  that  he  did  not 
leave  the  least  particle  of  the  gland,  is  equally  established.     M.  Bernt  pro- 
fessed also  to  have  performed  it  with  success.     The  Archives  contain  another 
example,  in  which  layer  by  layer  was  removed  down  to  the  carotid.     The 
German  journals  of  the  last  year  report  a  new  case  of  the  successful  removal 
of  the  parotid.     In  the  operation  which  M.  A.  Fonthein  de  Syke  performed, 
in  November,  1828,  on  a  woman  twenty -three  years  old,  the  carotid  was  not 
wounded,  no  hemorrhage  took  place,  and  the  cure  perfect  on  the  thirtieth 
day.     The  paralysis  itself,  which  was  apparent  at  first  as  in  the  preceding 
cases,  had  completely  ceased.     The  most  recent  case  that  I  am  acquainted 
M'ith,  is  that  of  M.  A.  Magri,  of  Soreinese.     In  January,  1829,  this  surgeon, 
assisted  by  M.  Madonini,  extirpated  from  the  side  of  the  neck  a  tumor  which 
included  the  whole  of  the  parotid,  without  being  obliged  to  tie  the  trunk  of 
the  carotid.     The  patient,  a  countryman,  thirty-six  years  old,  was  restored  in 
twenty-six  days,  with  the  exception  of  paralysis  of  the  face,  which  remained. 
M.  Dugied,  who  gives  an  extract  of  the  greater  part  of  these  facts,  mentioned 
also  by  Messrs.  Hourman  and  Pillet  in  their  dissertation,  says  that  Messrs. 
A.  Cooper  and  Weinhold  have  extirpated  several  times  the  entire  parotid. 
But  I  have  not  been  able  to  find  where  these  observations  have  been  published, 
except  those  of  M.  Weinhold,  who  preserves  one  of  the  glands  in  his  cabinet, 
and  exhibits  it  to  any  one  who  desires  to  see  it. 

Anatomical  JRemarks. — This  gland,  which  is  enveloped  in  its  aponeurosis, 
and  continuous  in  some  measure  with  the  sub -maxillary  gland  in  passing  over 
the  internal  face  of  the  angle  of  the  jaw,  separated  from  the  skin  by  a  layer 
of  adipo-cellular  tissue  of  more  or  less  density,  is  nearly  of  a  pyramidal  shape, 
and  is  somewhat  firmly  connected  to  the  auditory  canal  above,  to  the  mastoid 
process  and  sterno-mastoid  muscle  behind,  and  more  or  less  prolonged  in 
front,  upon  ih^  external  face  of  the  masseter.  On  its  anterior  face,  it  con- 
ceals or  incloses  between  its  lobes,  as  you  go  from  above  downwards  and  from 


470  NEW   ELEMENTS    OF 

without  inwards,  first,  the  arteria  transversalis  faciei,  and  the  two  principal 
branches  of  the  facial  nerve  at  the  point  of  their  passage  over  the  margin  of 
the  jaw;  secondly,  parallel  to  this  margin,  the  superficial  temporal  artery  and 
vein ;  thirdly,  the  external  carotid  and  the  origin  of  the  internal  maxillary ; 
and  fourthly,  the  pterygoid  muscles,  and  some  branches  of  the  pharyngeal 
vessels.  It  rests  below  upon  the  stylo-maxillary  ligament,  the  digastric  and 
stylo-hyoid  muscles  ;  behind,  between  the  ear  and  the  mastoid  process,  upon 
the  auricula  artery;  lower  down  upon  another  quite  large  branch,  which 
crosses  the  mammoid  protuberance;  more  deeply,  upon  the  stylo-mastoid 
artery,  and  mediately  upon  the  occipital.  By  its  summit  it  passes  near 
the  internal  jugular  vein,  the  great  hypo-glossal,  the  pneumogastric  and 
the  great  sympathetic  nerves,  between  the  transverse  process  of  the  first 
vertebra  and  the  pharynx.  One  of  its  branches  is  generally  prolonged 
between  the  two  carotids ;  another  often  advances  between  the  stylo-glossus  and 
the  stylo-pharyngeus  muscles,  the  internal  carotid  artery,  and  the  jugular  vein : 
the  whole  cover  the  styloid  process,  which  they  embrace,  and  the  root  of  the 
anatomical  bouquet  of  Riolan.  In  fine,  it  is  traversed  obliquely  from  above 
downwards,  from  within  outwards,  and  from  behind  forwards,  by  the  trunk  of 
the  facial  nerve,  which  ramifies  in  its  substance,  where  is  also  found  the 
vein  which  forms  the  communication  between  the  two  jugulars,  very  small  lym- 
phatic ganglia,  and  other  arterial  and  venous  branches  of  much  less  importance. 

Manual. — ^When  the  operation  is  determined  upon,  the  first  question  that 
presents  is,  whether  it  is  necessary  or  not  to  imitate  M.  Goodlad,  who  pre- 
viously tied  the  carotid  artery?  At  the  commencement,  it  is  never  known 
whether  the  whole  of  the  gland  will  have  to  be  removed,  or  whether  we  may 
be  permitted  to  leave  a  part.  If  in  the  first  case  a  wound  of  the  external 
carotid  is  almost  inevitable,  the  internal  carotid  may  very  frequently  be 
respected.  In  the  second,  there  is  a  probability  of  preserving  both.  By  its 
action  on  the  encephalon,  and  the  rest  of  the  organization,  this  ligature  is  far 
from  being  indifferent.  Without  admitting,  with  M.Tuson,  that  proximately 
or  remotely  it  is  constantly  fatal,  it  would  at  least  be  very  wrong,  whatever 
may  be  said  of  it  by  some  moderns,  not  to  regard  it  as  one  of  the  most  dangerous 
operations  in  surgery.  Here,  besides,  its  execution  would  be  extremely 
difficult  on  account  of  the  changes  of  relation  between  the  parts,  at  least  if  the 
external  carotid  only  is  to  be  tied.  In  keeping  the  thread  around  it  only  du- 
ring the  operation,  as  was  done,  or  appears  to  have  been  done  by  Beclard^ 
Carmichael,  Gensoul  and  Lisfranc,  we  have  at  least  the  chance  of  dispensing 
with  it,  if  it  be  possible,  without  being  thereby  exposed  to  meet  more  nu- 
merous obstacles,  than  in  any  other  manner. 

1.  Operation. — The  instruments  which  may  be  required  are  a  straight  bis- 
toury; a  convex  bistoury;  a  probe-pointed  bistoury;  straight  and  curved 
scissors;  a  dissecting  forceps;  a  steel  director;  a  scalpel,  of  which  the  flat 
handle  may  serve  to  separate  the  parts  if  occasion  require ;  needles  armed 
with  ligatures,  and  all  that  may  be  necessary  for  placing  a  ligature  on  the 
carotid  artery.  The  rest  of  the  apparatus  consists  of  sponges,  rolls  of  charpie» 
dossils  of  lint,  agaric,  long  and  square  compresses,  one  or  two  bandages,  and 
other  things  required  in  every  great  operation. 

First  Stage. — Resting  on  the  sound  side  and  supported  by  assistants,  the 
patient  is  to  be  placed  so  as  to  be  able  to  breathe  and  spit  freely.    One  person 


OPERATIVE    SURGERY.  471 

t 

should  be  ready  to  compress  the  trunk  of  the  primitive  carotid  in  case  of 
accident.  The  volume,  the  form  of  the  tumor,  and  the  state  of  the  integu- 
ments, determine  the  kind  of  incision  which  should  be  first  preferred.  If  the 
skin  is  sound,  and  free  from  adhesions ;  if  the  body  to  be  removed  does  not 
exceed  in  size  a  hen's  egg,  the  crucial  or  the  T  incision  is  the  best :  otherwise 
recourse  must  be  had  to  the  elliptic  incision,  in  order  to  remove  with  the 
scirrhus  a  flap  of  the  cutaneous  cushion.  In  this  latter  case,  if  the  extent  of 
the  tumor  require  it,  nothing  prevents  making  on  each  lip  of  the  ellipse  after- 
wards another  incision,  which  will  transform  it  into  a  T,  and  after  the  opera- 
tion will  reduce  the  whole  to  a  crucial  incision.  Unless  the  disease  extends 
very  far  towards  the  mouth,  it  is  less  advantageous,  without  doubt,  to  make 
the  great  diameter  of  the  wound  transversely,  as  done  by  Mr.  Goodlad  and 
advised  by  M.  Fonthein,  than  perpendicularly.  These  are  the  only  general 
rules  that  can  be  established  on  this  first  point.  It  is  upon  himself,  his  know- 
ledge, and  his  peculiar  ability,  that  the  operator  will  be  obliged  to  rely  in  fol- 
lowing, modifying,  or  infringing  them. 

Second  Stage. — The  integuments  being  dissected  and  the  flaps  turned  back, 
the  surgeon  detaches  the  altered  mass  commencing  at  its  superior  part  and  on 
its  posterior  edge,  so  as  not  at  first  to  fall  upon  the  carotid ;  he  ties  all  the 
arterial  branches  as  they  are  opened,  or,  if  they  are  of  inconsiderable  size,  fol- 
lows the  precepts  of  Zang,  leaving  them  to  be  compressed  by  the  finger  of  an 
assistant,  observing  when  about  the  margin  of  the  maxilla  or  near  the  ptery- 
goid muscles,  to  keep  the  edge  of  his  knife  rather  backwards  than  forwards, 
directed  against  the  tissues  to  be  extirpated  rather  than  towards  those  which 
ai-e  to  be  preserved.  When  the  handle  of  the  scalpel  is  sufficient,  it  ought  to 
be  preferred.  With  this  instrument  most  of  the  lobes  of  the  gland  may  be 
torn  loose  and  insulated,  and  disengaged  from  between  the  vessels,  without 
any  risk  of  wounding  the  arteries,  and  the  dangers  of  the  operation  are  by  so 
much  diminished.  However,  when  it  is  certain  that  the  adhesions  to  be 
destroyed  contain  nothing  important,  the  bistoury  is  to  take  the  place 
of  the  scalpel.  By  temng,  the  dissection  is  more  certain  ;  by  incision,  it  is 
quicker,  less  painful,  and  more  favorable  in  the  sequel.  Behind  the  ramus 
of  the  jaw,  the  operator  is  to  redouble  his  precautions.  There,  are  located  the 
external  carotid,  completely  enveloped  with  glandular  granulations,  in  some 
subjects,  and  the  origin  of  the  temporal  and  internal  maxillary.  Deeper,  at 
the  apex  of  the  parotid  fossa,  if  any  pedicle  exist,  or  any  portion  that  cannot 
be  removed  by  the  handle  of  the  knife,  prudence  dictates  that  a  ligature  be 
passed  around  on  the  side  of  the  sound  parts  before  cutting  them.  Supposing 
that  during  this  operation  a  large  artery,  the  external  carotid  for  instance, 
should  be  opened,  or  that  its  lesion  appears  inevitable,  before  proceeding  fur- 
ther in  the  operation  it  is  laid  bare  towards  its  origin,  that  the  ligature  may  be 
applied  low  enough  to  prevent  its  being  touched  again  during  the  operation. 
If  the  muscles  of  the  styloid  process,  the  digastric  especially,  have  not  dege- 
nerated, we  should  endeavor  to  preserve  them.  In  the  opposite  c^se,  they 
are  sacrificed  without  hesitation,  as  also  the  trunk  of  the  facial  nerve,  which  it 
is  useless  to  attempt  to  save  when  the  entire  parotid  is  disorganized.  In  the 
end,  it  is  possible  that  the  gland  may  resist  only  at  its  summit;  and  notwith- 
standing the  tractions  exercised  by  the  left  hand  on  the  one  part,  and  by  the 
handle  of  tlie  scalpel  on  the  other,  this  point  holds  firmly  at  the  bottom  of  the 


472  NEW  ELEMENTS  OF 

wound.  Then,  for  fear  that  it  contain  some  large  vascular  trunk,  it  is  best  to 
include  it  in  a  ligature  and  strangulate  it  as  in  the  case  of  a  polypus,  conform- 
ing to  the  advice  of  Hezel,  and  confining  ourselves  at  the  moment  to  the 
excision  of  the  free  part  of  the  tumor  only. 

Remarks. — The  arteries  which  may  have  to  be  destroyed,  are,  besides  the 
carotids,  the  transversalis  faciei,  the  temporal,  the  auricular,  the  mastoid,  the 
stylo-mastoid,  the  occipital,  the  internal  maxillary,  the  inferior  pharyngeal, 
the  lingual  itself,  and  the  facial.  It  is  necessary,  therefore,  to  tie  successively 
all  these  branches,  if  their  common  trunk  has  not  been  previously  secured. 
The  blood  which  continues  to  flow  afterwards,  can  only  come  from  the  veins, 
and  requires  no  other  care  than  the  application  of  a  compress,  if  it  do  not 
cease  spontaneously.  At  first  sight,  the  excavation  which  has  been  produced 
has  something  frightful  in  it,  but  its  depth  alone  does  not  prove  that  the  whole 
gland  has  been  extirpated.  In  swelling,  the  ganglia  which  are  in  the  centre 
or  at  the  borders  of  this  organ,  force  it  in  every  direction,  produce  in  it  atro- 
phia, and  cause  it  in  some  measure  to  disappear,  so  that  after  their  removal,  it 
is  very  easy  to  be  deceived,  and  to  believe  that  the  parotid  itself  has  been  extir- 
pated. It  is  a  remark  on  which  Messrs.  Murat,  Cullerier,  Richerand,  and 
Boycr  justly  insist,  which  it  is  important  not  to  forget;  and  which  allows  us  to 
estimate  at  their  true  value  the  assertions  of  authors  whose  observation  I  have 
noted  above,  and  to  understand  how  this  operation  can  be  performed  without 
producing  hemorrhage,  by  dividing  only  the  smaller  vessels,  &c.  If  the 
wounds  be  but  of  few  inches  in  extent,  the  flaps  may  be  approximated,  and 
united  by  strips  or  the  suture.  But  when  it  is  very  broad,  by  attempting  to 
close  it  immediately  and  fully,  it  is  liable  to  purulent  discharge,  to  simple  or 
phlegmonous  erysipelas,  and  all  their  consequences,  as  was  seen  in  the  cases 
reported  in  the  name  of  Beclard  and  several  others.  After  cicatrization  the 
patient  may  remain  weak,  and  he  should  be  apprised  of  it  beforehand.  The 
motions  of  the  pharynx,  of  the  larynx  of  the  tongue,  of  the  jav/  itself,  suffer 
sometimes  greatly  from  this  operation  on  account  of  the  division  of  the 
muscles.  Most  frequently  the  division  of  the  facial  nerve  paralyzes  more  or 
less  completely  the  eye  lids,  the  ala  of  the  nose,  the  labial  angle,  and  all  the  cor- 
responding half  of  the  face.  In  time,  however,  the  most  of  these  parts  recover 
their  powers,  and  it  is  rare  in  the  end  that  the  countenance  does  not  resume 
its  former  expression. 

2.  Ligature, — The  cutting  instrument  is  not  the  only  means  in  the  hands 
of  practitioners  to  destroy  the  schirrous  parotid.  Intimidated  by  the  dangers 
of  hemorrhage,  Roonhuysen,  who  had  already  proposed  to  substitute  the  liga- 
ture, passed  a  double  ligature  deeply  through  the  base  of  the  tumor,  and  tied 
its  two  portions  separately,  the  one  above  and  the  other  below,  so  as  to  produce 
mortification  of  the  diseased  tissues  by  depriving  them  of  all  circulation. 
M.  Mayor  recommends  that  it  be  first  exposed,  as  if  for  its  extirpation  ;  and 
after  insulating  all  the  portion  which  makes  the  projection  externally,  it  is 
traversed,  as  by  Roonhuysen,  or  rather  it  is  drawn  outwards  as  much  as  pos- 
sible with  a  hook-foVccps,  and  a  strong  ligature  is  passed  beneath  its  root,  which 
is  gradually  tightened  by  his  chaplet-constrictor.  In  five  or  six  days,  says  he, 
the  degeneration  is  entirely  cut  off  or  reduced  to  decay,  without  risk  of  the 
lesion  of  any  artery.  In  this  manner  he  cured  a  girl,  fourteen  years  old,  of  a 
tumor  which  had  existed  for  three  years  in  front  of  the  ear ;  and  another 


OPERATIVE    SURGERY.  473 

person  eighteen  years  old,  upon  whose  person  the  gland  extended  from  the 
zygomatic  arch  to  beneath  the  angle  of  the  maxilla;  and  again,  a  third  on 
whom  the  morbid  mass,  eight  inches  long  and  four  broad,  was  situated  in  the 
parotid  region.  But  whatever  may  be  said  by  this  author,  these  facts  relate 
rather  to  the  extirpation  of  degenerated  lymphatic  gangliae  than  to  that  of  the 
parotid  gland,  properly  called.  I  observe,  besides,  a  disadvantage  in  this 
method  ;  it  is  likely  to  remove  but  a  part  of  the  disease  when  it  is  deeply  seated, 
and  if  it  be  superficial,  as  the  use  of  the  bistoury  then  ceases  to  be  formidable, 
it  loses  much  of  its  importance.  However,  in  the  first  of  these  cases  I  would 
willingly  try  it  in  combination  with  dissection.  Without  the  trouble  of  ex- 
tracting all  the  branches  of  the  gland,  one  after  the  other,  a  strong  ligature 
which  would  include  them  en  masse,  and  allow  them  to  be  gradually  strangu- 
lated, seems  to  offer  a  resource  which  has  been  too  much  neglected,  as  M. 
Mayor  justly  complains. 

3.  Caustics, — The  advice  of  Desault  and  of  Chopart,  who  require  that  after 
excising  all  the  projecting  part  of  the  scirrhus  the  rest  shall  be  destroyed  with 
hot  iron  or  caustics,  is  assuredly  of  the  very  least  value,  and  scarcely  deserves 
to  be  noticed.  Cautery  could  not  be  useful  in  this  operation,  except  to  close 
tlie  mouths  of  vessels  escaped  from  the  ligature,  and  to  consume  some  morbid 
particles,  if  any  have  been  left  by  the  instrument  against  the  intention  of  the 
operator. 

*^rt.  2.  Submaxillary  Gland, 

No  conclusive  observation  proves  that  the  submaxillary  gland  ever  passes 
to  the  state  of  scirrhus  or  cancer.  The  cases  which  have  been  reported  refer 
to  the  conglobate  glands  which  border  on  it,  and  are  found  between  it,  the 
margin  of  the  jaw,  and  the  platysma  myoides.  Its  induration  in  consequence 
of  chronic  inflammation,  in  ranula,  for  example,  is  far  from  being  equally  rare. 
Abscesses  developed  in  the  cellular  tissue  of  the  surrounding  parts,  and  which 
remain  fistulous  after  being  opened,  also  produce  it.  But  however  obstinate 
it  may  be,  this  disease  generally  yields  to  other  means  than  extirpation,  which, 
to  me,  does  not  appear  altogether  indispensable.  Of  the  two  cases  of  it  which 
were  published  in  France  some  time  since,  the  one  which  1  reported  and  which 
belongs  to  M.  J.  Cloquet,  was  a  pure  and  simple  case  of  the  extirpation  of 
sub-hyoid  ganglia;  the  other,  related  by  M.  Amassat,  belongs  probably  to  the 
same  class,  and,  by  the  way,  it  is  far  from  being  demonstrated  that  the  ope- 
ration in  this  case  was  absolutely  necessary.  Whether  the  disease  is  seated 
in  the  gland,  or  the  ganglia  which  surround  it,  the  process  to  be  followed  in  its 
removal  is  nearly  the  same.  Embraced  as  it  were  inferiorly  by  the  concavity 
of  the  digastric  musckj  and  separated  from  the  integuments  by  the  facial  vein 
and  the  platysma  myoides,  the  submaxillary  gland  rests  superiorly  against  the 
internal  face  of  the  jaw,  and  inwards  against  the  hyo-glossus  and  the  mylo- 
hyoides  muscles,  upon  the  external  face  of  which  it  sends  one  of  its  prolong- 
ations. The  facial  artery  coasts  along  its  superior  and  internal  side ;  the 
lingual  nerve  and  artery  pass  beneath.  Quite  high  up  it  receives  the  plexus 
of  the  myloid  nerve. 

Manual — All  that  has  been  said  of  the  form  and  direction  to  be  given 
to  the  incision  in  speaking  of  the  parotid,  is  equally  applicable  here.    The 
CO 


4T4  NEW  ELEMENTS   OF 

patient  is  to  have  his  mouth  closed,  the  chin  elevated,  the  head  thrown  back 
and  to  one  side ;  the  gland  of  the  tumor  is  thus  brought  entirely  in  view.  The 
surgeon  divides  the  skin  at  first  from  above  downwards,  from  the  margin 
of  the  jaw  to  the  os  hyoides,  and  then  transversely ;  he  dissects,  detaches,  and 
turns  back  the  flaps  thus  traced  out;  applies  two  ligatures  upon  the  facial  vein, 
and  divides  it  between  them  if  it  is  too  much  in  the  way  and  cannot  be  kept 
aside  by  a  hook ;  inserts  a  hook  into  the  body  of  the  gland  and  has  it  drawn 
outwards  and  upwards,  then  backwards  and  downwards,  while  with  short 
strokes  he  detaches  the  inferior  portion  or  the  anterior  moiety ;  avoiding  care- 
fully the  lingual  artery  and  the  concomitant  nerve,  he  seeks  posteriorly  the 
trunk  of  the  external  maxillary  and  ties  it;  has  the  hook  carried  forwards  and 
downwards;  separates  the  morbid  mass  from  tlie  side  of  the  tongue,  and 
removes  it  without  difficulty.  If  it  be  preferred  to  commence  by  tying 
the  facial  artery,  the  first  incision  is  to  be  directed  over  it,  and  it  h  to 
be  looked  for  at  the  point  which  I  have  indicated  in  another  chapter.  It  may 
not  even  be  tied  at  all  if  care  is  used  to  preserve  untouched  to  the  end  tiie 
point  through  which  its  branches  penetrate  the  gland,  and  to  embrace  it  as  a 
pedicle  with  a  strong  ligature.  As  for  the  dressing  and  treatment,  we  are  to 
act  as  after  the  extirpation  of  the  parotid,  always  recollecting,  that  beneath 
the  jaw  immediate  reunion  presents  infinitely  less  danger,  and  that  the  whole 
of  the  operation  is  incomparably  less  formidable  than  in  the  subauricular 
fossa. 

SECTION    II. 

Anterior  Region. 

Jrt,  1  .--Tliyroid  Body. 

Goitre  or  bronchocele  is  another  tumor  with  which  modern  surgery  has 
been  much  occupied,  and  which  is  not  to  be  attacked  by  surgical  means  until 
after  having  been  vainly  opposed  by  iodine,  the  powder  of  Sency,  and 
the  other  pharmaceutical  resources,  extolled  at  the  present  day;  and  if  it 
should  become  so  oppressive  to  the  patient  as  to  endanger  his  existence. 
Caustics y  which  were  employed  for  its  destruction  in  the  days  of  Celsus, 
and  since  by  a  small  number  of  practitioners,  are  no  longer  in  use.  The 
seton  which  the  elder  Monro,  Gerard,  and  more  particularly  Flajani,  have 
tried,  or  seen  tried  with  success,  and  which  M.  Quadri,  of  Naples,  recently 
published  as  a  new  resource,  does  not  deserve  the  same  proscription.  The 
advantages  to  be  derived  from  it  are  placed  beyond  doubt  by  a  number 
of  authentic  cases,  and  whenever,  instead  of  hypertrophy,  fungous  or  cancer- 
ous degeneration,  the  tumor  is  formed  by  cysts  of  liquid  or  semiliquid 
substances,  its  application  is  most  rational.  M.  Quadri  applies  it  in  general 
from  above  downwards  with  an  instrument  analagous  to  the  needle  of  M. 
Boyer,  and  rarely  carries  it  beyond  half  an  inch  in  depth  for  fear  of  wounding 
the  blood  vessels.  If  the  mass  to  be  destroyed  is  very  voluminous,  he 
passes  through  it  two,  three,  and  even  four  ligatures,  at  difierent  points.  The 
goitre  soon  begins  to  shrink,  and  resolution,  which  is  eifected  gradually,  con- 
tinues in  most  cases,  even  after  discontinuance  of  the  seton  and  cicatrization  • 
of  the  wounds.    The  thyroid  is  often  the  seat  of  hard  swelling,     I  have  met 


OPERATIVE    SURGERY.  ^5 

with  scirrhus  in  it.  Burns  and  M.  Wardrop,  have  there  met  with  encephaloid 
matter  2inA  fungus  hsematodes.  But  the  facts  brought  forward  by  the  Naples' 
surgeon  do  not  prove  that  in  such  cases  the  seton  is  able  to  triumpli  over  the 
disease.  Under  these  dreadful  circumstances  there  have  been  proposed,  liga- 
ture of  the  bronchocele,  its  extirpation,  or  the  ligature  of  the  principal  arteries 
entering  it. 

Ligature. — To  Moreau,  surgeon  of  the  Hotel  Dieu,  Valentine  attributes  the 
idea  of  attacking  the  goitre  by  ligature.  One  of  the  patients  thus  treated 
in  1779  was  not  relieved,  the  other  was  perfectly  restored.  The  tumor  in  the 
first  was  cancer,  that  of  the  second  v/as  of  an  adipose  nature.  The  surgeon 
passed  a  double  ligature  through  its  base,  so  as  to  divide  it  into  two  equal 
parts,  which  he  strangulated  separately.  Some  years  afterwards  Desault  had 
also  recourse  to  it,  but  it  was  to  terminate  an  extirpation,  the  last  stage  of 
which  had  become  dangerous.  Bruninghausen  used  it  with  complete  success 
in  1805,  to  destroy  an  enlargement  about  the  size  of  an  egg,  which  was  situated 
in  front  of  the  neck  between  the  larynx  and  the  sternum,  of  a  young  man 
twenty-five  years  old.  The  science  rested  at  this  point  until,  some  years 
since,  M.  Mayor  carried  forward  its  boundaries ;  a  child  twelve  years  old, 
upon  whom  he  operated  in  1821  for  a  goitre  of  the  size  of  an  orange,  at  the 
end  of  a  month  left  the  hospital  in  perfect  health.  On  a  man  twenty-one 
years  of  age,  the  tumor  occupied  the  front  and  both  sides  of  the  neck,  extend- 
ing from  the  maxillary  angles  and  the  parotid  region  to  very  near  the  sternum 
and  the  clavicles.  Of  the  three  lobes  which  composed  it,  the  middle  was  as 
large  as  the  head  of  a  foetus  of  seven  or  eight  months.  The  whole  mass  was 
nine  inches  in  depth,  and  twenty-six  in  breadth  beneath  the  jaw.  The 
general  health  of  the  patient  was  bad,  and  yet  M.  Mayor  cured  him 
radically  in  less  than  a  month.  He  was  equally  successful  on  a  lady,  of 
Sackendorf,  who  had  in  vain  consulted  the  most  distinguished  men  of  every 
country,  to  free  her  of  a  tumor  which  had  existed  for  nearly  thirty  years. 
This  tumor,  which  had  not  ceased  to  grow,  occupied  all  the  left  side  of  the 
neck,  had  pushed  to  the  right  the  larynx  and  trachea,  compressed  the  carotid 
artery  and  internal  jugular,  and  seemed  seriously  to  threaten  the  life  of 
the  patient.  His  process  consists  in  laying  bare  the  whole  anterior  face 
of  the  bronchocele  by  a  crucial  or  T  incision ;  then  insulating  it  more  or  less 
from  the  adjacent  parts  with  the  fingers  or  the  handle  of  the  scalpel;  after- 
wards to  pass  a  strong  ligature  round  the  root  of  each  of  its  lobes,  or  to 
traverse  its  base  with  a  double  ligature,  which  permits  it  to  be  strangulated 
upwards  and  downwards.  Instead  of  one  or  two  ligatures  he  sometimes 
employs  as  many  as  four,  which  are  then  to  embrace  each  a  fourth  or  third  of 
the  gland.  As  many  constrictors  are  necessary  as  there  are  nooses  of  thread; 
and  it  is  to  the  chaplet-constrictor,  as  we  may  well  guess,  that  he  accords  the 
preference.  From  these  details  it  is  evident  that  the  ligature  here  is  but  an 
accessory  means,  a  resource  against  hemorrhage,  a  kihd  of  make-shift,  good 
to  be  used  when  there  is  danger  of  wounding  vessels  of  some  importance ; 
and  that  if  it  were  certain  that  all  the  large  arteries  could  be  avoided, 
extirpation  with  the  bistoury  would  be  much  more  advantageous.  It  is  an 
operation  besides  which  cannot  but  be  a  serious  one  ;  two  of  the  patients  ope- 
rated on  by  M.  Mayor  himself  sunk  under  it.  It  causes  suffocation,  angina, 
difficulty  of  respiration,  and  frequently  some  of  the  symptoms  of  putrid  fever. 


476  «  '  NEW   ELEMENTS    OF 

Consequently  I  would  not  advise  it,  but  with  the  condition  of  first  detaching 
the  tumor  with  a  cutting  instrument  or  the  fingers  to  the  greatest  extent 
possible,  so  as  to  have  a  pedicle  instead  of  a  large  base  to  strangulate ;  with 
the  condition  also  of  cutting:  off  the  tumor  without  the  knot,  and  not  leaving  it 
to  putrifj  in  the  wound. 

Obliteration  of  the  Arteries. — Some  practitioners  were  of  opinion  that  by 
tying  the  thyroid  arteries  they  would  probably  obtain  resolution  of  the  goitre. 
Burns  refers  the  first  idea  of  it  to  Mr.  W.  Blizard,  of  London.  The  patient 
upon  whom  this  surgeon  operated,  did  very  well  for  a  week,  but  several 
hemorrhages,  and  hospital  gangrene  soon  exhausted  him,  and  finally  caused 
his  death.  Since  then,  M.  Walther,  who  conformed  to  the  precept  of  the 
English  surgeon,  in  1814,  performed  it  with  full  success.  To  Mr.  H.  Coates 
is  also  due  another  successful  case.  Mr.  Earle  and  Mr.  Green  have  not  been 
less  fortunate;  and  M.  Boileau,  being  obliged  to  tie  the  carotid  for  atraumatic 
lesion,  in  1825,  had  the  satisfaction  not  only  of  saving  his  patient,  but  also  of 
seeing  him  cured  of  a  goitre  of  many  years'  standing,  Mr.  S.  Cooper,  however, 
informs  us  that  a  ligature  of  the  thyroid  vessels,  performed  by  M.  Brodie, 
produced  no  diminution  of  volume  in  the  tumor  he  wished  to  destroy.  With- 
out being  very  numerous,  these  facts  are,  however,  sufficiently  conclusive  to 
justify  subjecting  this  mode  of  relief  to  new  experiments.  It  ought  particu- 
larly to  be  tried  in  pure  and  simple  bronchocele,  or  in  hypertrophy  of  the  thyroid 
body.  Instead  of  one  or  two,  in  my  opinion  the  four  thyroid  arteries  should 
be  tied,  otherwise  it  is  to  be  feared  that  the  blood  which  is  cut  off  on  one  side 
may  return  by  the  other ;  the  more  so,  as  the  long  continued  irritation  of  the 
parts  has  in  general  produced  there  a  very  decided  development  of  the 
vascular  system.  After  all,  the  operation  has  nothing  in  it  which  should 
deter  the  enlightened  surgeon.  If  the  natural  pulsations  of  the  vessels  are  not 
sufficiently  strong  to  serve  as  a  guide  to  the  instrument,  each  thyroid  artery  is 
to  be  sought  for  at  its  origin  from  the  carotid,  tlie  superior  on  the  internal  side 
of  this  trunk,  the  inferior  by  following  the  rules  laid  down  elsewhere. 

Extirpation. — By  extirpation  the  whole  of  the  disease  is  removed,  and  the 
patient  promptly  freed  from  it:  but  this  operation  is  attended  with  so  many 
and  such  formidable  dangers,  that  all  the  members  of  the  old  academy  of 
surgery,  and  the  great  majority  of  the  authors  of  the  present  age,  concur  in 
proscribing  it.  It  seems  to  me  probalile,  however,  that  we  shall  soon  have 
cause  to  form  a  different  judgment.  Tliat  in  the  time  of  Albucasis,  a  patient 
who  had  submitted  to  it  died  of  hemorrhage,  is  not  very  surprising ;  and  that 
the  young  woman,  mentioned  byPalfm,  sunk  from  the  same  cause  during  the 
operation,  is  also  easily  imagined.  Although  one  of  the  patients  mentioned 
by  Gooch  died,  sinking,  at  the  end  of  eight  days,  and  to  save  the  other  it  was 
necessary  for  assistants  to  succeed  each  other  constantly  during  a  week,  in 
order  to  compress  with  the  fingers  without  relaxation  all  the  arterial  mouths 
which  had  been  opened ;  although  an  officer,  whose  case  is  told  by  Percy,  died 
also  of  hemorrhage,  and  the  patient  of  M.  Dupuytren  survived  but  thirty- 
five  hours  the  removal  of  the  tumor ;  although  the  cases  of  extirpation  brought 
forward  by  Freytag,  Vogel,  Theden,  Desault,  Giraudi  of  Marseilles,  M. 
Fodere,  and  the  barber  who,  according  to  Paradi,  performed  it  with  success 
on  his  wife,  are  not  all  very  conclusive ;  although  the  girl  more  recently  treated 
by  Klein  was  the  next  day  seized  with  an  apoplexy  to  which  she  fell  a  victim. 


OPERATIVE    SURGERY.  477 

it  would  be  wrong  to  condemn  attempts  which  are  intended  to  familiarize  us 
further  with  this  operation.  Bj  combining  it  with  the  ligature,  as  practised 
so  successfully  by  M.  Mayor,  and  at  the  same  time  by  M.  Hedenus,  of  Dres- 
den, it  cannot  be  doubted  that  much  success  may  be  derived  from  it  in  future. 
The  most  complicated  cases  have  not  intimidated  this  last  surgeon,  who  in 
1822,  had  succeeded  in  six  cases.  His  process  differs  from  that  of  M. 
Mayor,  in  his  dissecting  the  bronchocele  carefully  with  the  scalpel  to  its  whole 
depth,  and  tying  the  arteries  as  soon  as  divided  by  the  instrument;  in  this 
also,  that  the  ligature  which  he  places  the  same  as  the  surgeon  of  Lausanne, 
but  tics  it  as  for  the  obliteration  of  a  large  vessel,  has  no  other  design 
than  to  strangulate  what  he  dares  not  cut,  and  to  permit  him  to  excise  all  the 
morbid  mass  immediately  and  safely.  For  my  part  I  will  not  decide  on  the 
extirpation  of  a  real  goitre,  until  I  am  assured  that  it  is  complicated  with  no 
lesion  of  the  heart,  no  tendency  to  apoplexy,  and  that  the  surrounding  lym- 
phatic glands  are  sound ;  nor  until  after  having  tried  either  the  seton,  after  the 
manner  of  M.  Quadri ;  the  simple  incision,  advised  by  M.  Fodere,  and  prac- 
tised with  success  by  M.  Delpech;  or,  as  advised  byM.  Rullier,  an  irritating 
injection  thrown  into  the  cyst,  if  there  be  one;  or  the  preliminary  ligature  of 
the  thyroid  arteries;  only  at  the  earnest  entreaties  of  the  patient,  and 
when,  instead  of  being  merely  a  deformity,  the  bronchocele  constitutes  a  disease 
whose  progress  and  nature  threaten  more  or  less  imminently  the  life  of  the 
patient. 

Manual. — Suppose  a  goitre  occupying  every  point  of  the  gland.  The  pre- 
parations are  much  the  same  as  in  removal  of  the  parotid.  The  patient  is  laid 
on  his  back,  his  head  moderately  bent  back  and  held  by  assistants.  Placed 
on  the  right,  the  operator  makes  his  first  incision  on  the  median  line,  com- 
mencing above  and  terminating  below  the  tumor;  transforms  this  wound  into 
a  crucial  incision ;  detaches  the  flaps  and  dissects  them  as  far  as  their  base ; 
divides  transversely  the  fleshy  strips,  and  turns  them  back  to  their  point  of 
attachment,  if  they  are  sound,  or,  if  diseased,  includes  them  in  the  subse- 
quent excisions ;  ties  the  vessels  that  are  in  the  way;  reaches,  gradually,  the 
edges  of  the  thyroid  body,  draws  them  towards  him,  tearing  rather  than  cut- 
ting ;  finds,  deeply  seated,  at  their  superior  and  inferior  parts  the  four  prin- 
cipal arteries  of  the  organ,  insulates  them,  and  passes  round  each  a  ligature; 
avoids  with  all  possible  care  the  trunk  of  the  carotids,  the  internal  jugular 
vein,  the  descendens  noni,  the  pneumogastric,  the  great  sympathetic,  and  the 
cardiac  nerves  which  are  to  be  found  a  little  further  outwards,  crossed  by 
numerous  secondary  veins  ;  then  detaches  the  tumor,  by  its  superior  part,  from 
the  sides  and  anterior  face  of  the  larynx  which  it  surrounds  and  sometimes 
deforms,  by  depressing  the  thyroid  and  cricoid  cartilages,  from  which  it  is  se- 
parated only  by  the  thyro-hyoid  muscles,  cellular  lamellae,  and  some  small 
arteries  which  it  is  necessary  to  tie,  furnished  by  the  lingual  or  maxillary 
branches ;  returns  towards  its  edges,  which  he  raises  and  separates  from  the 
oesophagus,  then  from  the  trachea  near  which  are  the  laryngeal  nerves ;  in  fine, 
when  it  is  only  held  by  its  inferior  edge,  if  the  venous  plexus  which  issue 
from  it,  and  the  thyroid  artery  of  Neubauer,  which  is  frequently  to  be 
found  there,  cause  its  complete  separation  to  be  dreaded,  he  includes  all  these 
objects  in  a  ligature,  or  rather  traverses  its  pedicle  with  a  double  ligature; 
strangulates  them  as  forcibly  and  as  near  their  root  as  possible ;  after  which 


478  NEW   ELEMENTS   OT" 

he  removes  without  fear  the  whole  of  the  goitre.  A  dissection  so  painful 
and  so  delicate  cannot  be  quickly  performed.  The  patient  has  need  of 
resting  from  time  to  time.  All  pressure  on  the  trachea  or  the  larynx  ought 
to  be  avoided  with  the  greatest  care,  and  the  surgeon  should  keep  in  mind 
that  if  the  inspirations  are  not  free,  the  blood  accumulates  in  the  veins  and 
flows  in  torrents  under  the  least  cut  of  the  bistoury.  Before  proceeding 
to  the  dressing  it  is  necessary  to  tie  the  smallest  arteries.  As  to  the  veins, 
they  will  cease  to  bleed  as  soon  as  the  patient,  freed  from  restraint,  can  ex- 
pand his  chest  freely  and  without  fear.  If  it  happen  otherwise,  they  are  to 
be  tied ;  which,  by  the  way,  is  far  from  inducing  phlebitis  as  surely  as  some 
modern  observers  contend.  The  convulsive  movements,  and  even  death, 
whi<:h  have  sometimes  occurred  during  the  extirpation  of  tumors  accom- 
panied with  great  development  of  the  vascular  system,  being  attributed  by 
some  to  the  opening  of  these  veins,  it  has  been  supposed  that  bubbles  of 
air,  penetrating  thereby,  have  been  carried  to  the  heart  and  caused  these 
frightful  eiFects.  Experiments  upon  animals,  related  by  M.  Magendie;  M. 
Larrey,  who  declares  that  he  saw  a  puncture  of  the  external  jugular  prove 
suddenly  fatal,  gave  the  first  idea  of  this  theory.  An  accident  that  hap- 
pened at  Hotel  Dieu  under  the  knife  of  M.  Dupuytren,  another  of  the  same 
kind  experienced  by  M.  Grsefe,  and  a  third  by  Dr.  Mott,  have  seemed  to 
confirm  it.  It  is  not  on  the  neck  alone  that  accidents  of  this  kind  have 
been  observed.  M.  Piedagnel  relates  the  history  of  a  man  from  whose 
shoulder  an  enormous  tumor  was  extirpated  by  M.  Beauchene,  in  1818. 
The  operation  had  not  been  completed  when  the  patient  exclaimed,  there 
is  blood  falling  in  my  heart,  I  am  a  dead  man!  and  he  died,  in  reality.  The 
same  happened  to  M.  Clemot  after  removing  a  tumor  from  the  breast,  and  two 
patients  upon  whom  he  opened  one  of  the  axillary  v6ins  were  on  the  point  of 
meeting  the  same  fate.  These  observations  do  not,  in  my  opinion,  place  the 
matter  beyond  all  dispute.  The  late  experiments  of  M.  Poiseuille,  tend  to 
prove  that  if  the  absence  of  valves  in  the  large  veins  of  the  neck  renders  it 
possible,  it  is  not  so  in  the  extremities  and  other  parts  of  the  body.  The 
patient  of  Klein,  and  the  adult  operated  upon  in  1 830,  by  M.  Dupuytren,  for  a 
thyrocele,  also  died  suddenly,  and  yet  there  was  no  thought  of  referring  this 
occurrence  to  the  passage  of  air  through  the  veins.  Thus,  without  denying  its 
possibility  (at  least  when  the  veins,  lost  as  it  were  in  the  midst  of  firm  tissues 
to  which  their  external  surface  adheres  and  which  they  excavate  in  form  of 
canals,  after  their  division  remain  patulous  at  the  bottom  of  the  wound),  I 
still  think  that  this  phenomenon  requires  to  be  confirmed  by  further  observ- 
ations. The  surfaces  being  well  sponged  and  the  threads  brought  out  at  the 
angles  of  the  wound,  it  remains  only  to  approximate  the  flaps  and  to  close 
the  wound  more  or  less  completely.  As  in  front  of  the  neck  the  centre 
of  the  wound  is  more  elevated  than  its  sides,  I  see  only  advantage  in 
attempting  immediate  union  rather  by  adhesive  strips  or  several  stitches, 
provided,  however,  that  with  the  exception  of  the  ligatures  no  foreign  body 
is  obliged  to  be  left  under  the  skin.  For  the  rest,  the  several  parts  of  the 
dressing  should  be  light,  and  very  softly  applied.  All  compression  in  this 
place  would  be  dangerous,  and  a  too  great  load  of  apparatus  would  occasion 
an  injurious  degree  of  warmth.  If  the  tumor  includes  but  one  side  of  the 
thyroid,  or,  if  independent  of  that  body,  it  is  situated  on  some  other  point  of 


OPERATIVE  SURGERY.  479 

the  anterior  half  of  the  neck,  the  modifications  to  be  adopted  in  the  process  I 
have  just  described,  are  very  trifling,  and  too  easily  conceived  to  render  it 
necessary  to  give  them  here  at  length. 

Art,  2. — Air  Passages, 

§  1.  Broncliotomy, 

By  the  term  bronchotomy,  the  ancients  intended  to  designate  the  artificial 
and  methodical  opening  of  the  aeriferous  canal  in  its  cervical  region,  and  by 
no  means  that  of  the  bronchia  as  its  etymolog}'  would  lead  us  to  infer.  At 
present,  as  it  is  performed  on  different  points  of  the  respiratory  canal,  by  the 
word  hronchotomy  is  to  be  understood  the  operation  in  general,  while  in  its 
special  application  it  includes,  tracheotomy y  laryngotomy,  and  laryngo -tracheo- 
tomy, Asclepiades  of  Bithynia  was  the  first,  I  believe,  who  ventured  to  per- 
form it.  No  one  previous  to  Antyllus  and  Paulus  Egineta,  had  described  it. 
C.  Aurelianus,  Aretaeus,  and  most  of  the  Greek  authors  reject  even  the  idea ; 
on  the  one  hand,  because,  according  to  them,  a  wound  of  the  cartilages  is 
mortal,  and  on  the  other,  because  bronchotomy  appeared  to  them  only  calcu- 
lated to  increase  the  inflammation  of  the  trachea.  Rhazes  advises  it  only  in 
the  case  of  imminent  death ;  and  although,  to  prove  that  the  divided  cartilages 
can  reunite,  Albucasis  cites  the  case  of  a  young  girl  whose  throat  was  cut, 
and  who  recovered  completely ;  and  for  the  same  purpose  Avenzoar  made 
several  successful  experiments  upon  goats,  it  is  yet  necessary  to  come  down 
to  1 529  and  1543,  to  see  it  repeated  by  A.  Benivieni  and  M.  Brassavole.  Only 
since  the  time  of  Fabricius  ab  Aquapendente,  have  writers  in  general  ad- 
mitted its  utility,  and  even  necessity,  under  some  circumstances.  And  they 
have  not  always  agreed  upon  the  cases  which  require  it. 

Indications  and  Appreciation. — P.  d'Abano,  who  called  it  sw^scanno^ioyi,  and 
after  him  Gherli  of  Modena,  G.  Martini,  6z:c.,  thought  it  indicated  in  every 
case  of  angina  tonsillaris  or  laryngea^  which  threatened  suffocation;  but 
although  defended  by  Mead  and  Louis,  their  opinion,  which  by  the  way  is  as 
old  as  the  days  of  Avicenna,  and  was  strenuously  opposed  by  Cheyne,  is 
scarcely  admitted  any  longer,  but  by  Drs.  Baillie  and  Fare.  Purely  inflam- 
matory angina,  however  intense  it  may  be,  rarely  goes  so  far  as  to  require 
such  a  relief;  medicine  possesses  means  to  oppose  it  not  less  efficacious  and 
much  less  fearful.  It  can  scarcely  be  comprehended  how  acute  swelling  of 
the  tonsils,  for  which  Flajani  did  not  fear  to  have  recourse  to  it,  can  ever 
require  it.  The  same  with  greater  reason  applies  to  their  cliroriic  engorge- 
ment, which  with  much  less  danger  is  always  to  be  removed  by  excision. 
When  the  tongue  suddenly  swells  so  as  to  fill  the  mouth  and  close  the 
istlimus  of  the  fauces,  Richter  and  B.  Bell,  who  recommended  it,  certainly 
forgot  that  two  or  three  deep  incisions  on  the  dorsum  of  the  affected  organ 
would  cause  its  diminution,  and  probably  they  were  not  acquainted  with 
the  observations  of  Delamalle  on  this  subject.  I  can  hardly  believe  that  it 
was  not  possible  to  dispense  with  it  in  the  case  in  which  Mr.  Burgess  lately 
performed  it;  since  there  was  but  an  inflammatory  intumescence,  produced 
by  a  burn,  at  the  bottom  of  the  buccal  cavity.  Moreover,  it  is  almost 
universally  admitted,  since  Desault,  that  it  is  not  proper  in  the  consequences 


A* 


480  NEW    ELEMENTS    OF 

of  submersion,  and  that  in  prescribing  it  in  asphyxia  of  drowned  persons, 
Detharding  was  entirely  mistaken  as  to  the  manner  in  which  death  is  caused 
under  such  circumstances.  Nevertheless,  Mr.  S.  Cooper,  who  considers  it 
more  prompt  and  easy  than  the  introduction  of  a  gum-elastic  sound  through 
the  nose  or  mouth,  is  right  in  my  opinion  in  maintaining  that  it  should  not  be 
proscribed  without  restriction.  If  the  mouth  is  firmly  closed,  if  the  sound 
does  not  strike  the  opening  of  the  larynx,  bronchotomy  is  better  than  nothing, 
since  prompt  action  is  necessary,  and  air  must  be  made  to  enter  the  lungs. 
When  we  reflect  on  the  difficulty  of  closing  the  glottis  entirely  with  the  tube 
which  we  engage  in  it,  and  of  preventing  the  insufflated  air  from  escaping  by 
the  digestive  passages,  in  every  case  in  which  the  surgeon  thinks  proper  to 
attempt  artificial  respiration,  we  must  feel  disposed  to  accord  this  operation 
over  the  use  of  the  catheter. 

(Edematous  Angina,  that  is  serous  enlargement  of  the  lips  of  the  glottis, 
is  a  disease  of  which  bronchotomy  seems  to  constitute  the  remedy  par  excel- 
lence. By  supplying  a  passage  for  the  respiration,  it  affords  the  physician  time 
to  attack  the  disease  by  appropriate  means,  and  to  the  organism  the  means  of 
extinguishing  it,  or  at  least  of  resisting  its  further  advances.  The  antagonists 
of  Bayle,  the  first  who  speaks  of  it  on  this  occasion,  reject  it  under  a  pretext 
which  to  me  does  not  seem  valid.  Their  permanent  tube  in  the  natural 
passages,  could  not  be  left  in  the  trachea  for  from  eight  to  fifteen  days  without 
danger ;  while  a  canula,  once  inserted  through  an  artificial  opening  in  the  air 
canal,  gives  but  little  inconvenience.  I  think  therefore,  with  Mr.  Lawrence, 
that  in  this  species  of  disease,  otherwise  almost  constantly  fatal,  it  deserves 
some  attention,  and  offers  a  much  better  chance  of  success  than  scarifications 
of  the  infiltrated  parts,  which  have  been  proposed  by  some  practitioners.  The 
patient,  whose  case  is  given  by  M.  RouUois,  of  Mayenne  in  his  thesis,  and 
who  was  operated  upon  at  the  hospital  Saint  Antoine,  by  M.  Kapeler,  in  1828, 
died,  it  is  true,  at  the  expiration  of  thirty-six  hours,  but  after  having  been 
recalled  as  by.a  miracle  from  death  to  life,  and  very  probably  because  the 
air  could  not  be  made  to  pass  in  sufficient  quantity  and  without  interruption 
into  the  lungs.  The  subject  mentioned  in  the  supplementary  journal  was 
more  fortunate:  he  survived.  A  polypus,  a  tumor  in  the  nasal  fossae  or 
pharynx,  the  thyroid  body  or  some  lymphatic  ganglia,  swelled,  indurated,  and 
large  enough  to  prevent  the  passage  of  the  air  through  the  trachea,  do  not 
render  the  operation  indispensable  except  when  there  is  imminent  danger  of 
suffocation,  or  when  it  is  impossible  or  too  dangerous  to  attempt  the  removal 
of  the  morbid  mass.  Sharp  reserved  it  in  some  measure  for  these  cases  alone ; 
for  it  did  not  appear  to  him  absolutely  necessary  in  the  extraction  of  foreign 
bodies. 

Foreign  Bodies, — At  present  it  is  chiefly  to  reach  heterogeneous  substances 
of  some  consistence,  which  are  often  introduced  into  the  larynx  or  trachea, 
that  this  operation  is  willingly  performed.  It  is  used  in  this  way  for  the  ex- 
traction of  clots  of  blood  which  have  fallen  from  the  mouth  or  from  a  wound 
of  the  larynx;  lumbrici ;  flies;  portions  of  food,  such  as  fish  bones,  bones  of 
poultry ;  fragments  of  mushrooms,  of  apples,  of  chesnuts,  or  of  acorns ;  poly- 
pus of  the  pharnyx ;  a  cherry,  prune,  or  apricot  stones ;  a  French  bean,  a  grape  - 
seed,  a  pill,  a  filbert,  a  piece  of  gold,  a  piece  of  silver,  flocks  of  wool  or  tow, 
a  bullet,  a  button  mould,  a  pebble,  a  pin,  a  needle ;  fibrous  tumors,  probably 


OPERATIVE  SURGERY.  481 

syphilitic,  such  as  M.  Senn  has  recently  described,  developed  in  the  interior 
of  the  pharynx ;  a  piece  of  cartilage,  of  tendon,  of  wood,  of  iron,  of  mem- 
braniform  concretion ;  in  a  word,  of  every  body  which  in  any  way  may  be  lodged 
in  the  glottis  or  the  trachea.  When  the  presence  of  one  of  these  bodies  in 
the  respiratory  passages  is  duly  ascertained,  in  case  it  cannot  be  seized  through 
the  mouth  by  the  fingers  or  forceps,  there  is  no  Question  of  the  advantages  of 
bronchotomy.  In  the  case  published  by  M.  d'Arcy,  although  the  accident 
had  occurred  but  a  few  hours  before,  the  bean  had  already  become  trebled  in 
size.  Although  the  primitive  symptoms  which  the  foreign  body  has  occasioned 
are  partially  calmed,  it  does  not  cease  to  be  the  less  positively  indicated.  In 
fact  the  monk  mentioned  in  the  Eph,  des  cmt.  de  la  nat.,  and  who  did  not  dare  to 
complain  at  first,  did  not  die  phthysical  until  the  expiration  of  two  years.  One 
of  the  patients  cited  by  Louis,  was  so  well  that  he  was  regarded  as  almost  cured ; 
yet  he  sunk  at  the  end  of  the  third  week.  Another  who  lived  several  years 
with  a  louis  d'or  in  the  bronchia,  died  at  last  in  consequence  of  its  presence. 
Tulpius,  V.  D.  Wiel,  Bartholin,  Pelletan,  and  M.  Dupuytren,  have  also  seen 
in  some  cases,  the  foreign  body  permitting  respiration  to  resume  in  some 
degree  its  original  ease,  and  causing  death  after  the  lapse  of  one  or  several 
months;  and  even  years.  There  are  also  some,  which,  after  this  lapse  of  time 
have  been  spontaneously  expelled :  witness  the  rump  of  the  fowl  mentioned  by 
Sue.  But  these  happy  efforts  of  the  organism  so  rarely  occur,  that  it  would 
be  imprudent  to  reckon  on  them,  and  bronchotomy  should  never  be  dispensed 
with  under  such  insufficient  pretexts.  Foreign  bodies  lodged  in  the  oesopha- 
gus, inflammatory  swellings  sometimes  caused  by  wounds,  injuries  of  the 
neck,  have  also  induced  some  practitioners  to  perform  bronchotomy  to  prevent 
suffocation  and  give  time  to  subdue  the  principal  disease.  Habicot  imme- 
diately subjected  a  lad  to  it,  who,  in  returning  from  a  fair,  had  no  other  re- 
source to  escape  robbers  than  to  swallow  all  the  gold  he  had  with  him,  rolled 
into  a  pacquet.  In  the  same  manner  he  successfully  treated  a  patient,  who, 
covered  with  wounds,  was  on  the  point  of  perishing  for  want  of  the  power  of 
respiration.  We  should  evidently  do  the  same  when  life  is  seriously  threat- 
ened by  the  presence  of  heterogeneous  masses  in  the  oesophagus,  or  the  swell- 
ing of  the  lips  of  a  wound  in  the  larynx,  when  it  is  not  possible  immediately 
to  remove  in  any  other  manner  the  cause  of  suffocation. 

Croup  or  laryngeal  and  tracheal  diphthentis,  that  horrible  disease,  the 
nature  and  treatment  of  which  have  been  made  equally  clear  by  the  excellent 
researches  of  M.  Bretonneau,  is  one  of  those  affections  which  it  seems  at 
first  may  be  opposed  with  the  greatest  advantage  by  bronchotomy.  Yet,  not- 
withstanding the  assertions  of  M.  A.  Severin,  Bartholin,  and  some  other 
practitioners  of  the  seventeenth  and  eighteenth  century,  who  are  said  to 
have  employed  it  with  the  best  results,  the  physicians  of  our  day  still 
doubted,  in  1825,  that  in  the  existence  of  the  disease  it  was  of  great  import- 
ance, and  that  science  had  more  than  conclusive  and  authentic  example 
of  cure  that  could  reasonably  be  attributed  to  it.  Those  given  by  Mr.  S. 
Cooper,  in  his  own  name,  or  that  of  Mr.  Lawrence,  or  M.  Chevallier,  by  no 
means  prove  that  these  surgeons  observed  the  real  croup.  The  case  reported 
in  the  name  of  Dr.  Andree,  by  Bursieri,  Locatelli,  Michaelis,  and  White,  is 
the  only  one  accompanied  with  details  sufficiently  circumstantial  to  partially 
satisfy  the  mind.  The  view  in  which  bronchotomy  has  been  considered  until 
61 


482  NEW  ELEMENTS    OF 

the  present  day,  does  not  permit  us  to  draw  much  advantage  from  it  in  croup. 
Indeed  it  is  not  understood  how  it  can  remedy  inflammation  or  spasm  of  the 
larynx,  which,  according  to  Royer-Colard,  &c.,  in  this  disease  bring  on  the 
fatal  termination,  or  pulmonary  engorgement,  any  more  than  the  reproduction 
of  the  morbid  product,  which  by  this  means  is  removed  from  tlie  trachea  without 
influencing  in  the  least  its  extension  in  the  bronchia.  Tn  this  particular.  Dr. 
Canon  has  certainly  exaggerated  its  importance,  while  MM.  DesruUes,  Bland, 
&c.,  are  right  in  contesting  its  utility.  But  it  is  not  to  be  considered  in 
this  point  of  view.  Subjects  affected  with  diphtheritis  die  in  a  state  of 
asphyxia  for  want  of  the  power  of  respiration.  The  asphyxia  is  constantly 
caused  by  the  presence  of  a  false  membrane,  or  swelling  of  the  laryngeal 
membrane,  and  never  depends  on  a  spasmodic  affection,  which  the  cartilaginous 
texture  renders  impossible  or  insignificant  in  the  large  bronchia,  the  trachia, 
and  the  larynx.  Now,  we  are  to  resort  to  bronchotomy  less  for  the  purpose  of 
extracting  membraniform  concretions,  than  for  gaining  time  and  placing  the 
patient  in  a  condition  to  breathe  while  means  of  cure  are  devised.  M.  Breton - 
neau  has  proved,  moreover,  that  after  the  trachea  has  been  opened,  calomel  may 
be  pushed  through  with  advantage,  6r  even  a  solution  of  the  nitrate  of  silver  may 
be  carried  down  by  a  small  sponge  on  the  end  of  a  slip  of  whalebone,  and  the 
false  membrane,  followed  even  into  the  bronchia  and  diphtheritis  of  the  trachea, 
treated  as  he  has  done  with  so  much  success  that  of  the  throat.  In  this  view 
bronchotomy  is  a  precious  resource  which  should  be  employed  whenever  the 
disease,  occurring  in  the  larynx  or  below  it,  cannot  be  reached  through  the 
mouth  with  topical  remedies,  but  which,  however,  has  not  yet  passed  below  the 
first  bronchial  divisions.  Four  unexpected  cures  are  adduced  in  support  of 
this  doctrine.  In  the  month  of  July,  1825,  M.  Bretonneau  being  called  to  see 
Mademoiselle  de  Puysegur,  a  child  four  years  old,  whose  three  brothers  had  died 
of  croup  andwho  was  herself  aff*ected  to  the  last  degree,  opened  the  trachea 
freely  and  introduced  a  canula  through  the  wound ;  false  membranes  escaped 
in  great  number  for  several  days;  he  blew  in  calomel  in  powder,  which  was  not 
borne  well;  afterwards  the  same  substance  mingled  with  water;  and  thus  suc- 
ceeded in  saving  this  unfortunate  child.  In  a  boy,  seven  or  eight  years  old, 
whom  I  examined  at  Tours,  in  1827',  a  month  after  his  cure,  and  who  in  the 
most  advanced  stage  of  the  disorder  had  been  given  up  for  dead  by  his  parents, 
M.  Bretonneau  opened  the  trachea  as  before,  and  saw  life  return  at  the 
expiration  of  several  minutes  ;  he  extracted  numerous  membraniform  concre- 
tions, and  felt  obliged  a  little  later  to  introduce  through  a  canula  which  he  kept 
in  the  wound,  a  solution  of  lunar  caustic,  by  means  of  a  small  piece  of  sponge 
fixed  on  the  end  of  a  slender  bit  of  whalebone,  and  after  various  obstacles, 
which  were  overcome  as  soon  as  perceived,  the  child  was  entirely  restored. 
Quite  recently  (October,  1831)  the  same  practitioner  was  no  less  successful 
with  a  third  patient.  The  child,  eleven  years  old,  was  looked  upon  as  dead, 
when  M.  Bretonneau  was  called  to  him.  He  opened  the  trachea  immediately, 
and  after  several  casualties,  which  were  met  by  the  best  conceived  means, 
the  young  patient  was  completely  cured. 

A  similar  success  has  just  been  obtained  at  Paris,  by  M.  Trousseau.  A  boy 
of  six  years  and  a  half,  was  seized  on  the  21st  November,  1831,  with  a  violent 
sore  throat,  attended  with  cough,  hoarseness,  and  some  fever.  On  the  23d,  at 
nine  o'clock  at  night,  three  physicians  met  in  consultation-    They  were 


OPERATIVE  SURGERY.  483 

all  of  opinion  that  the  child  was  affected  with  croup,  and  that  death  would 
infallibly  take  place  before  two  hours.  M.  Trousseau  proposed  tracheo- 
tomy, and  performed  it  on  the  spot.  The  trachea  was  opened,  beginning 
from  the  cricoid  cartilage,  to  the  extent  of  seven  lines.  Hemorrhage  from 
the  veins  ceased  almost  immediately.  However,  a  considerable  quantity  of 
blood  fell  into  the  bronchia,  which  the  child  immediately  threw  out  by 
the  wound,  together  with  fragments  of  false  membrane-  Respiration  imme- 
diately became  perfectly  easy.  A  flat  canula,  was  then  introduced,  similar  to 
tlie  one  described  by  M.  Bretonneau  in  his  treatise  on  diphtheritis ;  then  twenty 
drops  of  a  solution  of  nitrate  of  silver  were  dropped  into  the  bronchia  (3J  for 
3J  of  water).  This  instillation  was  repeated  every  six  hours  for  three  days 
and  a  half.  Every  hour  twenty  drops  of  tepid  infusion  of  mallows  was 
thrown  in.  It  was  not  until  the  fourth  day  of  the  operation  that  the 
child  ceased  to  throw  up  diphtheritic  concretions.  The  canula  was  withdrawn 
and  cleansed  three  times  a  day.  While  in  the  wound  it  was  cleared  several 
times  every  hour  by  means  of  a  small  mop  of  horse-hair.  On  the  tenth  day 
the  air  began  to  pass  freely  through  the  larynx ;  and  on  the  twenty-fifth  the 
wound  of  the  integuments  was  completely  cicatrized.  At  present  (January 
1832)  the  child  enjoys  excellent  health. 

Other  diseases  in  my  opinion  are  susceptible  of  being  advantageously  modi- 
fied by  bronchotomy.  Phthysis  laryhgea  for  instance,  and  those  chronic 
phlegmasise  which  eventually  produce  a  certain  diminution  of  the  glottis.  The 
air  finding  a  free  passage  beneath,  leaves  the  larynx  at  rest,  and  offers 
no  obstacle  to  the  healing  efforts  of  the  organism.  Besides,  we  thus  have  a 
new  passage  tlirougli  which  topical  remedies  may  come  in  immediate  contact 
with  the  disease.  Horses  affected  with  the  hives,  have  also  the  glottis 
diminished,  and  present  to  the  observer  experiments  altogether  in  favor 
of  what  I  have  just  advanced.  Two  of  these  animals  employed  in  a  manu- 
factory of  red  lead  at  Tours,  recovered  their  ordinary  state  of  health  after  a 
large  canula  had  been  fixed  in  the  trachea.  M.  Barthelemy,  and  other  veteri- 
nary surgeoas  have  given  cases  much  similar.  Applied  to  man,  these  data 
have  not  deceived  the  expectations  of  practitioners.  M.  Clouet  of  Verdun, 
instructed  a  woman,  whom  a  fistula  in  the  larynx  and  other  disorders  had 
rendered  liable  to  suffocation,  to  wear  a  similar  canula  for  twelve  years.  Price, 
of  Plymouth,  owed  ten  years  of  flourishing  health  to  the  same  kind  of  assist- 
ance. In  1824,  M.  Bulliard,  restored  to  existence  a  young  soldier  whom  a 
chronic  laryngitis,  and  not  the  croup  as  he  supposed,  had  borne  to  the  gates  of 
death,  after  several  fits  of  suffocation,  by  placing  in  the  larynx  a  canula  which 
the  patient  wore  for  fifteen  months.  M.  Godeve  was  no  less  fortunate  with 
a  patient  affected,  as  he  says,  with  an  ulcer  of  the  larynx,  but  rather  as  I  think 
with  a  swelling  of  the  vocal  chords,  who  discontinued  the  use  of  the  canula 
witliout  inconvenience  at  the  end  of  six  months.  A  patient  of  Mr.  White 
wore  one  for  two  years.  M.  Senn  of  Geneva,  mentions  the  case  of  a  cliild, 
ten  or  twelve  years  old,  who  was  threatened  every  instant  with  imminent  suf- 
focation, in  consequence  of  frequently  repeated  inflammations,  and  was  cured 
as  by  a  miracle  by  means  of  laryngotomy  and  a  canula,  which  was  not  laid 
by  until  the  expiration  of  eleven  months.  It  was  much  the  same  with  two 
patients  operated  on  by  M.  Regnoli,  who  had  a  real  coarctation  of  the  larynx. 

In  a  word,  bronchotomy  is  an  operation  to  be  tried  always,  or  almost  always. 


484  NEW   ELEMENTS   OF 

when  a  mechanical  obstacle,  from  whatever  part  it  come,  tends  to  produce 
asphyxia,  by  diminishing  more  or  less  the  calibre  of  the  respiratory  tube. 
It  is  really  very  little  dangerous  in  its  nature.  If  up  to  the  present  day  it 
has  not  been  more  frequently  practised,  it  was  for  want  of  a  correct  view  of  its 
mode  of  action  in  cases  other  than  those  of  foreign  bodies,  of  reflecting  that  to 
re-establish  respiration  it  was  sufiicient  to  open  any  kind  of  passage  to  the 
air,  and  of  perceiving  that  if  the  artificial  opening  is  sensibly  less  than  the 
natural  passa^s,  the  lungs  remain  incapable  of  performing  their  functions 
completely,  and  in  this  case  the  operation  in  a  great  measure  fails  of  its 
intention.  On  this  point  there  is  a  truth  placed  beyond  doubt  by  M.  Bre- 
tonneau,  and  likely  to  be  attended  with  the  most  happy  practical  conse- 
quences. In  the  case  of  one  of  the  horses  just  mentioned  the  tracheal 
canula  was  only  six  lines  in  diameter.  When  the  animal  became  a  little 
fatigued  it  was  panting  and  out  of  breath.  A  canula  of  an  inch  was  sub- 
stituted for  the  first,  and  the  horse  immediately  breathed  freely  and  was 
able  to  bear  the  most  violent  exertions.  In  the  little  patients  whom  the 
practitioner  of  Tours  cured  by  bronchotomy,  was  the  canula  of  itself  too 
small,  or  was  its  diameter  diminished  by  concretions  and  mucosities  ?  If 
the  symptoms  of  asphyxia  disappeared  for  a  moment,  we  see  that  they 
quickly  returned.  On  the  contrary,  when  it  was  cleared  out  or  made  larger 
the  child  seemed  to  revive.  The  same  peculiarities  are  found  in  the  observa- 
tions of  Messrs.  Bulliard,  Senn,  and  Trousseau.  Mr.  W.  CuUen,  who  omits 
to  credit  this  idea  to  M.  Bretonneau,  collected  in  1S9.7  other  facts  no  less 
conclusive  to  support  it,  and  render  it  prevalent  in  England.  After  all,  on 
this  point  every  one  may  make  himself  a  subject  of  experiment.  Diminish  for 
example  the  size  of  the  atmospheric  column  which  naturally  goes  to  the  lungs, 
take  from  the  opening  of  the  nose  one-half  or  two-thirds  of  their  dimensions, 
by  closing  them  with  a  quill  or  gum-elastic  tube;  respiration  will  not  be 
arrested,  but  it  will  soon  become  painful,  and  in  proportion  to  the  narrowing 
of  the  passage.  It  is  of  importance,  therefore,  in  having  recourse  to  broncho- 
tomy for  the  purpose  of  maintaining  respiration  beyond  several  minutes,  to 
open  the  air  tube  freely,  and  to  leave  in  the  wound  a  canula  of  sufficient 
diameter.  This  leads  us  to  inquire  which  is  best,  tracheotomy,  laryngotomy, 
or  laryngo-tracheotomy.  The  ancients  had  not  to  discuss  this  question. 
They  had  only  to  do  with  the  opening  of  the  trachea.  That  of  the  crico- 
thyroid membrane  was  not  employed  until  Vicq  d'Azyr,  who  proposed  it 
before  the  end  of  the  last  century.  Desault  is  the  first  who  conceived  tlie 
idea  of  completely  dividing  the  thyroid  cartilage  on  the  median  line;  and  to 
M.  Boyer  belongs  that  of  incising  at  once  from  above  downwards  the  encoid 
cartilage  and  the  first  rings  of  the  trachea. 

A.  Anatomical  and  Surgical  Remarks. — 1.  Larynx.  Formed  of  solid  carti- 
lages, of  muscles  tense  as  chords,  and  of  a  membrane  pliant  as  well  as  vascular, 
the  larynx  is  beyond  the  danger  of  all  spasmodic  contraction  capable  of  dimi- 
nishing its  dimensions  with  any  degree  of  permanence.  But  on  the  other 
hand  the  accumulation  of  fluids  in  its  internal  membrane,  the  least  tur- 
gescence  soon  diminishes  all  its  diameters,  so  as  to  endanger  life.  The  larynx 
is  free  posteriorly,  where  it  forms  part  of  the  anterior  wall  of  the  pharynx  ; 
covered  in  front  only  by  the  skin  and  aponeurosis,  on  its  sides  by  the  sterno- 
hyoid and  thyro'-hyoid  muscles,  accompanied  laterally  by  the  trunks  of  the 


OPERATIVE   SURGERY.  485 

carotids;  separated  from  the  os  hyoides  by  a  furrow,  at  the  bottom  of  wliichis 
found  the  thjro-hyoid  membrane,  which  is  pierced  laterally  by  the  superior 
laryngeal  nerve  and  an  arterial  branch.  It  presents  on  the  median  line  the 
prominence  of  the  principal  cartilage  much  more  apparent  in  man  than  in 
woman,  and  in  adult  age  tlian  in  childhood ;  and  has  lower  down  a  slight 
depression  corresponding  to  the  crico-thyroid  membrane,  which  is  crossed  by 
the  artery  of  the  same  name,  sometimes  a  little  higher  sometimes  lower;  with 
another  small  prominence  owing  to  the  presence  of  the  cricoid  cartilage, 
below  which  is  found  the  thyroid  mass,  and  the  anterior  face  of  wliich  is 
often  covered  with  an  arteriole,  single  or  double,  which  descends  vertically 
from  the  cricoid  arch  towards  the  thyroid  body.  When  it  preserves  its  natural 
proportions,  it  is  much  larger  in  the  adult  man  than  in  individuals  of  different 
sex  or  age  (hence  the  dangers  induced  by  inflammations  before  the  age  of 
puberty),  and  receives  behind  and  on  its  sides  the  termination  of  the  recurrent 
nerve. 

Laryngotomy  after  the  manner  of  Vicq  d'Azyr,  adopted  at  present  by  a 
great  number  of  surgeons,  offers  the  undoubted  advantage  of  being  easier  of 
performance,  of  acting  onl}^  on  a  membrane  scarcely  organized  and  very 
superficially  situated,  of  not  exposing  any  vessel  or  any  important  part  to  be 
wounded,  and  of  leaving  the  glottis  untouched;  but  on  the  one  part  it  does 
not  produce  an  opening  sufficiently  large  to  allow  passage  to  the  instruments 
required  for  the  extraction  of  foreign  bodies ;  and  on  the  other,  tlie  canula 
which  can  be  thus  employed  will  rarely  be  large  enougli  to  admit  a 
sufficient  quantity  of  air.  By  imitating  Desault,  on  the  contrary,  as  has 
been  done  in  America  and  in  England,  as  also  by  Mr.  Whately,  by  an 
incision  from  above  downwards,  and  M.  Blandin  in  1829,  no  risk  is  run  of 
dividing  a  vein  or  artery  of  any  size.  It  is  t)ie  only  means  of  bringing  in  some 
measure  into  view  foreign  bodies  which  lodge  or  are  arrested  between  tlie 
lips  of  the  glottis,  polypi,  or  other  vegetations,  whicli,  as  well  as  worms,  may 
be  found  at  this  part  of  the  organ.  However,  although  lesion  of  the  vocal 
chords,  so  much  dreaded  by  those  opposed  to  Desault,  is  easy  to  be  avoided, 
and  moreover  is  but  of  minor  importance,  although  the  voice  of  patients 
treated  by  this  method  has  not  suffered  more  tlian  by  every  other,  yet  it  only 
deserves  preference  in  the  cases  just  pointed  out;  besides,  the  patient  should 
not  be  of  an  age  to  have  the  thyroid  cartilage  too  much  cliarged  witli  phos- 
phate of  lime.  If  the  fear  of  wounding  the  vocal  chords  be  an  obstacle, 
the  surgeon  may  follow  the  advice  of  M.  Fouilhoux,  and  divide  the  thyroid 
cartilage  on  the  side,  and  then  open  the  soft  parts  of  the  glottis  transversely 
to  avoid  it.  When  the  foreign  body  is  below  the  larynx,  or  when  tlie  inten- 
tion is  to  place  a  tube  in  the  wound,  it  is  evident  that  this  process  is  not  the 
proper  one;  perhaps  it  would  be  possible  always  to  supply  it  by  another 
operation  lately  proposed  by  M.  Vidal,  of  Cassis,  for  opening  abscess  of  the 
glottis,  and  by  M.  Malgaine  ;  an  operation,  the  idea  of  which  no  doubt  arose 
from  the  experiments  of  Bichat  on  the  voice,  and  which  consists  in  penetra- 
ting through  the  thyroid  membrane,  and  even  the  epiglottis,  if  it  be  too 
difficult  to  reflect  it  forwards  through  the  wound.  However,  this  operation** 
has  something  repugnant  in  it,  at  least  at  first  sight,  which  induces  me  to  say 
iiothing  further  of  it,  although  I  have  succeeded  very  well  in  experiments  on 
the  dead  body. 


486  NEW  ELEMENTS  OF 

Laryngo-tracheotomy,  which  usually  leaves  the  thyroid  body  entire,  and 
exposes  only  the  crico-thyroid  artery  to  be  cut,  does  not,  like  Desault's 
method,  permit  us  to  see  to  the  bottom  of  the  larynx,  and  acts  upon  a  point 
too  distant  from  the  bronchia  for  foreign  bodies  not  very  movable  to  be  easily 
brought  to  the  opening,  and  too  near  the  glottis  not  to  render  the  use  of  a 
perpetual  canula  very  dangerous ;  so  that,  notwithstanding  its  inconveniences, 
tracheotomy  seems  to  me  to  unite  more  advantages  under  all  circumstances 
in  which  the  process  of  Desault  is  not  positively  required. 

2d.  Trachea. — The  trachea,  a  kind  of  cylindrical  canal,  which  descends 
to  a  level  with  the  second  or  third  dorsal  vertebra,  formed  of  a  score  of  carti- 
laginous rings  completed  at  their  posterior  fifth  by  a  fibro-muscular  membrane, 
rests  upon  the  oesophagus,  inclining  a  little  more  to  the  right  than  to  the 
left,  and  is  covered  first  by  the  common  integuments,  secondly  by  the 
cervical  fascia,  single  above,  bifoliated  below,  where  adipose  masses  and  vascu- 
lar tissue,  and  then  the  sternum,  separate  it  into  two  laminse ;  thirdly,  by 
the  isthmus  of  the  thyroid  body  near  the  cricoid  cartilage ;  lower  down  by 
the  supra-sternal  venous  plexus,  lymphatic  ganglia,  common  tissue,  and  the 
middle  thyroid  artery  when  it  exists ;  fourthly,  by  a  last  fibro-cellular  layer, 
which  is  sometimes  wanting ;  and  fifthly,  by  the  sterno-hyoid  and  sterno- 
thyroid muscles  placed  a  little  laterally.  Behind  the  inferior  laryngeal 
nerve,  and  at  some  distance  further,  the  primitive  carotids  run  along  it,  and 
it  is  sometimes  crossed  by  one  of  the  thyroid  arteries,  which  in  that  case  runs 
from  one  side  of  the  neck  to  the  other.  In  .children,  particularly,  the  arteria 
innominata  covers  nearly  always  its  anterior  face  until  beyond  the  limits  of 
the  thorax,  so  that  the  right  carotid  leaves  it  very  high  up  to  take  its  place 
quite  on  the  side,  and  it  would  be  easy  to  wound  either  in  performing 
tracheotomy,  if  this  disposition  were  forgotten.  I  have  also  seen  the  left  carotid 
rise  on  the  right,  and  pass  in  front  of  the  trachea  to  reach  its  ordinary  destina- 
tion, and  reciprocally  that  of  the  right  side.  Other  vascular  anomalies  have 
also  been  met  with  in  this  region,  and  merit  no  less  attention  than  the  preced- 
ing. From  all  these  considerations,  it  results  that  the  trachea,  though  quite 
superficial  above  where  the  thyroid  body,  which  protects  its  lateral  parts 
almost  solely  separates  it  from  the  integuments,  becomes  deeper  in  proportion 
as  we  descend  or  incline  towards  the  chest,  following  the  thoracic  concavity 
of  the  spine,  and  at  the  inferior  part  of  the  neck  it  must  be  sought  for  at  an 
inch  below  the  skin.  The  cartilaginous  rings  which  compose  it  should  be 
sufficient  of  themselves  to  banish  the  idea  of  spasmodic  contractions,  which 
have  been  so  gratuitously  attributed  to  it  in  croup.  The  membranous  and 
almost  fleshy  structure  of  its  posterior  portion,  which  rests  on  the  oesophagus 
and  partially  embraces  it,  explains  how  foreign  bodies,  lodged  in  the  canal 
of  deglutition,  have  sufficed  to  cause  suffocation,  or  pass  into  its  interior  and 
render  bronchotomy  necessary.  To  conclude,  the  great  mobility  it  enjoys, 
if  care  be  not  taken  in  attempting  to  open  it,  causes  it  to  be  very  easily  pushed 
aside,  so  much  that  the  instrument  strikes  on  the  primitive  carotid,  as 
happened  in  a  case  mentioned  by  Desault,  in  which  a  student  of  medicine  in 
asphyxia  was  thus  destroyed  by  one  of  his  companions  in  an  attempt  to  save 
him. 

Examination  of  the  Methods, — Those  authors,  who  in  ancient  times  recom- 
mended bronchotomy,  confined  themselves,  like  Antyllus,  to  a  transversa 


OPERATIVE    SURGERY.  487'^ 

division  in  the  middle  of  the  neck,  of  the  integuments  and  the  space  between 
the  third  and  fourth  rings  of  the  trachea.  J.  Fabricius  was  the  first  to  propose 
the  performance  of  the  operations  by  two  separate  stages ;  first,  to  incise  tl^e 
soft  parts  from  above  downwards  on  the  median  line,  and  then  to  open  the 
wintlpipe,  as  practised  by  the  ancients.  He  l^ft  in  the  wound  a  straight  canula 
furnished  with  wings.  Casserius  slightly  curved  his  canula,  which,  according 
to  Solingen,  should  be  flattened ;  its  external  opening  Moreau  covered  with 
a  sindon,  and  Garengeot  with  a  piece  of  muslin,  to  prevent  foreign  bodies  from 
entering  the  trachea.  To  prevent  its  obliteration,  and  the  necessity  of  re- 
moving it  for  the  purpose  of  cleaning  it,  G.  Martine  found  it  useful  to  employ 
two,  one  within  the  other.  Ficker,  who  adopts  the  idea  of  Martine,  requires 
the  external  canula  to  be  of  silver,  the  internal  one  of  gumelastic,  and  that 
both  should  have  a  certain  degree  of  curvature ;  in  fine,  some  moderns  have 
maintained,  with  Ferrein,  that  the  barrel  of  a  quill  may  advantageously  supply 
its  place.  The  manner  of  introducing  this  canula  and  fixing  it  has  not  been 
less  various  than  its  form.  Sanctorius  inserted  it  with  a  trocar,  and  Dekkers 
carried  it  into  the  trachea,  dividing  the  skin  also  with  the  same  instrument. 
Moreau  made  a  passage  for  it  between  two  rings  with  a  simple  lancet,  and 
Dionis  carried  it  in  upon  a  stylet.  That  of  Bauchot  is  very  short,  flat ;  and  its 
inventor,  who  used  besides  a  kind  of  crescent  mounted  on  a  handle  for  fixing 
the  larynx,  had,  like  Dekkers  and  Sanctorius,  a  stylet  of  tlie  same  form,  sharp 
at  its  extremity,  to  pass  through  the  skin  and  enter  at  once  the  trachea. 
Richter  bent  Bauchot's  instrument  into  a  circular  arch  for  the  purpose  of  render- 
ing it  more  tolerable ;  and  maintains  that  by  the  wound  of  the  trachea  being 
immediately  filled  by  the  canula,  hemorrhage  is  much  less  likely  to  occur  than 
in  previous  incision  of  the  tissues.  But  this  is  an  error,  and  notwithstanding 
what  has  been  said  of  it  by  Bergier  and  B.  Bell,  all  these  modes  of  entering 
this  passage  with  a  single  stroke  are  at  present  generally  and  justly  pro- 
scribed. 

The  dread  of  wounding  the  cartilaginous  arches,  revived  by  Purmann,  no 
longer  exists.  Heister  has  satisfactorily  demonstrated  that  they  may  be  di- 
vided without  the  least  risk.  Virgili,  of  Cadiz,  was  obliged  to  divide  them  as 
far  as  the  sixth  in  a  soldier,  to  rescue  him  from  the  danger  of  suffocation,  which 
the  ordinary  incision  was  about  producing  by  determining  a  flow  of  blood  into 
the  trachea.  Instead  of  a  canula  he  kept  in  the  wound  a  plate  of  lead  bent  on 
its  edges  and  perforated  with  holes.  To  extract  the  half  of  an  acorn  Wendt 
did  not  hesitate  to  cut  through  three  of  the  cartilages ;  and  Percy  advises  on 
this  head  to  use  scissors  instead  of  the  bistoury,  which,  however,  is  much  more 
convenient,  and  preferred  with  reason  by  almost  every  practitioner.  My  own 
opinion  on  these  diff*erent  modes  of  proceeding  has  no  doubt  been  already 
guessed.  In  the  first  place  I  would  banish  all  transverse  incisions.  In  the 
case  of  a  foreign  body  the  division  of  the  space  between  two  (Cartilages 
cannot  be  sufficient ;  and  if  the  operation  is  to  restore  the  power  of  respiration, 
such  a  wound  will  never  be  large  enough.  If  further  proof  be  necessary,  a 
subject  recently  operated  on  in  a  large  hospital  will  furnish  it.  The  opening 
of  the  trachea  had  been  well  made,  the  canula  was  properly  placed,  but  it  was 
a  portion  of  a  gumelastic  catheter,  and  the  patient  being  obliged  to  take  in  air 
by  so  small  an  orifice  was  only  half  delivered  from  the  suffocation  for  which 
bronchotomy  was  performed.    In  the  first  case  canulse  and  perforated  plates 


488  NEW    ELEMENTS   OF 

are  useless.  When  the  trachea  is  free  the  wound  is  to  be  united  or  permitted 
to  close.  If  the  foreign  body  is  Movable  the  air  from  the  lungs  may  force  it 
out.  If  it  do  not  spontaneously  present  at  the  wound  it  is  to  be  sought  for 
with  slender  curved  forceps,  or  some  other  appropriate  instrument,  in  the 
direction  of  the  bronchia.  When  it  is  not  possible  to  reach  it  or  meet  with 
it,  it  is  to  be  left,  the  wound  kept  open,  and  the  patient  watched.  The  next 
day,  or  the  one  succeeding,  it  will  generally  be  found  on  the  lower  surface  of 
the  apparatus.  Desault,  Pelletan,  and  M.  Dupuytren,  have  seen  escape  thus 
a  fruit  stone,  a  bean,  a  piece  of  money,  &c. ;  and  the  needle  which  M.  Blandin 
could  not  succeed  in  seizing,  after  cutting  the  thyroid  cartilage,  also  came 
away  in  this  manner.  In  the  second,  the  canula  is  indispensable;  but  as  no 
author  had  made  known  the  importance  of  a  large  and  permanent  opening, 
none  of  the  tubes  which  have  been  proposed  are  proper  for  it.  That  of  M. 
BuUiard  is  cylindrical,  long,  and  very  curved.  M.  Bretonneau  has  succes- 
sively formed  them  of  different  shapes.  The  canula  he  used  in  the  case  of 
Mmslle.  de  Puysegur  was  double  like  that  of  Martine,  flat,  a  little  concave 
on  its  inferior  edge,  and  four  lines  broad  in  its  greatest  diameter.  The  one 
he  employed  in  the  patient  whom  I  saw,  was  formed  of  two  parts,  one  supe- 
rior the  other  inferior,  which  he  placed  separately  in  the  wound,  and  which 
being  united  represented  an  instrument  similar  to  the  preceding.  Two  lan- 
guets,  in  the  form  of  a  finger  nail,  which  come  off  above  and  below  at  nearly 
a  right  angle,  fixed  it  very  firmly  in  the  trachea,  and  permitted  a  circular  fold 
of  linen,  pierced  in  the  centre,  to  be  placed  between  its  exterior  end  and  the 
integuments  of  the  neck,  and  which  could  be  opened  or  closed  at  pleasure  by 
means  of  a  kind  of  hinge.  This  piece  of  linen  fulfills  two  important  indicati(ms ; 
by  closing  it  with  more  or  less  force  it  compresses  the  backs  of  the  two  gutters, 
which  by  their  union  form  the  canula,  forces  them  to  close  within  each  other, 
and  in  this  manner  reduces  to  any  desirable  degree  the  diameter  of  the  artifi- 
cial tube.  According  to  the  thickness  given  to  it,  it  lengthens  or  shortens  the 
canula,  and  keeps  its  inner  extremity  exactly  applied  against  the  internal  face 
of  the  organ,  prevents  it  from  wounding  the  interior  of  this  canal,  and  makes 
the  same  tube  answer  for  patients,  the  thickness  of  the  walls  of  whose  necks 
may  be  very  different.  When  in  its  place,  if  it  is  desirable  to  enlarge  it,  or 
when  any  foreign  body  tends  to  obliterate  it,  we  have  only  to  pass  into  it 
another  canula  larger,  but  not  jointed,  which  is  withdrawn  and  reintroduced 
without  deranging  any  thing  else. 

Whether  a  canula  is  to  be  used  or  not,  some  persons  have  proposed  not  only 
section  of  the  cartilages  of  the  trachea,  but  also  to  cut  out  and  remove  a 
portion  of  the  anterior  wall  of  the  canal.  It  appears  that  veterinary  surgeons 
have  often  done  so.  Dr.  Andree  seems  also  to  have  followed  this  process, 
which  is  formally  recommended  by  Mr.  Lawrence,  Mr.  Porter,  &c.  But  it  is 
a  precaution  at  once  unnecessary  and  dangerous :  unnecessary,  as  pure  and 
simple  incision  always  permits  the  introduction  of  an  artificial  tube ;  and 
dangerous,  because  if  it  should  become  advantageous  to  close  it,  there  will 
result  as  a  necessary  consequence  an  incurable  contraction  of  the  diameter 
of  the  respiratory  canal.  Consequently,  the  process  of  M.  Colineau  to  effect 
this  loss  of  substance,  and  at  the  same  time  render  all  kinds  of  hemorrhage  im- 
possible— a  process  which  consists  in  piercing  the  trachea  by  means  of  a 
sharp  plate  projecting  from  the  circumference  of  a  flat  disk  of  copper  heated 


OPERATIVE   SURGERY.  489 

to  whiteness,  fastened  on  a  long  handle — ^has  not  in  my  opinion  any  useful  pur- 
pose, and  should  be  left  unapplied.  The  advice  of  Messrs.  Carmichael  and 
White  is  directed  to  the  same  end. 

Manual. — Th£  apparatus  consists  of  a  straight  or  convex  bistoury,  a  probe- 
pointed  bistoury,  one  or  more  canulas  supplied  with  ribands  and  every  thing 
necessary  to  fix  them,  a  forceps  with  rings,  and  a  polypus  forceps  very  slender, 
several  single  ligatures  and  needles,  hooks  or  probes  bent  into  crotchets,  and 
various  pieces  of  dressing.  The  patient  is  to  be  laid  on  his  back,  and  to  have 
his  head  moderately  bent  back.  Verduc  has  well  explained,  that  by  having 
the  head  bent  far  backwards  respiration  is  rendered  more  difficult,  a  remark 
which  applies  to  all  the  modes  of  performingbronchotomy.  Placed  on  the  right, 
in  order  to  cut  from  above  downwards,  and  not  from  below  upwards,  as 
directed  by  some,  the  surgeon  takes  hold  of  and  fixes  the  larynx  with  the  left 
hand,  while  with  the  right,  using  a  straight  or  convex  bistoury,  he  divides  the 
tissues. 

1.  Tracheotomy. — In  order  that  tracheotomy  should  be  well  performed,  it  is 
necessary  that  the  wound  of  the  soft  parts  extend  from  the  isthmus  of  the 
thyroid,  that  is,  from  the  boundary  of  the  cricoid  cartilage  until  quite  near  the 
sternum.   Beneath  the  integuments  and  fascia  are  the  blood  vessels,  which  are 
to  be  tied  as  soon  as  divided ;  the  veins  of  the  thyroid  plexus,  which  are  also 
to  be  tied  when  it  is  not  possible  to  avoid  them ;  and  the  middle  inferior  thyroid 
artery,  when  it  exists,  which  it  would  be  dangerous  to  wound.  Arrived  in  front 
of  the  trachea,  if  the  venous  blood  flows  abundantly  and  there  is  no  urgency, 
we  may  suspend  the  operation  from  twelve  to  twenty -four  hours,  after  the  ex- 
ample of  M,  Recamier,  and  some  others;  or  at  least  wait  some  minutes  for 
respiration  to  cause  the  hemorrhage  to  cease :  but  if  the  case  is  urgent  we  are 
to  pass  ligatures  round  the  bleeding  vessels,  or  even  proceed  to  open  the  air 
canal  itself.     Although  the  straight  bistoury  held  as  a  writing  pen  is  sufficient 
to  effect  this  opening,  which  should  include  at  least  the  fourth,  fifth,  and  sixth, 
if  not  the  seventh  and  third  cartilaginous  rings,  yet  there  are  practitioners 
who  prefer  the  probe-pointed  bistoury  to  continue  it  after  the  puncture.     In 
this  I  see  no  advantage  or  disadvantage :  should  even  the  point  of  the  instru- 
ment touch  the  posterior  wall  of  the  respiratory  tube,  which  appears  to  be  the 
cause  of  dread,  there  probably  would  not  result  much  danger.     This  part  of 
the  operation  being  over,  a  different  course  is  to  be  pursued,  according  as  the 
intention  is  to  extract  a  foreign  body,  or  to  relieve  suffocation  caused  by 
a  lesion  of  the  pharynx.     In  the  first  case,  if  the  body  is  not  immediately 
expelled  by  the  efforts  of  the  patient,  but  presents  at  the  wound,  the  operator 
is  gently  to  separate  the  lips  of  the  wound  with  the  forceps  or  hooks,  and 
endeavor  to  extract  it  with  an  appropriate  instrument.  When  it  is  fixed  in  the 
direction  of  the  bronchia,  wliich,  as  Favier  has  shown,  is  rather  rare,  there  is 
carried  with  all  possible  precaution  in  this  direction  a  proper  forceps,  or  rather 
a  small  curette,  to  hook  or  grasp  it.     If  these  attempts  prove  fruitless  they 
should  not  be  too  often  repeated.     A  number  of  cases  are  given,  in  which 
foreign  bodies,  which  no  attempt  could  discover,  afterwards  came  away, 
of  themselves,  and  have  been  found  among  the  dressings.  If  the  intention  of 
the  surgeon  is  only  to  establish  artificial  respiration  he  immediately  inserts  the 
canula,  taking  its  inferior  half,  if  he  uses  Bretonneau's,  and  carrying  it  into 
the  trachea,  while  with  a  peculiar  kind  of  forceps,  with  beaks  very  flat 
62 


490  NEW    ELEMENTS    OF 

and  bent  into  the  shape  of  a  Z  on  their  inferior  edge,  he  opens  tlie  wound ; 
he  then  fixes  the  other  half,  and  applies  the  linen  shield  between  the  shoulder 
of  the  instrument  and  the  neck ;  lines  its  interior  with  the  other  canula  pre- 
pared for  the  purpose ;  carries  the  two  ribands  attached  to  its  extremity  to  the 
nape  of  tlie  neck ;  brings  them  back  above  it  to  make  a  second  turn,  and  ties 
them  below  it  in  a  bow-knot.  If  during  the  operation  venous  hemorrhage 
should  be  too  abundant,  and  resist  ordinary  means,  we  sliould  not  be  fright- 
ened and  quit  the  patient,  as  was  done  by  Ferrand  in  a  similar  case.  If  the 
patient  enjoys  his  reason  he  should  be  soothed,  and  made  to  breathe  as  freely 
as  possible,  and  the  blood  will  soon  stop  of  itself.  If  it  escape  into  the 
trachea,  and  give  rise  to  unfavorable  symptoms,  it  will  be  a  further  motive  to 
imitate  Virgili  in  opening  largely  and  unhesitatingly  the  respiratory  tube. 
We  may  also,  like  M.  Roux,  if  danger  is  pressing,  place  the  mouth  over  the 
wound  and  suck  out  the  fluids  which  threaten  suifocation. 

2.  Thyroid  Laryngotomy. — When  the  larynx  is  to  be  opened,  the  incision 
should  commence  at  the  projecting  angle  of  the  thyroid  cartilage,  and  descend 
a-  little  below  the  cricoid ;  not  requying  to  be  as  long  as  for  tracheotomy. 
The  surgeon  cuts  successively  through  the  skin  the  subcutaneous  layer  and 
the  facia;  separates  the  thyroid  muscles;  carries  the  end  of  the  forefinger 
upon  the  crico-thyroid  membrane,  endeavors  to  feel  the  artery  of  the  same 
name;  raises  or  depresses  it  with  the  nail,  according  as  he  intends  cutting 
above  or  below ;  plunges  his  straight  bistoury  perpendicularly  into  the  mem- 
brane, guiding  it  on  the  finger  nail,  turning  its  edge  upwards  or  downwards, 
according  to  the  side  to  which  the  arterial  arch  may  have  been  pushed,  and 
there  makes  an  opening  of  proper  dimensions. 

S.  Laryngo -tracheotomy. — To  transform  the  preceding  operation  into  laryn- 
go-tracheotomy  we  have  only  to  use  a  probe-pointed  bistoury  instead  of  the 
straight,  and  to  enlarge  the  wound  from  above  downwards  by  dividing  the 
cricoid  cartilage  and  the  first  rings  of  the  trachea  on  the  median  line.  The 
same  instrument  carried  from  below  upwards,  may  also  serve  very  well  for 
separating  the  two  halves  of  the  thyroid  cartilage  according  to  the  plan  of 
Desault.  Supposing  that  in  spite  of  every  precaution  the  crico-thyroid  artery 
be  cut,  and  it  should  chance  to  prove  the  cause  of  a  harrassing  hemorrhage, 
it  may  be  easily  tied  on  the  right  and  on  the  left;  and  I  am  astonished 
that  a  vessel  of  such  little  importance  should  have  caused  so  much  anxiety. 
The  little  finger  inti'oduced  in  the  wound  first  seeks  for  the  foreign  body,  and 
then  serves  as  a  conductor  to  the  forceps  or  any  other  instrument  that  it  may 
be  necessary  to  employ.  .  When  that  is  removed  the  wound  is  immediately 
to  be  closed,  and  tlie  cure  is  in  general  very  speedy.  When,  on  the  contrary, 
it  cannot  be  found,  the  wound  is  left  open  and  treated  as  in  tracheotomy.  I 
do  not  think  that  the  suture  advised  by  some  authors  and  practised  by  Herold 
should  ever  be  used,  notwithstanding  the  opinions  of  MM.  Delpech  and 
Serre.  The  patient  mentioned  by  Wilmer,  who  had  been  thus  treated,  died 
suddenly  on  the  fifth  day  of  the  operation.  It  is  only  proper  in  this  case  to 
solicit  the  flow  of  blood  or  other  fluids,  either  between  the  air  tube  and  tissues 
which  surround  it  or  the  interior  of  the  canal  itself,  and  the  other  retentive 
means  are  always  suflicient  for  the  union  of  a  wound  like  this. 

4.  TTiyro-hyoid  Laryngotomy^ — After  laying  bare  the  thyro-hyoid  mem- 
brane on  the  median  line,  by  an  incision  of  two  inches  in  extent,  it  is  less  diffi- 


OPERATIVE  SURGERY.  491: 

cult  than  may  be  imagined  to  reach  the  superior  vocal  chords,  by  dividing  it 
transversely  above  and  a  little  behind  the  cartilage  to  which  it  is  attached.  A 
bistoury,  entered  at  this  point  from  above  downwards  and  from  before  back- 
wards, traverses  the  root  of  the  epiglottis  and  immediately  falls  into  the  larynx, 
the  finger  or  forceps  clearing  a  way,  which  may  be  enlarged  at  pleasure,  and 
which  allows  a  full  examination  of  the  glottis  without  deranging  either  the 
vocal  chords  or  the  cartilages.  No  artery  of  any  size,  and  no  important  nei-ve 
can  be  wounded.  The  laryngeal  branch  of  the  superior  thyroid  and  the  cor- 
responding nerve,  are  at  a  sufficient  distance  from  the  median  line  to  be  easily 
avoided,  and  no  venous  plexus  is  to  be  found  at  this  point.  The  wound  which 
results  will  have  some  tendency  to  remain  open,  but  it  is  probable  tliat  in  the 
living  subject  inflammation  will  soon  approximate  its  edges,  and  cicatrization 
take  place  without  difficulty.  Let  me  add,  that  if  bronchotomy  often  fails  of 
success  it  is  because  the  operation  is  too  long  deferred,  tliat  it  is  rarely  decided 
upon  before  pulmonary  engorgement  has  rendered  the  preservation  of  life 
almost  impossible,  and  that  in  reality  there  is  very  little  danger  in  the  opera- 
tion. When  it  is  performed  for  croup,  and  to  permit  remedies  to  be  dropped 
into  the  trachea,  the  consecutive  treatment  forms  its  capital  point.  On  this 
point  I  can  but  refer  to  the  Treatise  of  M.  Bretonneau  and  the  observation 
of  M.  Trousseau, 

§  2.  Branchoplasm, 

If  it  happen  that  after  wearing  a  canula  a  long  time  in  the  week,  or  that  in 
consequence  of  any  wound  whatever  the  patient  retain  a  fistulous  opening  to 
the  air  passages,  he  may  be  subjected  to  the  ti'eatment  of  fistula  in  general, 
and  if  nothingelse  will  succeed  it  will  be  allowable,  as  M.  Dupuytren  has  once 
done,  to  resort  to  the  process  of  cheiloplasm,  and  particularly  that  of  M. 
Roux.  A  cutaneous  flap  turned  back  from  below  upwards,  rolled  as  a  stopper 
and  fixed  in  the  fistula  by  two  stitches,  in  a  patient  upon  whom  I  have  just 
t»perated,  is  another  resource  which  in  my  opinion  ought  not  to  be  disregarded. 

§  3.  Catheterism. 

In  new  born  infants,  or  at  any  other  period  of  life,  catheterism  of  the  larynx 
is  an  operation  too  simple  to  require  a  longer  description.  While  one  hand 
conducts  the  instrument  through  the  nose,  or  rather  through  the  mouth,  one  or 
two  fingers  of  the  other  carried  into  the  fauces,  take  hold  of  its  extremity, 
direct  it  into  the  glottis,  and  prevent  its  going  towards  the  oesophagus. 


^rf.  3. — Jilimmtary  Passages, 

§  1.  Catheterism, 

Various  affections  render  necessary  the  introduction  of  a  sound  or  catheter 
into  the  oesophagus.  It  is  used  as  an  exploring,  extracting,  or  repelling  means, 
as  will  be  shown  when  we  come  to  speak  of  foreign  bodies ;  it  is  an  indis- 
pensable operation  for  entering  the  stomach,  or  when  food  or  remedial  sub- 


492  NEW   ELEMENTS  OT 

stances  are  to  be  artificially  introduced,  and  lastly,  it  may  be  employed  in 
the  treatment  of  certain  diseases  of  the  oesophagus  itself.  The  performance 
is  easy  and  in  the  power  of  every  one.  It  may  be  effected  through  the  nose 
as  well  as  the  mouth,  with  metallic  instruments  of  proper  curvature,  and  par- 
ticularly with  flexible  bodies ;  such  as  canulae  of  gumelastic,  bougies,  whale- 
bone, rods  &c. 

jBy  the  Nose. — The  first  method,  that  of  passing  through  the  nasal  fossae, 
for  a  long  time  adopted  as  the  best,  at  present  is  almost  generally  abandoned. 
It  is  often  difficult  and  fatiguing  to  the  patient,  and  should  only  be  retained 
as  an  exceptional  method.  If  the  catheter  is  stiff,  its  curve  scarcely  allows 
it  to  go  further  than  the  summit  of  the  pharyngeal  cavity,  and  consequently 
hardly  permits  it  to  enter  the  oesophagus ;  if  straight  and  flexible,  it  impinges 
against  the  spinal  wall  of  the  back  part  of  the  mouth,  so  as  to  he  not  always 
easily  disengaged.  This  way  is  better  than  none,  hov/ever,  if  the  other  be  not 
practicable.  The  sound  held  in  the  right  hand  as  a  pen,  is  carried  through 
the  nostril  in  the  same  manner  and  with  the  same  precaution  as  for  catheterism 
of  the  Eustachian  tube,  except,  that  instead  of  being  turned  outwards  or  in- 
wards, the  concavity  of  its  beak  ought  rather  to  look  downwards.  By  means 
of  the  index  finger,  or  a  blunt  hook  passed  into  the  mouth,  the  operator  reaches 
its  extremity  as  soon  as  it  arrives  at  the  upper  part  of  the  pharynx,  depresses 
it  a  little  with  the  left  hand,  while  with  tlie  right  he  continues  to  push  it  for- 
ward ;  he  thus  directs  its  point  in  the  axis  of  the  oesophagus,  avoiding  with 
care  the  entrance  of  the  larynx,  and  rubbing  too  hard  against  the  parieties  of 
the  organ;  advances  gradually,  stops  at  the  least  difficulty;  changes  a  little 
the  direction  of  his  efforts,  withdraws  the  instrument  in  some  degree  to  push 
it  in  another  direction  if  he  meet  any  resistance ;  and  descends  to  a  greater 
or  less  depth,  according  to  the  indication  to  be  fulfilled.  Supposing  a  straight 
gumelastic  tube  cause  some  embarrassment,  nothing  will  be  easier  than  to 
overcome  this  difficulty;  it  is  to  be  carried  until  on  a  level  with  the  glottis,  by 
means  of  a  bent  stylet  it  is  then  to  be  withdrawn  from  the  sound,  and  the  pro- 
cess is  then  to  be  conducted  as  above. 

Through  the  Mouth. — Whatever  be  the  mode  adopted,  the  patient  is  to  be 
seated  on  a  chair  and  held  as  in  all  operations  on  the  face.  When  he  pene- 
trates by  the  mouth,  the  surgeon  depresses  the  tongue  moderately  with  the 
left  index  finger,  which  he  carries,  if  he  can,  as  far  as  the  epiglottis,  so  as  to 
keep  it  as  a  guard  against  the  deviations  of  the  instrument  on  the  side  of  the 
respiratory  passages ;  glides  the  sound  or  catheter  along  the  radial  edge  of  tliis 
finger,  following  the  dorsal  face  of  the  tongue ;  enters  without  difficulty  the 
oesophagus  if  it  has  the  least  curvature ;  hooks  the  extremity  in  the  contrary 
case  with  the  directing  finger  to  oblige  it  to  follow  the  axis  of  the  canal,  and 
at  length  carries  it  as  far  as  he  judges  proper.  When  circumstances  require 
it  to  be  left  in  place  after  the  operation,  it  is  inclined  to  one  side  and  laid  in 
any  vacancy  which  may  have  been  left  by  the  extraction  of  teeth  and  fixes  it 
at  one  of  the  labial  commissures  by  means  of  a  riband  carried  round  ihe  head. 
Although  introduced  by  the  mouth,  if  its  presence  is  likely  to  fatigue  this 
cavity  too  much,  nothing  prevents,  as  judiciously  remarked  by  M.  Boyer,  the 
external  part  from  being  brought  through  the  nose.  For  this  purpose,  after 
being  placed,  it  will  be  sufficient  to  attach  it  to  Bellog's,  or  any  flexible  sound 
introduced  through  the  nostril,  and  draw  it  by  means  of  a  thread  previously 


ePERATIVE    SURGERY.  495 

fixed  to  its  extremity,  as  in  plugging  of  the  nasal  fossae.  Unless  the  oesop  agus 
be  devious,  contracted,  or  deformed,  the  operation  is  ordinarily  very  simple. 
There  is  no  risk  of  injuring  its  parietes,  of  taking  a  wrong  direction,  or  of 
piercing  it,  as  happened  to  the  surgeon  mentioned  by  Charles  Bell,  unless  we 
act  with  extreme  imprudence,  or  a  force  that  no  experienced  man  would 
attempt  to  exert.  The  finger  being  used  for  following  the  sound  beyond  the 
epiglottis,  it  cannot  be  very  difficult  to  knov/  if  by  chance  it  has  descended 
into  the  larynx,  as  seems  to  have  been  the  case  in  the  patient  mentioned  by 
M.  Worbe.  A  lighted  taper  presented  to  the  orifice  of  the  instrument,  the 
almost  impossibility  of  penetrating  further  than  the  bronchia,  or  still  better  the 
injection  of  a  few  drops  of  liquid,  which  would  not  fail  to  produce  cough,  &c., 
would  soon  afford  a  certainty  on  this  point. 

The  presence  of  a  foreign  body  in  the  cEsophagus  is  not  borne  by  all  subjects 
with  indiff*erence.  In  some  it  produces  inclination  to  vomit,  irritation,  and 
sometimes  even  fever.  When  more  serious  symptoms  arise,  whatever  may 
be  its  utility,  it  is  to  be  withdrawn,  and  replaced  some  time  afterwards  if  re- 
quisite. One  of  its  most  formidable  disadvantages,  although  authors  have 
scarcely  noticed  it,  is,  that  either  by  its  beak,  or  by  the  convexity  which  it  is 
forced  to  assume,  it  exercises  greater  pressure  necessarily  on  some  points  of 
the  posterior  wall  of  the  organic  tube  than  upon  others.  This  pressure,  slight 
as  it  may  appear,  being  uninterrupted,  is  of  a  nature  to  produce  at  first  a 
purulent  discharge,  then  ulceration  or  an  eschar,  and  finally  a  perforation. 
The  possibility  of  such  an  occurrence  it  is  difficult  to  call  in  question,  when 
we  know  that  the  tip  of  a  simple  gumelastic  sound  has  determined  them  more 
than  once  upon  the  rectal  side  of  the  bulb  of  the  urethra^  I  fear  too  that  the 
patient,  in  whom  the  oesophagus  was  found  **  destroyed  for  the  extent  of  two 
inches  at  least,  at  an  inch  and  a  half  above  its  passage  through  tlie  diaphragm" — 
a  patient  who  had  been  treated  by  means  of  dilating  bougies  with  apparent 
success  by  M.  Carrier — was  really  its  victim. 

Stricture. — Since  Mauchail  established  the  analogy  between  coarctations 
of  the  urethra  and  those  of  nearly  all  tlie  mucous  canals,  surgeons,  have  at- 
tempted, at  various  times,  to  apply  to  strictures  of  the  oesophagus  nearly  all 
the  treatment  useful  in  those  of  the  urinary  canal.  Mechanical  dilatation  is 
one  of  the  first  attempted  to  be  employed.  It  was  advised  by  MM.  Riche- 
rand  and  Dupuytren,  and  once  put  to  the  test  by  MM.  Carrier  and  Jallon 
upon  a  merchant  of  Orleans,  who  for  a  month  was  better,  but  sunk  in  the  end 
with  an  ulcerous  destruction  of  the  canal  of  deglutition ;  applied  by  M.  Boyer 
in  1797  in  the  case  of  a  woman  who  derived  but  little  advantage  from  it;  and 
by  M.  Sanson  on  a  patient  who,  after  obtaining  considerable  relief,  wished  . 
to  leave  the  Hotel  Dieu,  under  the  belief  that  further  treatment  was  not  re- 
quisite ;  it  seems  to  have  been  attended  with  complete  success  to  Migliavacca, 
cited  by  Paletta,  to  Mr.  Home,  Mr.  Earle,  and  Mr.  Mcllvain,  The  catheter 
is  the  instrument  for  effecting  it.  Bougies,  whether  emplastic,  elastic,  conical 
rather  than  cylindrical,  or  still  better  hollow  catheters,  employed  so  as  to  be 
able  gradually  to  increase  their  size,  should  be  here  managed  with  the  same 
reserve,  and  the  same  prudence  as  in  the  urethra ;  but  the  canal  being  larger, 
or  requiring  to  be  brought  to  greater  dimensions,  the  volume  which  it  is  at  first 
necessary  to  give  to  these  instruments  has  made  it  desirable  to  substitute  for 
them  other  apparatus.    That  of  Mr.  Fletcher,  curved,  slender,  and  made  of 


494  '  NEW  ELEMENtS  OF 

metal,  is  formed  of  three  branches,  which  a  central  staff,  armed  with  a  head, 
separates  or  approximates  at  pleasure.  After  being  introduced  beyond  the 
stricture,  the  movable  axis  is  drawn  back,  so  that  the  branches  insensibly  se- 
parate to  the  degree  which  the  surgeon  thinks  proper.  Though  ingenious  as 
it  may  appear,  this  instrument  should  be  rejected.  It  is  from  equal  com- 
pression, and  not  only  at  these  points  of  the  constricted  circle,  that  dilatation 
offers  a  prospect  of  success.  It  is  most  particularly  necessary  that  this  indi- 
cation be  exactly  fulfilled,  which  Mr.  Fletcher  seems  to  have  entirely  forgot. 
The  air  dilator  of  Mr.  Arnott,  and  the  flexible  seton  carrier  recently  devised 
by  M.  Costalat,  to  reach  deep  strictures  of  the  rectum,  and  particularly  of  the 
urethra,  will  have  incontestible  advantages  over  it.  I  will  recur  to  these  under 
the  articles  urethra  and  rectum.  Many  surgeons  have  also  directed  their 
views  to  cauterization.  Although  this  mode  of  treatment  has  not  yet  been 
tested  among  us,  and  M.  Boyer  has  deemed  it  necessary  to  proscribe  it  for- 
mally, with  the  conviction  that  no  experienced  and  prudent  surgeon  would 
be  bold  enough  to  attempt  it,  it  is  not  so  elsewhere.  In  his  excellent  work 
just  published,  on  Chronic  Affections  of  the  (Esophagus,  M.  Mondiere  shows 
that  it  has  been  employed  in  Italy,  England,  and  America.  A  flexible  staff, 
armed  with  a  piece  of  lint  soaked  in  a  caustic  liquid,  was  carried  by  Paletta 
as  far  as  the  stricture,  and  the  patient,  who  died  some  weeks  after,  was  at  first 
relieved.  Rejecting  justly  all  fluid  substances,  Sir  E.  Home  preferred  the 
nitrate  of  silver,  and  has  used  it  seven  times.  Four  of  his  patients  were  cured, 
and  the  other  three  sunk  under  the  natural  progress  of  their  disorder.  Of  three 
cases  reported  by  Mr.  Andrews,  of  Madeira,  only  one  did  well,  the  two  others 
could  not  be  saved.  Lastly,  Messrs.  Ch.  Bell  and  Mcllvain  have  declared 
in  its  favor,  as  Darwin  had  done  before,  and  appear  to  have  used  only  the 
nitrate  of  silver.  The  difliculty  that  first  presents  is  to  know  the  nature  of 
the  stricture  to  be  treated.  Those  which  depend  on  chronic  phlegmasia,  indu- 
ration, or  a  lardaceous  transformation  of  the  mucous  coat,  or  the  adjacent 
layer,  admit  of  the  trial  of  cauterization ;  but  how  distinguish  them  from  lesions 
caused  by  tumors,  cancerous  or  fungous  degenerations,  ulcers,  aneurisms, 
polypi,  &c.?  The  urethra  being  as  it  were  not  subject  to  any  but  the  first, 
does  not  occasion  this  kind  of  embarrassment.  Its  small  diameter,  its  super- 
ficial position,  and  the  arrangement  of  its  parietes,  render  its  mechanical  dila- 
tation easy  and  almost  without  danger.  The  oesophagus  surrounded  by 
yielding  tissues,  and  naturally  very  dilatable,  is  fap  from  presenting  in  this 
point  of  view  such  advantageous  circumstances.  In  holding  apart  the  sides 
at  the  contracted  point,  bougies  merely  throw  outwards  the  projection  which 
tends  inwards,  and  the  disorder  returns  almost  immediately  on  the  suspen- 
sion of  the  treatment,  which  therefore  is  only  palliative.  As  to  the  nitrate 
of  silver  it  is  less  in  the  character  of  a  caustic  than  of  a  modifier  of  the  morbid 
condition  of  the  part  that  I  would  be  willing  to  employ  it.  In  this  view  the 
exactness  with  which  we  touch  one  point  rather  than  another,  is  less  important 
than  may  be  thought.  It  is,  for  the  rest,  a  subject  which  will  come  under  the 
treatment  of  the  urethra. 

§  2.  Foreign  Bodies* 
Incision  into  the  "oesophagus,  first  promulgated   by  Verduc,  formally 


OPERATIVE  SURGERY.  495 

proposed  by  Guattani,  practised  for  the  first  time  by  Guattani  in  1730,  and 
since  by  Roland,  is  an  operation  which  is  only  applicable  to  two  particular 
cases ;  first  for  the  extraction  of  a  foreign  body,  which,  by  its  presence  in 
the  CESophagus,  endangers  more  or  less  the  life  of  the  patient;  secondly, 
for  the  artificial  introduction  of  nutritive  substances  into  the  digestive 
passages  in  case  of  impassable  stricture  of  the  inferior  part  of  the  pharynx. 

In  the  first  case,  before  proceeding  to  oesophagotomy,  every  means  should 
be  tried  to  make  the  foreign  body  return  by  the  natural  passages,  unless  it  is 
of  such  a  nature  as  to  be  pushed  into  the  stomach  without  danger.  A  crust 
of  bread,  a  piece  of  tripe,  large  lumps  of  hard  and  coriaceous  food,  skin,  a 
slice  of  frwit,  a  sugar-plum,  a  morsel  of  cake,  the  rind  of  bacon,  a  whole  egg, 
a  chestnut,  a  pear,  a  fig,  and  all  solid  substances  which  enter  into  tlie  compo- 
sition of  food,  may  lodge  in  the  oesophagus  and  give  rise  to  serious  accidents. 
However,  as  these  various  bodies  are  more  or  less  soluble  in  the  juice  of  the 
digestive  passages,  it  is  rare  that  they  do  not  in  the  end  descend  into  the 
stomach.  Pebbles,  pieces  of  glass,  fish  bone,  a  piece  of  coin,  a  knife  handle, 
a  fork,  and  a  thousand  different  foreign  bodies,  of  which  the  memoirs  of 
Hevin  and  Sue  contain  so  many  examples,  are  much  more  dangerous, 
although  the  organism  has  more  than  once  triumphed  over  them  without 
assistance.  They  tear  or  contuse  the  parts,  and  produce  inflammations  and 
abscess  and  horrible  pains,  which  have  often  no  end  but  death.  To  the 
numerous  facts  already  given  by  authors,  it  would  be  very  easy  to  add  a  host 
of  others.  MM.  Gibert,  Murat,  Bard,  &c.,  have  recently  added  to  the 
list,  and  practitioners  meet  with  new  cases  every  day.  Thus,  Dumortier 
has  seen  the  presence  of  a  piece  of  money  in  the  oesophagus  produce  perfora- 
tion of  the  primitive  carotid;  and  M.  Begin  gave,  in  1828,  the  case  of  a 
soldier,  in  whom  the  trunk  of  the  thoracic  aorta  was  opened  in  the  same 
manner  by  a  five-franc  piece.  When  their  presence  is  evidently  capable  of 
doing  injury,  and  when  the  organism  is  unable  singly  to  remove  them,  three 
modes  may  be  employed  before  proceeding  to  open  into  the  oesophagus.  To 
push  it  into  the  stomach,  to  force  it  to  return  by  the  natural  passage,  and  to 
prevent,  or  meet  with  energy  if  they  already  exist,  the  symptoms  which  may 
arise. 

1st.  Propulsion. — Only  those  bodies  should  be  pushed  into  the  stomach 
which,  being  too  difficult  to  remove  by  the  mouth,  are  not  dangerous  to  the 
patient  if  once  out  of  the  oesophagus.  Water,  swallowed  in  abundance, 
large  mouthfuls  of  bread,  beef,  buiscuit,  figs  turned  inside  outwards,  prunes 
freed  from  their  stones,  pieces  of  sponge  tied  to  a  thread,  long  bougies  lubri- 
cated with  oil,  slight  blows  on  the  back  with  the  fist  as  recommended  by  De 
la  Motte,  and  rarely  omitted  by  common  people,  and  I  know  not  how  many 
other  means  have  been  proposed  and  successively  practised  with  advantages 
more  or  less  marked,  and  often  again  without  any  kind  of  success.  In  this 
case,  the  leaden  staff  of  Albucasis  and  Rhazes,  tlie  ball  of  the  same  metal 
cast  and  fixed  on  the  end  of  iron,  silver,  or  brass  wire,  so  highly  approved  by 
Mesnier,  Verduc's  silver  rod  terminating  in  an  olive,  the  curved  sound,  &c., 
are  far  from  always  succeeding.  In  all  this  I  can  see  scarcely  any  thing  but 
the  pear -headed  staff  generally  used  since  A.  Pare,  and  the  ball  of  lead, 
which  is  really  worthy  of  any  confidence ;  still  will  it  be  necessary  that  both 
these  instruments  be  made  with  flexible  rods,  capable  of  following  with- 


496  ^  NEW    ELEMENTS    OF 

out  difficulty  the  tortuous  form  of  the  mouth,  pharynx,  and  oesophagus, 
yet  with  sufficient  solidity  however  to  prevent  their  breaking  during  the 
operation. 

2d.  Extraction. — When  the  fingers  cannot  reach  the  foreign  bodies  engaged 
in  the  pharynx  or  oesophagus,  there  should  be  used  long  forceps,  a  little  curved ; 
like  the  urethra  forceps  of  Hunter  for  example.  The  crotchet,  or  wire  hook 
of  Reviere  or  Perrotin  exposes  the  tissues  to  be  torn  upon  its  being  withdrawn, 
as  was  experienced  by  Petit,  of  Nevers.  By  tipping  it  with  a  button,  Sted- 
man  really  improved  it;  and  M.  Dupuytren,  who  substituted  a  long  silver 
v/ire  terminating  in  a  ball  at  one  end  and  a  ring  at  the  other,  making  it  an 
exploring  instrument,  a  kind  of  catheter  when  straight,  and  using  it  as  a  hook 
by  bending  it,  has  rendered  it  easier  of  managemerit.  The  crotchet  of  F, 
de  Hilden  would  be  much  more  dangerous;  that  of  Petit,  made  of  a  double 
flexible  wire  of  silver,  twisted  and  bent  in  the  manner  of  the  palpebral  eleva- 
tor of  Petlier,  has  nothing  against  it  but  its  want  of  firmness.  The  stylet  or 
v/halebone  rod,  carrying  a  bunch  of  small  movable  rings,  extolled  by  the 
same  practitioner,  and  which  De  la  Faye  modified  by  merely  fixing  threads 
of  flax  to  the  small  ring  of  a  stylet  of  the  ordinary  catheter,  is  not  to  be  despised 
when  the  body  to  be  extracted  is  uneven  and  of  small  dimensions.  The  noose 
of  packthread  or  twine,  which  Mauchart  had  occasion  to  praise,  the  sponge 
tied  strongly  to  a  thread  and  carried  below  the  foreign  body  by  means  of  a 
large  leaden  sound,  to  the  end  of  which  it  is  fastened,  by  drawing  en  the  two 
ends  of  the  string  brought  back,  one  through  the  canal  the  other  along  the 
external  face  of  the  instrument,  as  practised  by  Brouillard  ;  the  same  sub- 
stance attached  to  the  end  of  a  whalebone  rod,  as  described  by  Willis, 
of  an  ordinary  catheter,  or  the  leaden,  or  copper  sound,  perforated  with  holes, 
borro\yed  from  Arculanus  or  rather  from  Ryfl",  and  modified  by  Hilden, 
who,  to  render  it  stronger,  added  to  it  a  leaden  stylet ;  the  sponge,  which 
Hevin  enclosed  in  a  pouch  of  lambskin  or  silk  to  prevent  its  dilating  before 
descending  low  enough  ;  which  Petit  fixed  to  the  end  of  a  slip  of  whalebone, 
enclosed  as  far  as  its  handle  in  a  flexible  sound  made  of  silver  wire  wrapped 
spirally;  which  Quesney  covered  with  intestine  of  sheep;  which  Ollenrotz 
suspended  to  the  end  of  a  chain  or  chaplet  composed  of  sixty-one  balls  of  tin, 
may  have  in  every  one  of  tliose  ways  its  particular  application ;  as  also  the 
kind  of  brush,  mop,  or  broom,  the  excutia  ventriculi  mentioned  byWedel,Teich- 
meyer  and  Heister,  and  which  the  English,  who  call  it  provmdor,  form  of 
small  pieces  of  linen,  or  a  bunch  of  hog's  bristles  at  the  end  of  a  piece  of 
whalebone,  or  brass  wire.  The  manner  of  using  these  various  instruments, 
whether  for  forcing  into  the  stomach  or  extracting  by  the  mouth  the  bodies  in 
question,  is  too  easily  understood  to  require  more  to  be  said  of  it.  The  same 
may  be  said  of  their  relative  value  in  the  different  cases  in  which  more  than 
one  of  them  would  be  applicable.  The  skillful  surgeon  will  select  the  best, 
the  most  simple,  the  most  certain,  and  the  most  inoffensive  among  those 
within  his  reach.  The  forceps  with  multiplied  branches,  which  are  opened 
and  closed  by  a  peculiar  mechanism  before  and  after  seiz.ing  the  foreign  body, 
and  which  M.  Missoux  described,  in  1825,  in  his  thesis  under  tlie  name  of 
Geranorhynque,  although  ingenious,  is  too  complicated  for  adoption.  That 
just  proposed  by  M.  Blondeau,  and  which  is  founded  on  the  principle  of  the 
litholabe  forceps,  enclosed  in  a  flexible  sheath,  would  answer  a  little  better 


OPERATIVE    SURGERY.  497 

if  it  were  not  also  too  complex.  The  same  must  be  said  of  the  ingenious 
apparatus  recently  invented  by  M.  Parent. 

3d.  The  efforts  at  vomiting,  which  many  authors  have  advised  us  to  provoke 
(notwithstanding  the  objections  of  B.  Bell)  either  by  tickling  the  palate  or  the 
bottom  of  the  fauces,  or  by  gorging  the  patient  with  warm  water,  or  in  any  other 
way,  form  a  resource  which  we  should  not  employ  but.  for  bodies  free  from 
asperities  or  any  projecting  points,  or  after  having  vainly  tried  the  two  kinds  of 
resource  pointed  out  above,  and  only  then  that  we  may  not  have  to  reproach 
ourselves  with  recurring  too  qui(;kly  or  without  necessity  to  oesophagotomy. 

4th.  (Esoplmgotomy. — Although  this  operation  was  not  formally  proposed  by 
any  one  before  Verduc  and  Guattani,  yet  it  must  be  admitted  that  the  idea 
may  be  found  in  other  and  older  authors.  The  opening  of  the  abscess  con- 
taining a  small  bone  which  had  escaped  from  the  oesophagus,  and  approached 
the  integuments  of  the  neck,  already  practised  by  Arculanus  and  Plater ;  the 
fish  bone  extracted  in  the  same  manner  by  Houlier  and  Glandorp;  the  open- 
ing of  tumors  of  more  or  less  density  and  volume  developed  on  the  same 
region,  by  Kerkring,  Rivals,  &c.  naturally  led  to  it.  But  wounds  of  the 
oesophagus  until  then  had  been  considered  so  dangerous  that  practitioners  had 
need  of  numerous  facts  and  direct  experiments  to  dissipate  their  fears  and 
their  scruples.  Since  oesophagotomy  has  taken  its  station  among  the  regular 
operations  of  surgery,  it  has  received,  like  almost  every  other,  various  degrees 
of  improvement.  Guattani  who  was  not  ignorant  that  the  oesophagus  is 
situated  a  little  more  to  the  left  than  to  the  right  of  the  trachea,  advises  to 
make  a  transverse  fold  of  the  skin,  and  make  an  incision  from  the  level  of  the 
cricoid  cartilage  down  to  the  sternum  on  the  left  side  of  the  neck,  to  separate 
the  lips  of  the  wound  with  hooks,  and  arrive  by  degrees  at  the  oesophagus,  and 
divide  it  parallel  with  its  fibres.  According  to  B.  Bell  the  place  of  incision  is 
by  no  means  fixed ;  for  it  is  proper  to  make  it  always  upon  the  projection  caused 
by  the  foreign  body.  He  knew,  besides,  that  by'these  precautions  the  recur- 
rent nerve  would  be  easily  avoided.  To  be  more  certain  of  not  opening  a 
vessel  of  any  size,  Richter  advises  the  muscles  to  be  separated  by  an  ivory 
knife.  The  method  of  Echoldt,  praised  I  know  not  why  by  Sprengel,  which 
consists  in  making  the  incision  fall  upon  the  triangular  space  which  separates 
the  roots  of  the  sterno-mastoid  muscle,  seems  to  me  to  deserve  the  oblivion 
into  which  it  has  fallen.  •  Sir  Chas.  Bell  says,  that  if  the  thumb  be  placed  on 
the  course  of  the  internal  jugular  vein  to  make  it  swell  during  the  incision  of 
the  skin,  the  platisma-myoids,  the  nervous  filaments  of  the  cervical  plexus, 
and  while  the  other  muscles  are  separated  with  the  handle  of  the  scalpel,  the 
oesophagus  will  soon,  in  some  measure,  present  itself,  and  in  this  manner 
oesophagotomy  is  not  dangerous ;  but'  this  author  is  evidently  deceived  as  to 
the  value  of  such  a  precaution.  M.  Richerand,  who  admits  oesophagoto- 
my only  in  cases  where  the  volume  of  the  foreign  body  is  considerable 
enough  to  make  it  project  beyond  the  surrounding  parts,  and  who  main- 
tains with  reason  that  it  is  almost  always  at  the  entrance  of  the  canal  of  de- 
glutition that  these  bodies  lodge,  simply  adopts  the  process 'of  Guattani  or 
B.  Bell.  In  this  hypothesis,  indeed,  the  external  projection  is  a^ure  guide 
to  the  oesophagus,  and  favors  the  separation  of  all  the  organs  which  it  is  impor- 
tant to  save.  An  instrument  devised  by  Vacca,  allows,  in  every  case,  the 
same  end  to  be  fulfilled.  It  is  a  long  metallic  staff  terminating  in  a  knob, 
and  split  in  the  form  of  a  forceps  at  one  of  its  extremities.  This  staff  slides 
63 


498  .NEW   ELEMENTS   OF 

in  a  canula,  which  presents  laterally  an  opening  several  inches  above  its  termi- 
nation. The  whole  instrument  is  introduced  closed  until  arrived  beyond  the 
foreign  body.  The  surgeon  then  draws  the  forceps  gently  towards  him,  when 
one  of  its  branches,  from  its  own  elasticity  does  not  fail  to  be  engaged  in  the 
lateral  hole  of  the  sound,  which  forms  its  sheath  and  pushes  out  on  the  side 
of  the  neck  the  several  layers  to  be  divided.  But  the  barbed  sound  invented 
by  Frere  Come  for  the  supra  pubic  operation  is,  without  doubt,  far  more  con- 
venient than  the  instrument  of  Vacca,  if  a  conductor  is  necessary  when  ceso- 
phagotomy  is  performed.  By  raising  all  the  soft  parts  to  the  left  and  front 
with  the  beak  of  a  common  catheter  previously  carried  down  to  the  body  to 
be  extracted,  as  proposed  by  M.  Roux,  the  carotid  artery,  the  jugular 
vein,  and  the  pneumo -gastric  nerve  necessarily  remain  posteriorly;  the 
thyroid  vessels  themselves  and  the  trachea  are  also  sufficiently  distant  to  re- 
move all  danger  from  pushing  his  dart  from  within  outwards,  which  then  is 
used  as  a  grooved  director,  in  lithotomy.  However,  it  is  unnecessary  thus 
to  grope  in  the  dark.  Nothing  prevents  cutting  first,  layer  by  layer,  the 
several  tissues  which  separate  the  oesophagus  from  the  integuments,  and  only 
using  the  sound  in  the  last  stage  of  the  operation.  In  this  manner  oesophago- 
tomy  has  nothing  dreadful  nor  difficult,  and  may  be  performed  by  every  sur- 
geon. Strictly  speaking  there  is  nothing  to  prevent  the  substitution  of  an 
ordinary  sound  for  that  of  Frere  Come. 

Manual. — The  patient  is  placed  as  for  tracheotomy,  only  that  his  face  is 
turned  a  little  to  the  right.  Standing  at  the  left,  armed  with  a  straight 
bistoury,  the  surgeon  divides  the  integuments  and  the  platysma-myoides  to 
the  extent  of  two  or  thi'ee  inches  upon  the  anterior  edge  of  the  sterno -mastoid 
muscle,  between  the  sternum  and  the  larynx,  and  as  directly  as  possible  oppo- 
site the  foreign  body,  whose  situation  he  has  previously  discovered,  either  with 
the  blunt  staff  of  M.  Dupuytren,  the  barbed  sound,  or  other  instrument;  turns 
this  muscle  outwards;  displays  the  omo-hyoid  and  sterno-hyoid  muscles; 
divides  them  in  turn ;  tears  with  the  beak  of  a  director,  or  divides  carefully 
with  the  bistoury,  the  fibro-cellular  layers  which  are  found  a  little  deeper,  as 
if  for  tying  the  primitive  carotid  artery ;  raises  and  pushes  inwards  and  for- 
wards the  thyroid  body,  continues  with  the  same  precautions  as  far  as  the 
lateral  groove  between  the  oesophagus  and  the  trachea;  introduces  the  arrow 
sound  by  the  mouth,  if  he  chooses  to  employ  it;  makes  its  tube  project 
through  the  oesophagus  at  the  bottom  of  the  wound;  fixes  it  with  the 
left  thumb  and  index  finger ;  directs  an  assistant  to  push  its  stylet ;  carries 
the  point  of  his  bistoury  on  the  grooved  concavity  of  this  staft",  and  makes 
an  incision  on  the  oesophagus  proportionate  to  the  size  of  the  body  to  be 
extracted.  When  the  conductor  is  not  employed,  the  canal  is  first  to  be 
opened  on  the  side  by  a  small  puncture,  to  permit  a  conductor  to  be  imme- 
diately carried  into  its  interior,  and  the  wound  then  enlarged  with  a  bistoury 
or  blunt  scissors.  If  the  substance  to  be  removed  does  not  present  at  the 
opening  just  made,  it  is  to  be  sought  for  with  forceps  or  any  appropriate 
instrument.  Tlie  wound  may  be  united  by  the  first  intention.  If  an  artery 
of  any  size  be  wounded,  it  is  to  be  obliterated  by  a  ligature.  A  gumelastic 
oesophagus  sound  is  to  be  carried  through  the  nostrils  or  mouth  into  the 
stomach,  and  is  not  to  be  removed  before  the  third  or  fourth  day,  in  order 
that  food  and  drink  given  to  the  patient  during  this  time  may  not  prevent 
adhesion  of  the  wound,  and  be  infiltrated  into  the  tissues  of  the  sub-hyoid 


OPERATIVE  SURGERY.  499 

region.  I  learn  from  M.  H.  Larrey,  that  a  patient  operated  on  after  these 
principles  at  the  Val  de  Grace,  was  perfectly  restored.  The  anomaly  pub- 
lished by  Steadman,  Kirby,  Hart,  Godman,  and  Robert,  of  a  carotid  or  sub- 
clavian twining  spirally  round  the  oesophagus,  or  gliding  under  its  spinal 
surface  to  reach  the  side  of  the  neck,  will  not  cause  danger  unless  the 
operation  be  performed  too  low  down. 


CHAPTER   II. 

The  Chest. 


SECTION  I. 

Tumors, 

Art,  1. — Extirpation  of  the  Mamma, 

Compression,  employed  from  1809  to  1816  by  Yonge,  rejected  in  1817  as 
dangerous  by  the  Middlesex  physicians  on  the  report  of  Charles  Bell,  intro- 
duced again  by  Pearson,  has  recently  afforded  to  M.  Recamier  results  worthy 
of  fixing  the  attention  in  the  treatment  of  tumors  of  the  breast.  Up  to  the 
month  of  September,  1829,  this  practitioner  had  obtained  ten  instances  of 
complete  success,  four  of  very  decided  improvement,  and  four  others  of  more 
moderate  encouragement,  out  of  thirty  patients  whom  he  treated.  In  the 
greater  part  of  the  other  cases  it  rendered  removal  much  more  easy  and 
certain,  by  reducing  the  tumor  to  the  smallest  possible  size,  and  in  some 
measure  insulating  it  from  the  surrounding  parts.  But  this  is  not  a  reason 
for  rejecting  the  operation,  nor  as  some  seem  to  think  for  leaving  it  as  a  des- 
perate remedy  for  a  desperate  case.  Many  women  cannot  endure  compres- 
sion, however  well  applied.  Many  cases  invincibly  resist  it.  Under  the 
most  favorable  circumstances,  the  assiduous  attentions  which  it  requires  for 
months,  are  of  themselves  sufficiently  wearisome  to  suggest  the  question, 
whether  extirpation  ought  not  to  be  preferred.  It  is  not,  in  fact,  as  an  opera- 
tion that  extirpation  of  the  breast  is  dangerous,  but  because  it  is  frequently 
followed  by  a  return  of  the  disease.  The  amount  of  pain  which  it  causes  is 
assuredly  less  than  what  results  from  a  treatment  which  must  continue  from 
two  to  three  months.  In  an  instant  the  patient  is  rid  of  the  disorder.  Fif- 
teen days  to  a  month  ordinarily  suffice  for  the  completion  of  the  cure.  On 
tlie  other  hand,  there  is  no  reason  to  believe  that  the  relapse  will  be  less  fre- 
quent after  the  use  of  the  bandage  than  by  removal  of  the  scirrhus.  Observa- 
tion has  already  proved,  that  if  it  become  necessary  to  discontinue  the 
compression  without  having  entirely  resolved  the  morbid  mass,  the  progress 
of  the  cancer  impeded  for  a  moment  soon  becomes  more  frightful  than  before. 

To  the  question  whether  extirpation  is  a  means  which  may  be  reasonably 
tried,  I  do  not  hesitate  to  answer  in  the  affirmative.  To  Celsus  who  forbids 
us  to  touch  cancer  because  it  always  returns ;  to  Avicenna,  who  never  saw 
the  operation  followed  by  complete  success ;  to  Monro,  who  proves  that  only 


500  NEW  ELEMENTS  OF 

four  women  out  of  more  than  sixty  whom  he  knew  had  had  no  return  of 
disease  at  the  end  of  two  years ;  to  M.  Boyer,  who  out  of  more  than  a  hundred 
cases  could  only  cite  a  very  small  number  of  radical  cures ;  to  Rouzet,  who 
professes  to  have  found  in  the  Annals  of  Science  but  equivocal  proofs  of  per- 
manent cures,  may  be  opposed  the  testimony  of  Hill,  who  met  with  but  twelve 
unsuccessful  cases  out  of  eighty-eight  extirpations  of  cancers,  for  the  most 
part  ulcerated,  although  all  his  cases  had  occurred  from  two  to  thirty  years 
before ;  that  of  B.  Bell  who  confirms  the  statement  of  Dr.  Hill ;  that  of  Dr. 
North,  quoted  by  Dorsey,  and  who  in  a  hundred  cases  remarked  but  a  very 
small  proportion  of  relapses.  MM.  Richerand,  Roux,  Dupuytren,  and  before 
them  Sabatier,  have  on  their  part  had  proof  that  cancer  is  far  from  always 
returning  when  extirpation  has  been  performed  in  time.  It  is  also  within  my 
knowledge  that  many  patients  operated  upon  at  Tours  by  M.  Gouraud,  at 
the  hospital  St.  Louis  by  M.  J.  Cloquet,  at  the  hospital  of  the  School  of  Me- 
dicine by  MM.  Boyer  and  Roux,  or  by  myself,  from  two  to  ten  years  since, 
continue  in  good  health.  Cancer  of  the  breast  is  not  an  external  sign  of  ge- 
neral disease,  as  maintained  by  M.  Delpech,  at  least  most  frequently,  except 
in  an  advanced  period  of  its  development.  In  the  majority  of  cases  it  is 
at  first  but  a  local  affection,  but  one  which  continually  tends  to  pervert  the 
solids  and  fluids  to  such  a  degree  as  to  be  reproduced,  in  some  part  or  other, 
although  it  seemed  to  be  entirely  destroyed  in  the  place  of  its  first  attack. 
Consequently  nothing  can  be  more  dangerous  than  to  defer  its  removal  under 
vain  pretexts ;  and  compression,  necessarily  less  efficacious,  is  to  be  proposed 
only  to  pusillanimous  patients,  or  to  those  who  from  some  other  reason  will 
not  submit  to  the  knife.  If  general  or  local  medications  are  of  any  value,  the 
operation,  which  is  by  no  means  incompatible  with  their  use,  can  only  con- 
tribute to  their  success.  It  would  be  wrong  to  be  imposed  upon  by  the 
presence  of  some  swellings  about  the  axilla  or  in  the  sub-clavicular  region. 
These  tumors  may  have  preceded  the  scirrhus,  or  be  the  effect  of  it,  without 
partaking  of  its  nature.  Bartholin,  Borrich,  Assalini,  and  Desault  have  seen 
them  spontaneously  disappear  after  amputation  of  a  cancerous  breast.  The 
same  remark  has  of  late  been  frequently  made.  This  was  the  case  with  a 
woman,  treated  in  1825  by  M.  Roux,  at  the  "  Hospice  de  Perfectionnement," 
who  had  a  row  of  hardened  glands  extending  from  the  side  of  the  neck  into 
the  hollow  of  the  axilla.  A  slight  yellowish  tint,  a  commencement  of  what 
is  called  cancerous  cachexia,  does  not  always  form  an  absolute  contra-indi- 
cation.  Having  to  treat  a  patient  in  this  condition,  Morgagni  operated  against 
the  formal  advice  of  Valsalva.  The  cancer  returned  at  the  end  of  five  years. 
Morgagni  operated  again,  and  the  disease  was  not  reproduced.  Adhesions  of 
the  tumor  to  the  ribs  diminish  considerably  the  chances  of  success,  but  do  not 
render  it  absolutely  impossible.  The  operation  ought,  therefore,  to  be  per- 
formed whenever  the  roots  of  the  disease  may  be  extirpated  without  occa- 
sioning too  great  a  loss  of  substance,  and  when  there  is  no  evidence  of  its 
actual  existence  in  other  organs. 

History, — That  extirpation  of  the  breast  still  causes  so  much  terror  m  the 
ordinary  ranks  of  society,  is  to  be  attributed  to  the  barbarous  processes  which 
have  been  employed  at  various  periods.  Cauterization  of  the  wound,  with  an 
iron  moderately  hot,  mentioned  in  the  writings  of  Galen  ;  the  precepts  of  Le- 
onidas  to  burn,  at  each  stroke  of  the  bistoury,  the  bottom  of  the  incision,  to 


OPERATIVE    SURGERV.  501 

prevent  hemorrhage ;  excision  with  a  knife  heated  to  whiteness,  or  when  the 
cancer  is  adherent,  with  a  blade  of  horn  dipped  in  aqua  fortis,  as  prescribed 
by  J.  Fabricius,  must  truly  have  been  accompanied  with  horrible  pains.  The 
process  of  Scultetus,  which  consists  in  passing  two  threads  crossed  through 
the  tumor  to  lift  it  up,  cutting  it  off  at  a  single  stroke  with  a  large  concave 
bistoury,  and  then  cauterizing  all  the  bleeding  surface  with  a  plate  of  red  hot 
iron ;  that  of  Purmann,  who  added  to  these  threads  a  tight  ligature  on  the 
the  root  of  the  disease  for  the  purpose  of  benumbing  the  parts ;  those  of  Nuck, 
who  used  a  double  hook  and  falciform  knife ;  of  Dionis,  w^ho  began  by  plunging 
into  the  cancerous  mass  his  famous  Helvetian  forceps,  so  much  spoken  of  at 
the  commencement  of  the  last  century ;  of  Hartmann  and  of  Vylhorne,  who, 
after  strangulating  the  tumor  at  its  base,  fixed  it  with  a  kind  of  forceps,  after- 
wards with  the  bident  of  Helvetius,  while  a  mechanical  instrument  of  their 
invention  performed  the  excision  ;  of  Schmucker,  who  after  dividing  the  skin, 
pressed  the  tumor  to  make  it  project,  passed  throiio:h  it  a  kind  of  awl  some- 
what bent,  and  then  separated  it  from  the  *Jurrounding  parts,  were  also  well 
calculated  to  excite  similar  fears.  Those  who  caused  the  tumor  to  drop  off 
by  surrounding  it  with  a  ligature  dipped,  in  aqua  fortis,  or  who,  after  com- 
pletely or  incompletely  excising  it  in  any  manner,  applied  at  several  times  arse- 
nic, orpiment,  potassa,  butter  of  antimony,  &c. ;  they  who  dissected  minutely 
all  the  surrounding  vessels  for  the  purpose  of  placing  a  double  ligature  around 
each,  and  cuttino;  without  fear  between  the  two  before  removino;  the  cancer, 
and  who  after  the  incision  of  the  integuments  used  only  their  fingers  and  ter- 
minated the  operation  by  extraction,  did  nothing  towards  inducing  the  public 
to  change  their  opinion  on  this  subject.  At  the  present  time,  when  removal 
of  the  breast  is  reduced  to  its  greatest  simplicity,  there  is  nothing  in  it  terrible 
or  really  cruel.  When  the  skin  is  not  diseased,  and  the  tumor  is  neither  vo- 
luminous nor  adherent,  the  surgeon  merely  divides  the  common  integuments, 
taking  care  to  give  the  incision  all  the  proper  extent,  and  to  have  its  lips  sepa- 
rated, while  with  a  hook,  or  even  the  ends  of  the  fingers,  he  draws  the  scirrhus 
outwards,  and  with  the  other  hand  armed  with  a  bistoury  destroys  all  its  cel- 
lular and  vascular  connexions.  When  the  patient  is  of  a  certain  embonpoint, 
or  when  the  nipples  are  naturally  very  much  developed,  although  the  carci- 
noma be  very  much  circumscribed  and  preserves  all  its  mobility,  there  is  some 
advantage  in  not  thus  saving  the  skin  in  cutting  out  an  ellipsis  of  more  or  less 
extent.  The  operation  is  thus  rendered  easier  and  more  prompt.  Its  success 
will  thereby  be  rendered  more  probable,  for  the  sides  of  the  wound,  being 
almost  perpendicular,  are  in  better  condition  to  be  exactly  brought  together 
than  if  the  whole  of  the  integuments  had  been  preserved.  If  the  skin  itself  is 
included  in  the  disorganization;  if  it  is  red  and  too  tliin  ever  to  resume  its 
primitive  character ;  if  it  adheres  by  its  under  surface  to  the  morbid  mass,  we 
are  obliged  to  follow  the  same  precept  and  include  all  the  diseased  portion 
between  two  incisions  which  should  always  comprise  a  certain  extent  of  the 
sound  parts.  On  the  whole,  it  is  better  to  remove  too  much  than  too  little, 
provided  enough  is  left  to  close  the  wound  immediately.  The  circular  in- 
cision, adopted  by  many  of  the  ancients,  and  by  Dionis  in  particular,  is  es- 
sentially defective.  It  forms  a  wound  extremely  difficult  to  cicatrize,  and 
the  loss  of  substance  which  it  occasions  is  much  more  considerable  than  in 
any  other  mode  of  operating.  The  elliptical  incision  used  by  Paulus  iEgineta, 


502  NEW  ELEMENTS  OF 

and  since  by  Cheselden,  &c.,  is  the  best  of  all.  The  crucial  incision,  pre- 
ferred by  Palfjn  and  Heister,  the  T  incision  used  by  Acrel,  and  even  by  Cho- 
part,  are  evidently  less  advantageous,  and  are  adapted  only  to  particular  cases. 
Some,  with  Gahrliep  and  Sir  Ch.  Bell,  make  the  great  diameter  of  this  in- 
cision vertical ;  others,  with  Desault,  transvere,  while  the  precept  of  Pim- 
pernelle,  laid  down  by  Verduc,  which  consists  in  directing  it  obliquely  from 
above  downwards,  and  from  without  inwards,  that  is,  in  the  direction  of  the 
fibres  of  the  pectoralis  major,  is  generally  followed  by  the  moderns. 

The  advantage  of  being  better  able  to  apply  the  means  of  union  in  the  first 
case,  is  more  than  compensated  by  the  risk  of  cutting  perpendicularly  tlie 
muscular  fibres,  and  of  finding  difficulty  in  bringing  outwards  the  sternal 
portion  of  the  integuments.  The  second  process  is  liable  to  the  same  incon- 
veniences without  offering  the  same  advantages.  Consequently  the  oblique 
incision,  which  permits  as  well  as  any  other,  the  use  of  the  strips,  and 
which  leaves  untouched  the  facia  of  the  pectoralis  major,  or  at  least  divides 
it  only  in  its  longitudinal  direction,  deserves  the  preference  which  is  now 
generally  given  to  it.  Strictly  speaking,  any  cutting  instruments  will  serve 
for  this  operation;  a  razor  or  amputating  knife  would  do  in  case  of  necessity. 
The  bistoury,  with  a  broad  square  point,  invented  by  M.  Dubois  for  the 
purpose  of  more  certainly  avoiding  the  chest,  is  not  of  more  or  less  value  than 
any  other.  The  common  straight  bistoury,  or  better,  the  convex  bistoury,  is 
what  is  commonly  used.  To  prevent  the  blood  which  flows  from  the  first 
incision  from  impeding  the  execution  of  the  second,  surgeons  begin,  as. 
directed  by  Palfyn  and  Desault,  with  the  inferior.  Yet  there  is  an  advantage 
after  division  of  the  integuments,  in  dissecting  the  tumor  from  above  down- 
wards. In  the  other  direction,  the  inferior  or  external  edge  of  the  pectoralis 
major  would  be  much  more  exposed  t6  the  knife.  For  the  rest,  no  one  now 
regards  the  advice  of  Home,  Lapeyronie,  and  Le  Dran,  to  begin  with  a 
crescentic  incision,  and  not  complete  the  ellipse  which  the  wound  is  to  represent 
until  after  having  detached  the  cancer,  proceeding  all  the  time  in  the  same 
direction,  and  then  to  cut  through  the  skin  from  within  outwards.  This 
mode,  however,  has  no  other  defect  than  of  rendering  the  end  of  the  ope- 
ration a  little  less  regular,  and  being  likely  to  remove  too  much  or  too  little  of 
the  cutaneous  covering.  When  the  loss  of  substance  is  considerable,  so  as^ 
to  render  the  coaptation  of  the  division  impossible,  or  at  least  very  difficult, 
M.  Lisfranc  proposes  to  insulate  each  margin  of  the  wound  from  the  parts 
beneath  for  one  or  more  inches,  in  the  hope  of  thus  removing  every  obstacle 
to  their  approximation.  This  is  a  modification,  the  full  value  of  which  I 
believe  has  not  been  felt  till  now.  By  this  means  enough  skin  is  always 
found  to  cover  immediately  the  solution  of  continuity.  The  integuments  are 
then  borrowed  from  the  surrounding  parts  as  in  the  cheiloplasmus,  and  this 
must  be  a  valuable  resource  when  it  is  necessary  to  remove  a  great  portion  of 
the  tegumentary  envelope.  The  arterial  branches  which  are  divided  belong 
to  the  external  inammary,  the  superior  thoracic,  the  internal  mammary,  or 
the  intercostal  arteries.  It  is  always  towards  the  outer  side  that  the  largest 
are  founds  which  are  first  to  be  attended  to.  By  casting  a  ligature  about 
them  as  soon  as  they  are  opened  there  is  no  fear  of  their  retracting  and  being 
lost  in  the  tissues,  nor  that  the  action  of  the  air  will  prevent  their  being  found 
afterwards ;  but  the  operation  becomes  thereby  much  more  tedious  and  pro- 


OPERATIVE    SURGERY.  503 

longed.  If  they  are  not  too  numerous  nor  very  large,  I  prefer  that  an 
assistant  should  close  them  with  his  fingers  as  soon  as  divided.  If  after 
cleansing  the  wound  some  remain  which  cannot  be  found  they  are  commonly 
too  small  to  cause  any  uneasiness.  Moreover,  in  the  opposite  case  it  would 
be  easy  to  establish  mediate  or  immediate  compression  over  them,  so  that 
on  this  point  there  is  really  little  cause  for  apprehension.  When  the  wound 
is  to  be  healed  by  the  first*  intention,  ligatures  are  not  always  indispensable. 
Theden  never  applied  them.  Petit  and  Le  Dran  usually  dispensed  with  them. 
D'Arce  and  Vanhorne,  who  also  omitted  them,  extracted  the  tumor  with  the 
fingers,  and  only  used  the  bistoury  for  dividing  the  integuments.  I  dispensed 
wiSi  them  upon  a  strong  and  plethoric  young  woman  from  whom  I  had  just 
removed  a  scirrhous  mass  as  large  as  the  fist.  Prudence,  however,  requires 
that  all  that  can  be  seen  should  be  tied  or  twisted,  and  that  if  any  escape  the 
eye  of  the  surgeon,  the  dressings  should  be  watched  attentively  for  a  day 
or  two.  The  precaution  of  not  definitively  dressing  the  wound  until  after 
several  hours,  so  as  to  give  time  for  the  eccentric  action  of  the  vascular 
system  to  be  re-established,  and  thus  discover  the  arterial  mouths  which  it  is 
necessary  to  close,  has  the  serious  disadvantage  of  annoying  the  patient 
greatly,  and  to  say  the  least,  of  being  unnecessary.  At  present  it  would  be 
ridiculous  and  cruel  to  dissect,  as  has  been  advised,  and  excise  afterwards  all 
the  veins  which  go  to  the  breast,  or  merely  to  squeeze  them  with  the  fingers  to 
drive  out  the  black  or  atrabiliary  humor,  so  much  dreaded  by  the  ancients. 
Immediate  union,  advised  by  Paul  and  Gahrliep,  praised  by  Nannoni,  who 
confined  himself  to  bringing  the  lips  of  the  wound  together ;  by  Cheselden 
and  Garengeot,  who  used  the  suture,  and  which  almost  all  modems  have 
adopted,  has  nevertheless  still  some  opponents.  It  is  correctly  accused  of 
preventing  the  escape  of  matter  if  it  form  at  the  bottom  of  the  wound ;  of  being 
frequently  followed  by  phlegmonous  erysipelas,  and  therefore  of  endangering 
in  a  high  degree  the  success  of  the  operation.  These  accidents,  formidable 
especially  to  such  women  as  are  large  or  cacochymic,  would  be  most  frequently 
avoided  if  no  vacancy  were  left  at  the  bottom  of  the  wound,  if  coaptation 
Were  more  exact  near  the  muscles  than  towards  the  skin,  if  the  strips  should 
act  principally  on  the  deep  parts,  and  not  on  the  skin  alone,  and  if  care  were 
taken  to  preserve  an  issue  at  the  most  depending  point  for  the  passage  of  the 
fluids.  For  the  rest  as  it  is  almost  impossible  to  obtain  completely  immediate 
union  (I  succeeded  once,  upon  a  man ;  I  had  but  one  artery  to  twist  and  the 
scirrhus  did  not  exceed  a  small  egg  in  size),  perhaps  it  would  be  wiser  to  treat 
the  wound  by  what  may  be  called  secondary  immediate  union.  The  cure  would 
not  be  sensibly  retarded,  and  the  patient  would  have  none  of  these  dangers  to 
encounter.  As  to  the  suture,  although  earnestly  recommended  anew  by  M. 
Serre,  I  cannot  dare  to  advise  its  use  in  this  place  until  having  seen  more 
fortunate  and  conclusive  results  than  those  yet  furnished.  It  evidently  ren- 
ders the  operation  more  painful,  and  except  some  cases  in  which  the  skin 
being  thin  and  dissected  up  tends  to  roll  upon  itself,  strips  or  the  simple 
bandage  will  fully  serve  the  purpose.  Since  without  it  a  difinitive  cure 
may  take  place  in  from  ten  to  twenty  days,  I  cannot  see  in  what  consist  it» 
advantages. 

ManuaL — Although,  according  to  the  custom  of  many  practitioners,  the 
patient  may  be  seated  in  a  chair  during  the  operation,  there  are,  neverthe- 
less, incontestable  advantages  in  a  recumbent  position  on  a  bed  or  operating 


504 


NEW    ELEMENTS    OF 


table.  Syncopes  are  then  less  to  be  apprehended,  and  in  reality  the  surgeon 
is  more  at  his  ease.  The  head  and  chest  are  kept  sufficiently  elevated  to 
render  the  breast  as  prominent  as  possible.  The  cushion  which  Bidloo  placed 
in  the  axilla  to  push  the  gland  forwards  while  the  arm  is  drawn  backwards 
would  not  deserve  mention,  if  Mr.  S.  Cooper  had  not  advised  a  precaution 
somewhat  similar  and  no  less  strange ;  he  directs,  in  order  to  keep  the  arm 
from  the  body,  to  govern  the  motions  of  the  patient  and  to  stretch  the  pecto- 
ralis  major,  that  a  stick  be  placed  in  the  axillary  hollow  on  each  side  between 
the  body  and  the  arm !  An  assistant  raises  the  tumor  with  one  hand,  and 
with  the  other  sponges  the  wound.  The  surgeon  drawing  the  skin  in  the  oppo- 
site direction,  begins  with  the  inferior  semi-lunar  incision,  depresses  the 
mass  to  be  removed,  causes  the  integuments  to  be  stretched  from  above; 
and  performs  the  superior  incision,  beginning  at  the  external  angle  of 
the  first  wound  and  carrying  it  to  its  other  extremity,  and  thus  com- 
pletes his  ellipsis;  takes  hold  of  the  scirrhus  or  directs  it  to  be  done, 
dissects  it  largely  first  from  below  upwards,  then  from  above  downwards,  and 
so  conducts  the  operation  that  the  diseased  gland  shall  be  surrounded  with 
sound  tissues,  and  not  be  removed  alone ;  goes,  or  should  not  fear  to  go^  as 
deep  as  the  fleshy  fibres,  and  even  to  the  osseous  arches  of  the  breast  if  the 
disease  extend  so  deeply.  If  he  does  not  tie  the  arteries,  as  I  prefer  at  least 
when  they  are  not  too  large,  he  orders  them  to  be  pressed  with  the  finger  as  they 
are  divided  by  the  bistoury,  and  may  thus  finish  in  a  few  seconds  the  extirpation 
of  the  largest  breast.  If  some  morbid  portions  escape  the  instrument  at  first 
they  should  be  removed  afterwards  without  hesitation.  When  belonging  to 
the  soft  parts  they  are  brought  away  by  the  knife  or  scissors.  If  the  bones 
be  affected  a  rugine  may  be  necessary.  Having  gone  thus  far  we  should  not 
shrink  from  removing  one  or  more  portions  of  the  ribs,  if  their  excision  appear 
to  destroy  all  the  disease;  but  if,  before  commencing,  this  necessity  be  indi- 
cated by  any  sign,  it  will  be  better,  in  my  opinion,  not  to  attempt  the  operation. 
If  any  tumors  exist  in  the  axilla,  which  create  apprehension,  they  are  to  be 
laid  bare  when  not  too  distant,  by  prolonging  thus  far  the  external  angle  of 
the  wound.  In  the  contrary  case  it  is  better  to  dissect  them  out  by  separate  ^ 
incisions.  Their  situation  although  capable  of  exciting  fear  at  first  sight  " 
permits  their  extirpation  in  almost  every  case  without  the  least  danger.  They 
are  in  fact  almost  constantly  found  on  the  external  face  of  the  serratus  magnus, 
so  that  to  keep  out  of  the  way  the  brachial  plexus,  it  is  sufficient  to  raise  the 
arm  and  hold  it  from  the  body.  Nothing  is  easier,  therefore,  when  the  wounding 
of  any  large  vessels  is  dreaded,  than  to  pass  a  ligature  round  the  pedicle, 
after  properly  insulating  them,  and  then  cut  them  without  the  knot.  This 
practice,  which  is  advised  by  J.  L.  Petit  and  Desault,  and  adopted  by  Zang, 
Dupuytren,  and  Lisfranc,  ought  to  be  retained.  As  to  opening  the  veins,  it 
is  rarely  troublesome  with  regard  to  hemorrhage.  I  have  seen  M.  Roux  wound 
the  axillary  vein  itself  in  this  operation,  and  plugging  was  enough  for  any 
return  of  the  effusion  of  blood.  Having  cleansed  the  wound  and  surrounding 
parts,  if  immediate  union  is  to  be  attempted,  the  operator  gently  approximates 
the  sides  of  the  disunion,  and  preserves  them  carefully  in  contact  with  the 
thumb  and  index  finger  of  each  hand,  while  an  assistant  applies  the  adhesive 
strips.  In  general,  the  longer  the  strips  the  better.  When  spread  over  a 
large  surface  their  action  is  less  felt  towards  the  division  of  the  skin,  and 
keep  in  place  much  better  than  if  short  and  more  numerous    Some  persons 


OPERATIVE    SURGERY.  505 

of  great  merit,  however,  maintain  the  contrary;  and  professor  A.  H.  Stevens, 
of  New  York,  among  others  directs  tliem  to  be  as  short  as  possible.  They 
should  cross  the  wound  at  riglit  angles.  When  the  loss  of  substance  is  con- 
siderable, or  when  the  integuments  are  with  difficulty  brought  in  coaptation, 
there  is  an  advantage  in  fixing  them  behind  the  sound  shoulder,  and  bringing 
them  over  the  clavicle,  carrying  them  belov/  the  axilla  towards  the  flank  of 
the  diseased  side ;  the  middle  one  is  first  applied,  and  those  of  the  ends  the 
iast.  Their  number  must  necessarily  vary  according  to  the  extent  of  the 
wound,  over  which  they  should  form  n'^grillage  quite  close,  whenever  a 
primitive  adhesion  is  desired,  otherwise  it  is  but  to  leave  considerable  spaces 
between  them,  that  the  pus  or  other  fluids,  if  any  be  produced,  may  not  be 
retained.  A  pledget  of  lint  spread  with  cerate,  one  or  two  dossils  of  dry 
charpie  supported  by  a  body  bandage,  or  circular  turns  of  a  long  bandage 
passed  once  or  twice  around  the  shoulders,  complete  the  apparatus,  and  the 
patient  may  be  immediately  put  to  bed.  When  immediate  union  is  impracti- 
cable or  is  not  desired,  the  plaster  strips  are  usually  unnecessary.  The  wound 
is  covered  with  strips  of  linen  spread  with  cerate,  or  a  fine  cloth  oiled  and 
pierced  with  holes,  so  that  the  charpie  which  is  placed  above  may  be  easily 
removed  from  the  first  dressing.  If,  afterwards,  the  least  vegetation  or 
tubercle  of  a  doubtful  nature  manifest  itself,  its  destruction  should  be  effected 
without  hesitation,  and  as  promptly  as  possible,  either  with  the  knife,  fire, 
arsenical  paste  or  other  caustic,  as  advised  by  De  la  Poterie,  F.  Come,  Dubois, 
Patrix,  &c.  Cancers  which  admit  the  least  hope  on  this  subject,  belong  to 
the  cerebriform,  melanare,  and  scirrhous  tissues.  Those  which  seem,  and 
really  do  extend  into  the  surrounding  cellular  tissue  by  a  number  of  diverging 
xatiii  or  roots,  are  the  most  formidable  of  all,  and  rarely  fail  to  return ;  while 
the  extirpation  of  colloid,  hydatiform,  encysted  and  tuberculous  cancers,  are, 
on  the  contrary,  most  frequently  followed  by  a  radical  cure. 

«5r/.  2. — Extirpation  of  Tumors  of  the  Axilla. 

Masses,  cancerous  or  not,  may  be  developed  in  the  axilla  without  disease  of 
the  breast,  as  well  in  man  as  in  woman,  and  there  acquire  an  enormous  size, 
so  as  to  be  destroyed  only  by  extirpation.  I  have  published  several  remark- 
able cases,  and  M.  Goyraux,  has  just  related  another  not  less  so.  Whenever 
they  may  be  removed  entire  by  the  base,  it  should  be  done  as  in  extirpation 
of  lupi  in  general.  If  the  clavicle  has  been  raised  up  and  the  pectoral  muscles 
extenuated  by  one  of  these  tumors,  it  is  to  be  attacked  on  its  anterior  face  as 
was  done  by  myself  in  the  case  of  a  young  woman  twenty-four  years  old,  at 
the  hospital  of  Improvement  in  1828.  One  of  the  branches  of  a  crucial 
incision,  directed  from  the  internal  third  of  the  clavicle,  to  the  posterior  edge 
of  the  axilla  divided  the  whole  thickness  of  the  pectoralis  major  and  minor 
muscles.  I  was  obliged  to  dissect  the  whole  brachial  plexus,  and  to  lay  bare 
the  principal  artery  to  the  extent  of  two  inches,  to  follow  even  into  the  sub- 
clavicular hollow,  and  insulate,  as  well  with  the  fingers  as  with  the  bistoury, 
the  morbid  production,  which  in  size  equalled  at  least  the  size  of  the  head  of 
a  new-born  child.  For  those  which  have  acquired  less  volume  and  retain 
their  mobility,  we  are  to  act  in  the  manner  just  laid  down  for  scirrhus  of  the 
mamella,  complicated  with  swellings  of  the  axilla.  What  I  have  advanced  in 
64 


506  NEW  ELEMENTS  OF 

regard  to  the  dangers  of  the  introduction  of  air  into  the  circulatory  passages 
and  wounds  of  the  veins,  in  speaking  of  extirpation  of  the  goitre,  being  equally 
applicable  here  it  is  not  necessary  to  revert  to  it. 


SECTION  II. 

Effusions. 

»Brt,  1. — Ejnpyema. 
Practised  since  the  highest  antiquity,  the  operation  for  empyema  owes  its 
origin,  according  to  fabulous  history,  to  the  despair  of  a  certain  Phales  or 
Jason,  who,  seeking  death  in  the  midst  of  battle,  received  a  lance  wound  in 
the  breast,  and  was  thus  cured  of  an  empyema  of  which  no  one  would  under- 
take the  cure.  Galen  asserts  that  it  was  performed  in  Greece  by  plunging 
a  red  hot  iron  into  the  thorax.  After  being  assured  of  the  existence  of  the 
collection,  at  the  time  of  Hippocrates,  one  of  the  last  intercostal  spaces  was 
opened  with  the  bistoury  or  a  lancet  wrapped  with  linen  to  within  a  certain 
distance  of  the  point.  For  fear  of  evacuating  too  quickly  all  the  morbid  matter, 
others  perforated  the  fourth  rib  with  a  trepan,  and  then  closed  the  opening 
with  a  plug  or  tent.  The  Arabians  seem  to  have  acted  on  this  point  in  the 
saifte  manner  as  the  Greeks  and  Romans.  With  all,  we  find  that  the  ope- 
ration for  empyema,  which  was  at  first  recommended  and  employed  without 
repugnance  by  most  practitioners,  in  the  end  was  recommended  by  none. 
Paulus  Egineta,  among  the  first,  directs  in  its  place  cauterization  of  the  thorax, 
and  Aly  Abbas,  among  the  second,  formally  rejects  it.  G.de  Salicet  and  Guy 
de  Chauliac,  mention  it  with  extreme  timidity.  A  Benedetti,  I.  de  Vigo,  and  A. 
Pare,  succeeded  in  raising  it  but  for  a  moment  from  the  discredit  into  which  it  had 
fallen,  and  it  required  no  less  than  all  the  efforts  of  J.  Fabricius  to  bring  it 
again  into  repute;  so  that  in  reality,  it  is  only  since  the  last  two  centuries  that 
its  advantages  and  disadvantages  have  been  discussed,  and  that  it  has  again 
fixed  the  attention  of  surgeons.  At  present  it  is  rarely  used,  perhaps  too 
rarely;  and  it  is  yet  to  be  demonstrated,  whether  the  kind  of  anathema  which 
the  moderns  have  hurled  against  it  be  legitimate  and  just  in  all  its  points. 

Sanguineous  Effusion, — Whether  the  blood  which  accumulates  in  the 
pleurae  be  given  out  by  the  intercostal  arteries  or  the  deep  vessels,  whether 
it  come  from  a  traumatic  lesion,  a  penetrating  wound  of  the  chest,  or  a 
spontaneous  rupture,  whether  it  be  arterial  or  venous,  the  dangers  which, 
result,  and  the  assistance  to  be  rendered,  are  in  all  cases  nearly  the  same. 
The  advice  of  the  ancients,  who  direct  the  immediate  removal  of  the  ex- 
travasated  fluid,  either  by  placing  the  patient  on  the  wounded  side,  or  by 
enlarging  the  wound,  or  by  using  the  mouth,  a  cupping  glass,  or  syringe,  to 
pump  it  out — an  advice  generally  followed  even  until  of  late — far  from  being 
advantageous,  appears  on  the  contrary  to  be  extremely  objectionable.  The 
injured  vessels  cannot  be  obliterated  and  closed,  except  under  the  influence 
of  coagula  more  or  less  solid,  and  of  some  compression.  If,  instead  of  being 
retained  within  the  chest,  the  blood  escape,  this  compression  will  not  be 
established  by  coagula,  and  the  hemorrhage  will  only  end  in  death.  Reason 
therefore  prompts  to  close  immediately  the  wounds  of  the  chest  instead  of 


OPERATIVE    SURGERY.  507 

dilating  them ;  to  imprison  in  the  interior  the  extravasated  fluid,  instead  of 
procuring  it  an  issue.  If  the  extravasation  is  inconsidei'kble,  absorption  will 
most  commonly  remove  it;  in  the  contrary  case  its  source  can  only  be  stopped 
by  its  own  presence — :by  the  mechanical  reaction  which  it  exerts  upon  the 
wounded  organs ;  so  that  the  operation  for  empyema  belongs  in  no  manner 
to  recent  traumatic  hemorrhages  of  the  thorax.  Some  facts  collected  from 
the  time  of  Vigo  and  Pare,  a  passage  of  Francois  d'Arce,  another  of  G.  Horst, 
the  words  of  Sharp,  and  especially  of  Valentine,  ought  to  have  pointed  out  the 
way  to  this  truth ;  but  it  was  reserved  for  A.  Petit,  and  M.  Larrey  to 
demonstrate  it  and  gain  the  admission  as  a  principle  by  all  modern  surgeons, 
that  the  first  indication  in  penetrating  wounds  of  the  chest,  with  or  without 
extravasation,  is  to  close  them  immediately.  If  in  the  end  the  organism, 
aided  by  a  well  directed  general  treatment,  continues  unable  to  remove  the 
morbid  collection;  if  when  the  wounded  vessels  have  had  time  to  become 
obliterated  this  collection  threatens  of  itself  serious  accidents,  it  is  then 
proper,  but  only  then,  to  have  recourse  to  the  operation,  and  to  make  what  is 
called  a  counter-opening. 

Effusions  of  Pus. — As  purulent  collections  in  the  chest  are  far  from  being 
always  the  principal  disease,  the  operation  for  empyema  is,  in  its  turn,  far 
from  being  always  of  great  assistance  in  the  case.  If  the  cause  is  ascertained 
to  be  a  tuberculous  vomica  or  any  other  incurable  lesion  of  the  pulmonary 
organ,  or  an  extensive  alteration  still  existing  of  the  heart  or  pleurss,  the 
opening  of  an  issue  only  hastens  the  end  of  the  patient.  If,  on  the  contrary, 
the  collection  is  the  consequence  of  a  simple  phlegmasia,  a  pleurisy  for 
example;  an  abscess  in  the  lungs  opening  into  the  pleura — in  a  word,  if  after 
removing  the  pus,  we  can  hope  to  stop  its  source,  the  operation  offers  some 
chance  of  success  and  oug-ht  to  be  tried,  if  nothino;  in  the  general  condition  of 
the  patient  contra-indicate  it.  A  peasant  from  the  neighborhood  of  Tours, 
operated  on  under  these  circumstances,  in  1814,  by  M.  Gouraud,  was  per- 
fectly restored.  In  the  cases  to  which  it  applies,  the  extravasation  approaches 
the  nature  of  an  external  abscess.  The  organism  has,  most  frequently,  taken 
care  to  surround  it  with  adhesions  which  more  or  less  circumscribe  its  limits ; 
so  that,  after  the  opening  is  made,  there  is  nothing  to  fear  from  contact  of  the 
air  with  the  rest  of  the  pleura.  In  proportion  as  it  is  emptied,  its  parietes  can 
gradually  close  upon  themselves,  and  soon  entirely  obliterate  it.  The  same 
remark  may  be  applied  to  sanguineous  effusions,  which  in  the  end  are  almost 
always  crowded  into  a  space  more  or  less  contracted,  under  the  influence  of 
adhesive  inflammation  of  the  surrounding  surfaces. 

Serous  Effusions. — Serum  does  not  give  the  same  chances  of  success.  The 
surfaces  which  furnish  it  are  not  sufficiently  irritated,  at  least  generally,  to 
contract  mutual  adhesion.  The  lungs  somewhat  compressed  towards  its  root, 
is  then  incapable  of  resuming  its  natural  dimensions;  and  the  chest,  once 
opened,  brings  the  whole  extent  of  the  pleura  in  contact  with  the  atmosphere, 
so  that  in  such  a  case  many  experienced  surgeons  inject  even  the  idea  of  an 
operation.  However,  if  all  the  means  which  reason  and  experience  indicate 
have  been  tried  in  vain,  if  it  is  not  certain  that  an  incurable  organic  lesion  is 
the  cause  of  the  extravasation,  and  if  alarming  symptoms  such  as  those  of  suf- 
focation threaten  the  life  of  the  patient,  the  operation  for  empyema  is  a  last 
resort,  which  it  would  be  inhuman  not  to  attempt.    M.  Gouraud,  who  ably 


508  NEW    ELEMENTS   OF 

defends  this  hypothesis,  obtained  by  it  a  remarkable  success  in  1808,  and  in 
scientific  compilations  are  found  here  and  there  some  other  examples.  The 
artificial  subtraction  of  a  part  of  the  extravasated  fluid  excites  in  such  a 
degree  absorption  in  the  pectoral  cavity,  that  a  number  of  practitioners  have 
thought  it  should  become  a  precept  that  the  operation  for  empyema  should  follow 
pleurisies  when  resolution  cannot  be  expected.  The  patient  mentioned  by 
M.  Martin  Solon,  who  is  one  of  its  declared  partisans,  died.  The  same  was 
the  case  with  a  patient  operated  on  in  1830,  at  La  Charite,  and  with  another 
whose  thorax  was  opened  at  the  hospital  St.  Antoine,  during  my  period  of 
service. 

Effusions  of  Gas, — The  presence  of  air  or  gas  in  the  interior  of  the  pleurae, 
which  so  many  physicians  have  found  there  since  M.Ttard  made  it  the  sub- 
ject of  an  interesting  work,  whether  owing  to  the  rupture  of  a  pulmonary 
cell,  to  the  decomposition  of  certain  liquids,  or  to  a  pure  and  simple  exha- 
lation, is  however  one  of  the  circumstances  which  may  in  strictness  require 
perforation  of  the  thorax.  Riolan  and  H.  Bass  have  had  proof  of  it  in  patients 
whose  chests,  instead  of  pus  which  they  expected  to  find,  contained  in  reality 
only  air.  The  researches  of  A.  Monro,  of  Gooch,  and  particularly  of  Hew- 
son,  leave  not  the  least  doubt  on  the  subject.  But  it  must  not  be  forgotten 
that  it  is  a  symptom  not  serious  of  itself,  and  capable  of  spontaneously  dis- 
appearing, and  that  if  it  is  coincident  with  profound  organic  alteration,  the 
operation  for  empyema  will  only  have  a  momentary  triumph.  Although  a 
mere  palliative  in  the  majority  of  cases,  perforation  of  the  thorax  will  yet 
sometimes  effect  a  complete  cure.  If  formerly  it  was  frequently  performed 
without  necessity,  it  appears  to  me  that  at  present  we  have  fallen  into  the 
opposite  fault,  in  too  generally  proscribing  its  use. 

Operation, — The  dangers  that  attend  it  are  easy  to  be  conceived.  If  the 
lung,  a  long  time  compressed,  has  not  lost  its  natural  permeability,  the  air 
rushes  in  with  force  immediately  after  the  substraction  of  the  effused  fluid, 
and  may  thus  become  the  cause  of  irritation  or  violent  inflammation.  Sup- 
posing this  organ  to  be  so  compressed  as  to  yield  only  gently  to  the 
mechanical  action  of  the  atmosphere,  the  kind  of  vacuum  which  is  formed 
immediately  around  parts  which  have  been  exactly  sustained  until  then, 
necessarily  disturbs  pectoral  circulation  and  respiration.  Without  being 
injurious  or  irritating  of  itself,  as  many  authors  still  admit,  yet  the  air  most 
commonly  exerts  a  dangerous  influence  over  the  sequelse  of  the  disease. 
Introduced  into  the  chest  through  an  opening  generally  very  small,  it  becomes 
warm  and  mingles  with  the  morbid  deposite  which  covers  or  bathes  the  pleura, 
combines  by  mutual  decomposition  with  the  remaining  effused  fluid,  which 
quickly  assumes  an  acrid  and  putrid  character  which  is  foreign  to  it,  the 
action  of  which  is  but  ill  borne  by  the  organism.  It  is  this  new  substance 
and  not  the  air  which  inflames  the  environs  of  the  disease,  and  produces  gene- 
ral reaction,  sometimes  very  intense  and  too  frequently  fatal ;  it  is  this  also, 
which  penetrating  in  greater  or  less  proportion  into  the  mass  of  circulating 
fluids,  infects  them  and  gives  rise  to  those  adynamic  phenomena,  of  which  a 
number  of  unfortunate  patients  thus  treated  are  the  victims.  The  danger 
will  then  be  in  proportion  to  the  extent  of  the  parietes  of  the  collection,  the 
degree  of  exhaustion,  irritability,  strength,  and  vital  resistance  of  the  patient, 
and  also  influenced  by  the  nature  of  the  effused  fluids,  and  the  condition  of 


OPERATIVE    SURGERY.  509 

the  thoracic  organs.  Three  points  deserve  the  attention  of  the  surgeon  in  the 
operation  for  empyema;  1st,  the  place  in  the  chest  where  it  should  be  per- 
formed ;  2d,  the  instrument  most  proper  for  its  performance ;  and  Sdly,  the 
requisite  dressing. 

Place  of  Election.-^When  the  eifusionis  not  circumscribed  by  any  adhe- 
sions, and  the  pleurae  are  entirely  free,  it  is  advised  to  open  the  pectoral  cavity 
at  the  point  most  depending  and  most  favorable  to  the  issue  of  the  fluids,  and 
this  point  is  called  the  place  of  election.  When  the  collection  occupies  only 
one  portion  of  the  chest,  and  is  so  limited  that  neither  the  position  nor  the 
movements  of  the  patient  can  make  it  change  its  place,  the  opening  must  be 
made  on  a  determined  point,  and  this  is  called  the  place  of  necessity.  This 
has  never  varied,  and  cannot  according  to  the  whim  of  practitioners.  The 
other,  on  the  contrary,  being  an  affair  of  choice,  could  not  be  expected  to  be, 
and  in  reality  has  not  been,  the  same  with  all  surgeons.  Some,  with  F.  Wal- 
ther  for  instance,  have  fixed  it  in  the  fourth  intercostal  space,  counting  from 
above  downwards ;  others  in  the  fifth,  with  Leonidas  and  Fabricius  d'  Aqua- 
pendente ;  others  in  the  sixth,  with  Sharp,  B.  Bell,  &c. ;  and  Heers  directs  it 
to  be  in  the  seventh.  There  are  some,  who  like  G.  de  Salicet  and  Lanfranc 
prefer  the  eighth ;  others,  with  A.  Pare,  the  ninth.  Solingen  thinks  that  the 
tenth,  directed  by  A.  Lusitanus,  for  the  left  side,  and  the  ninth  for  the  right, 
are  best ;  in  fine,  Vesalius  and  Werner  say  that  the  eleventh  offers  the  most 
advantages. 

At  present  the  general  preference  is  given,  in  France  at  least,  to  the  third 
on  the  left,  and  the  fourth  on  the  right.  Lower  down,  the  diaphragm  and  the 
liver  may  be  wounded,  and  the  instrument  may  be  carried  into  the  peritoneum 
and  strike  below  the  collection ;  higher,  we  would  miss  the  most  depending 
point,  and  the  liquid  will  not  flow  with  the  desirable  facility.  To  these  rea- 
sons, it  is  true,  it  may  be  objected ;  first,  that  in  abundant  collections  the  dia- 
phragm, and  the  liver  with  it,  are  too  powerfully  forced  downwards  to  be 
injured  even  when  we  penetrate  between  the  second  and  third  rib,  secondly 
that  we  may  change  at  pleasure  the  depending  point  of  the  thorax  by  the 
position  given  to  the  patient,  and  that  in  this  point  of  view,  the  sixth  or  the 
ninth  intercostal  space  is  nearly  as  advantageous  as  the  third ;  but  as  there 
is  no  disadvantage  in  following  the  precept  established  amongst  us,  it  may  as 
well  be  conformed  to  as  another,  and  the  more  so  as  the  feelino:  of  suffocation 
which  habitually  torments  patients  affected  with  effusion  into  the  thorax,  ren- 
ders it  difiicult  for  them  to  use  any  other  than  a  sitting  Or  nearly  vertical 
posture.  I  do  not  see,  however,  why  we  should  be  confined  too  rigorously  to 
strike  rather  above  the  third  than  the  fourth  rib  when  tliere  is  any  difficulty 
in  distinguishing  them.  The  intercostal  space  being  once  determined,  it 
remains  to  decide  on  what  point  of  its  length  the  operation  is  to  be  performed. 
Neai'  the  sternum  the  internal  mammary  may  be  wounded ;  more  externally 
are  found  the  descending  and  anastomosing  branches  of  this  artery.  On  the 
side  of  the  spine  is  the  mass  of  the  sacro-lumbalis  and  longissimus  dorsi;  a 
little  further  on  the  side  of  the  trunk  tlie  intercostal  artery  being  as  yet 
uncovered,  and  unprotected  by  the  inferior  edge  of  the  rib,  may  be  easily 
opened.  It  is  therefore  with  reason  that  the  point  of  union  of  the  posterior 
third  with  the  anterior  two  thirds  of  the  pectoral  boundary  has  been  selected. 
There  the  opening  falls  in  front  of  the  latissimus  dorsi,  between  tlie  faciae  or 


510  NEW  ELEMENTS  OF 

digitation  of  the  serratus  magnus  and  the  obliqus  externus.  There  are 
only  the  integuments,  the  intercostal  muscles,  and  the  pleura,  to  be  divided. 
The  artery  lodged  in  the  costal  groove,  is  not  yet  bifurcated,  and  the  space  is 
sufficiently  large  to  admit  the  end  of  the  linger.  However  if  this  point  did 
not  offer  the  very  great  advantage  of  being  the  most  depending,  when  the 
patient  is  gently  inclined  to  one  side,  sitting,  or  lying,  there  would  be  little 
disadvantage  in  going  more  behind  or  to  the  front,  as  David  and  some  other 
practitioners  have  recommended.  Many  means  have  been  proposed  to  deter- 
mine exactly  the  position  of  the  third  intercostal  space.  If  the  patient  is 
lean  and  not  anasarcous,  the  ribs  may  be  counted  from  above  downwards,  but 
when  oedema  or  a  thick  layer  of  cellular  or  adipose  tissue  covers  the  bars  of 
the  thorax,  we  are  obliged  to  act  otherwise.  According  to  some,  when  the 
hand  of  the  patient  is  applied  in  front  of  the  sternum,  and  the  arm  hanging 
along  the  side  of  the  trunk,  the  elbow  pushed  a  little  back  corresponds  exactly 
to  the  space  sought  for.  This  mode  of  exploration,  besides  being  very 
incorrect,  is  more  proper  to  designate  the  space  between  the  last  two  ribs  than 
between  the  ninth  and  tenth,  and  that  which  consists  in  penetrating  into  the 
chest  at  six  fingers'  breadth  below  the  inferior  angle  of  the  scapula,  would  be 
much  more  certain  and  rational  if  such  a  determination  had  really  the  im- 
portance formerly  bestowed  upon  it. 

Formerly  it  was  an  affair  of  great  moment  to  mark  the  place  of  necessity  in 
the  operation  for  empyema.  If  no  tumor  be  manifest,  or  no  external  indica- 
tion ;  if  the  use  of  a  cataplasm,  which  should  dry  up  quickly  according  to 
some,  on  the  contrary  remain  humid  according  to  others,  opposite  the  effu- 
sion, indicate  nothing,  it  will  be  necessary  to  refer  to  the  feelings  expressed 
by  the  patient,  to  succussion,  or  perhaps  to  means  still  more  fallacious.  But 
the  labors  of  Avenbrugger,  of  Corvisart,  of  Laennec,  and  of  M.  Piorry  have 
happily  removed  this  uncertainty;  so  that  at  present  it  is  almost  as  easy  to 
detect  the  precise  seat  and  limits  of  disease  in  the  interior  of  the  chest  as  if 
they  were  on  the  surface  of  the  body. 

Instruments. — To  guard  against  hemorrhage,  or  to  obtain  a  wound  with  loss 
of  substance,  or  because  they  attributed  some  particular  virtues  to  escharotics, 
the  ancients  and  several  authors  of  the  middle  ages  frequently  employed 
caustics,  chemical  or  metallic,  for  opening  the  chest.  The  contemporaries  of 
Leonidas  employed  a  cautery  in  the  shape  of  a  fruit  stone.  Cinesius,  men 
tioned  by  Galen,  also  used  the  red  hot  iron.  That  of  Rhazes  was  fine  and 
pointed.  Albucasis  used  one  of  a  triangular  form.  A.  Pare  directed  it  to  be 
furnished  with  a  concave  plate  at  some  distance  from  its  point.  But  this 
method,  long  since  abandoned  by  the  moderns,  would  scarcely  deserve  men- 
tion if  it  had  not  been  extolled  by  M.  Gouraud,  who  applied  it  particularly 
to  collections  of  pus,  and  who  attributes  to  hot  iron  the  advantage  of  permit- 
ting the  abscess  to  empty  itself  after  the  eschar  comes  away;  and  to  the 
wound  that  of  opposing  the  entrance  of  air,  by  the  swelling  of  its  edges.  The 
scolopomachairion  of  Paulus  Egineta,  the  phlebotome  of  the  Arabians,  and 
the  sagitella  of  Arculanus,  which  were  formerly  used,  have  disappeared  from 
practice.  The  common  bistoury  and  the  trocar  now  supersede  all  other 
instruments  in  tapping  the  chest.  Although  Pare  proposed  the  punch  for 
paracentesis,  in  order  to  perforate  a  rib  in  preference  to  an  intercostal  space, 
yet  it  has  only  been  since  Drouin  and  Nuck  that  attention  has  been  really 


./ 


OPERATIVE    SURGERY.  511 

directed  to  this  point.  Dionis,  Heister,  and  particularly  Morand,  have 
pleaded  the  cause  of  the  trocar,  which  still  reckons  many  partisans,  and  has 
the  advantage  of  rendering  the  operation  easy,  prompt,  and  but  little  painful, 
and  the  entrance  of  air  almost  impossible ;  of  not  forcing  the  collection  to  be 
emptied  at  once,  and  in  fine,  of  allowing  a  great  number  of  punctures  in  cases  in 
which  they  may  be  deemed  necessary.  But  as  its  canula  has  the  disadvantage 
of  not  always  giving  free  issue  to  matters  of  some  consistence,  such  as  grumous 
pus  and  blood  partly  coagulated,  it  is  far  from  suiting  every  case  indiscrimi- 
nately. Thus  it  is  not  generally  preferred  except  in  hydrothorax,  and  exten- 
sive pleuritic  effusions.  But  there  is  nothing  to  prevent  a  small  puncture 
from  being  transformed  into  a  large  wound  immediately,  if  the  liquid  does 
not  flow  readily  at  first;  and  I  cannot  see  why  the  lung  or  the  diaphragm  runs 
more  risk  of  being  wounded  with  this  instrument  than  with  any  other. 
Paracentesis  of  the  chest  is  in  other  respects  governed  by  the  same  rules  as 
paracentesis  abdominis,  of  which  we  shall  treat  hereafter. 

If  the  intention  of  the  operation  is  to  remedy  an  efiusion  of  air,  the  wound 
generally  requires  no  treatment.  In  the  other  cases  the  manner  of  proceeding 
is  not  so  clearly  laid  down.  In  truth,  the  pyulcon  of  Galen,  cupping  glasses, 
syringes,  and  suction  so  much  lauded  in  the  sixteenth  and  seventeenth  cen- 
tury, for  the  removal  of  the  very  last  particle  of  the  effused  fluid;  the 
various  species  of  canulae  for  a  long  time  used,  and  twice  by  Hey  to  prevent 
the  pleura  from  collapsing  too  soon,  and  for  emptying  the  chest  by  degrees, 
have  long  since  lost  nearly  all  their  reputation^  although  practitioners  still 
deliberate  whether  or  not  it  is  right  to  evacuate  at  once  the  seat  of  the  morbid 
collection,  to  keep  in  it  a  foreign  body  to  act  as  a  filter,  and  make  injections 
rather  than  heal  the  orifice  immediately.  Unless  the  lung  enjoy  all  its 
expansibility,  which  is  very  rare  in  hydrothorax,  there  is  undoubtedly  an 
advantage  in  letting  the  serosity  escape  but  little  at  a  time,  and  in  introducing 
a  strip  of  linen  or  a  tent  of  charpie  into  the  cavity  of  the  pleura,  so  that  at 
each  dressing  a  new  flow  may  be  produced.  When  the  case  is  an  empyema, 
properly  so  called,  or  is  an  effusion  of  blood,  this  tent  ought  not  to  be  neglected 
if  any  importance  is  attached  to  the  non-admission  of  air  into  the  cavity.  In 
other  respects,  the  rule  of  conduct  is  the  same  as  in  paracentesis  with  the 
trocar.  The  employment  of  injections  demands  all  the  solicitude  of  the  sur- 
geon. It  is  the  abuse  of  them  by  the  ancients  that  has  induced  the  moderns 
almost  generally  to  proscribe  them.  They  are  improper  in  hydrothorax  and 
in  effusions  which  are  not  bounded  by  any  adhesion.  In  oilier  cases,  on  the 
contrary,  their  advantages  cannot  be  contested.  As  soon  as  the  suppuration 
tends  to  become  corrupted,  they  alone  are  capable  of  preventing  adynamia 
and  decomposition  of  the  fluids,  by  cleansing  the  morbid  surface  and  bringing 
out  the  altered  matters  as  they  are  formed.  It  is  therefore  evident,  that  the 
precaution  of  raising  the  skin  while  perforating  the  intercostal  space,  in  order 
to  bring  at  different  heights  to  the  opening  of  the  pleura,  and  that  of  the  inte- 
guments, is  hardly  necessary,  and  far  from  deserving  the  importance  generally 
bestowed  upon  it  since  Bass  elevated  it  into  a  precept. 

Manual. — A  convex  bistoury,  a  straight  bistoury  or  a  trocar,  a  vessel  to 
receive  the  fluid,  a  strip  of  scraped  linen  a  yard  long  and  of  the  breadth  of  the 
finger,  several  pledgets  of  charpie,  compresses,  and  a  body  bandage,  together 
with  a  gum  elastic  canula  and  a  syringe,  are  all  the  objects  necessary.  ^  Seated 


512  NEW    ELEMENTS    OF 

on  his  bed,  rather  than  on  a  sofa  or  chair,  and  inclining  more  or  less  to  the 
right  side,  the  patient  is  kept  in  this  position  bj  assistants,  so  that  the  inter- 
costal space  to  be  opened  may  be  stretched  as  much  as  possible  and  quite  free. 
Placed  in  front  and  somewhat  to  the  right,  the  surgeon  stretches  tlie  skin  with 
his  left  hand,  and  with  a  bistoury  in  his  right  divides  it  parallel  witli  the 
superior  edge  of  the  lower  rib,  from  left  to  right  for  the  right  side,  but  in  the 
contrary  direction  for  the  left;  cuts  in  the  same  direction^  successively  layer 
by  layer,  the  adipose  tissue,  a  thin  laminse'of  cellular  substance,  the  external 
muscles  of  the  chest,  if  any  exist  at  the  point  selected,  and  the  external  and 
internal  intercostal  muscles;  having  arrived  at  the  pleura,  and  in  order  to 
pierce  it  without  fear  of  wounding  any  other  organ,  uses  only  the  point  of  tlie 
bistoury,  resting  with  its  back  on  the  end  of  the  left  index  finger  which  serves 
it  as  a  guide ;  gives  to  the  internal  opening  an  extent  of  from  six  lines  to  an 
inch,  and  thus  penetrates  into  the  interior  of  the  cavity  whence  the  fluid  is  seen 
immediately  to  flow.  If,  as  is  frequently  observed,  some  factitious  laminas 
are  attached  to  the  internal  surface  of  the  pleura,  there  is  so  much  the  less 
reason  for  stopping  at  this  difficulty,  as  we  may  in  strictness  penetrate  ever 
the  substance  of  the  lung  itself  if  the  seat  of  abscess  be  there.  The  point 
is  not  to  miss  the  morbid  sac.  Nevertheless,  in  the  case  where  this  point  may 
have  been  overlooked,  unless  the  matter  be  within  a  distance  which  permits 
us  to  feel  its  fluctuation  with  the  finger,  it  would  be  much  better  to  make  a 
second  opening  in  the  proper  place  than  to  break  down  the  surrounding  adhe- 
sions, either  with  the  finger,  the  handle  of  a  knife,  or  a  probe,  or  especially 
with  a  bladder  carried  empty  through  the  wound,  and  then  filled  with  air  or 
liquid  while  in  the  thorax,  which  was  recommended  by  some  old  writers. 

Process  of  the  Author. — The  motives  on  which  is  founded  the  perforation 
of  the  wall  of  the  thorax  with  so  much  preparation,  seem  to  me  unworthy  the 
sanction  they  have  received.  What  is  to  be  feared  from  penetrating  by  a 
single  thrust  into  the  pleura  .^  To  touch  the  lung.  But  this  accident  is  not 
possible  except  in  case  the  instrument  deviates  from  the  direction  of  the  dis- 
ease. Besides,  the  lung  is  free  and  sound  behind  the  wound,  and  then  the 
pleura  is  no  sooner  opened,  than  the  pressure  of  the  atmosphere  forces  it 
towards  the  spine,  unless  intimate  adhesions  unite  it  to  the  thoracic  parieties, 
and  in  this  case  what  danger  can  result  from  a  small  puncture  of  its  paren- 
chyma ?  I  think,  therefore,  that  the  operation  for  empyema  would  be  infinitely 
more  simple,-  and  equally  as  certain,  if  in  performing  it  we  were  to  pass 
through  suddenly,  and  without  hesitation,  the  intercostal  space  with  the  bis- 
toury held  in  the  second  or  third  position,  that  is  as  in  external  abscesses 
which  are  opened  from  within  outwards.  In  this  manner  will  be  united  in 
some  degree  the  advantages  of  paracentesis  with  those  of  incision,  and  the 
opening  of  the  chest,  which  at  first  sight  appears  so  formidable,  will  in  reality 
scarcely  deserve  the  title  of  an  operation. 

liemarks.-^l  designedly  omit  the  precept  of  those  who  direct  before  in- 
cision of  the  integuments  to  make  a  large  perpendicular  fold  of  them  over  the 
ribs,  instead  of  stretching  them  with  the  hand,  andof  others  who  have  thought 
the  incision  of  the  skin  should  be  perpendicular  and  not  horizontal.  It  is 
sufficient  to  mention  such  counsels  that  every  one  may  estimate  tliem  at  their 
proper  value.  I  will  say  still  less  of  the  method  of  Mercati,  which  consistecl 
iu  penetrating  only  to  the  pleura  M'ithout  touching  it,  that  the  fluid  itself 


OPERATIVE    5URGEKY.  5 IS 

might  cotnplete  the  perforation.  It  would  be  equally  puerile  to  finish  the  opera- 
tion with  the  lancet  after  using  a  bistoury  for  commencing  it.  The  intention  is, 
to  arrive  surely  and  without  danger  within  the  pathological  limits.  Nothing 
can  present  less  difficulty,  and  this  is  certainly  not  the  reason  why  the  operation 
for  empyema  should  appear  so  formidable.  An  effusion,  considerable  enough  to 
require  surgical  aid,  would  destroy  the  patient  if  it  existed  on  both  sides  at 
once  before  we  could  think  of  the  operation.  On  a  contrary  supposition  we 
must  follow  the  advice  given  formerly  by  A.  Benedetti,  to  open  the  two  la- 
minae of  the  pleura,  with  an  interval  of  several  days,  and  to  take  all  necessarj 
precaution  to  prevent  collapse,  and  shrinking  of  the  lungs.  If  the  operator 
does  not  wish  the  wound  to  remain  open,  he  brings  its  lips  together  when 
there  is  nothing  more  to  be  extracted  from  the  seat  of  disease ;  keeps  them 
In  contact  by  a  strip  of  diachylon ;  covers  it  then  with  charpie;  afterwards  a 
compress ;  and  fixes  the  whole  with  a  body- bandage  moderately  tight.  If  he 
has  not  removed  the  whole  of  the  matter,  a  flat  dressing  with  charpie  spread 
with  cerate  is  ordinarily  sufficient  to  obviate  the  too  speedy  adhesion  of  the 
edges  of  the  perforation.  To  be  more  at  ease  on  this  point,  however,  there  is 
nothing  to  prevent  the  insertion  in  the  solution  of  continuity  with  the  poHe- 
meche,  of  a  little  cone  of  charpie,  or  one  of  the  extremities  of  the  linen  band 
prepared  for  this  purpose ;  for  the  rest  every  thing  is  conducted  as  above. 
The  tents,  which  were  formerly  employed  for  the  same  end,  and  which  vvcre 
fastened  without  by  means  of  a  thread,  besides  the  inconvenience  of  formin<j; 
a  stopper,  were  also  liable  to  escape  into  the  morbid  cavity  and  be  there  lost, 
an  example  of  which  is  given  by  Guy.  As  long  as  the  fluids  which  are  dis- 
charged at  each  dressing  preserve  their  primitive  character,  and  do  not 
deteriorate,  injections  will  only  be  injurious.  On  the  contrary,  we  should 
iiave  recourse  to  them  when  the  least  change  is  manifest.  In  this  respect, 
v/arm  water,  at  first  honied  barley  water,  weak  lime  water,  then  lead  water,  or  a 
weak  decoction  of  kino,  are  to  be  successively  or  alternately  tried,  as  well  as  any 
other  detersive,  astringent,  or  antiseptic  fluids,  which  the  practitioner  may 
choose  according  to  the  indications.  M.  Bache  affirms  that  this  method,  long 
since  adopted  in  the  hospital  of  Grenoble  by  M.  Billery,  who  besides  was  in  the 
habit  of  closing  the  wound  with  a  plug  of  gentian  in  the  interval  of  the  dressings^ 
was  often  followed  with  complete  success.  The  apparatus  lately  devised  by  M* 
G.  Pelletan,  which  by  means  of  canulas  and  valves,  permits  the  establishment  of 
a  double  current  of  liquid  by  opposing  the  introduction  of  air  into  the  thorax, 
an  apparatus  in  other  respects  founded  on  that  of  M.  Heroldt,  is  too  compli- 
cated and  of  too  little  necessity  for  practitioners  to  consent  to  its  use. 

Art.  2. — Wound  of  the  Intercostal  Artery. 

Supposing  a  wound  of  the  diaphragm,  of  which  Solingen  says  he  was 
witness,  should  occur  during  the  operation  for  empyema,  there  is  no  resource 
but  that  of  medicine  to  be  summoned  against  it,  and  the  opening  of  the  inter- 
costal artery  is  in  fact  the  only  accident  which  can  here  require  surgical  aid. 
Although  rare,  this  wound  has  occupied  the  attention  of  writers,  so  that  a 
greater  number  of  means  have  been  proposed  to  overcome  its  effects  than  the 
times  it  has  been  observed ;  unless  perhaps  it  has  been  frequently  mistaken, 
or  the  remedy  has  been  neglected  even  in  cases  in  which  the  resulting  effusion 
has  become  fatal,  an  example  of  which  M.  Thierry  published  in  1828.  It 
65 


514  NEW    ELEMENTS    OF 

has  mostly  occurred  in  consequence  of  penetrating  wounds  of  the  chest.  It 
is  recognized  by  the  hemorrhage  it  occasions,  by  the  symptoms  of  effusion 
which  result,  by  the  pallor,  and  threatened  syncope,  &c.  A  piece  of  card 
carried  to  the  bottom  of  the  wound  and  bent  into  a  gutter  shows  on  what 
side  the  blood  escapes.  The  finger  passed  under  the  rib  often  distinguishes 
a  hot  jet  not  easy  to  mistake,  and  forms  one  of  the  most  certain  means  of 
diagnosis  when  it  can  be  employed.  By  means  of  a  thread  carried  through 
the  wound,  and  brought  out  through  the  intercostal  space  above,  Gerard 
conducted  a  tent  beneath  the  artery  which  he  hoped  thus  to  compress  by 
strangulating  it  with  the  rib.  Not  willing  to  withdraw  the  conducting  instru- 
ment entirely  through  the  new  wound,  Goulard  invented  a  needle  with  a 
curved  handle,  like  that  of  Gerard,  pierced  with  an  eye  near  its  point,  and 
hollowed  on  its  convexity  into  a  groove  for  carrying  the  ligature.  Heuermann 
contends,  that  with  a  needle  considerably  bent  and  fixed  at  an  angle  with  its 
handle,  it  is  possible  to  surround  the  bone  so  as  to  bring  out  the  two  extremities 
of  the  thread  at  the  same  wound.  Having  made  a  second  opening  above  the 
rib,  Leber  used  it  to  carry  a  tape  which  he  brought  out  of  the  wound,  and  then 
tied  its  two  ends  over  a  conpress,  in  the  manner  of  Gerard.  For  this  purpose 
he  employed  a  flat  flexible  sound,  for  which  Steidle  substituted  a  silver  one 
bent  into  the  shape  of  an  S,  to  which,  in  his  turn,  says  Sprengel,  Bostscher 
preferred  a  blunt  probe-pointed  one  of  steel.  In  fine,  instead  of  tying  the 
thread  into  a  knot,  Reich  advises  to  pass  its  two  extremities  into  a  gumelastic 
canula  which  is  kept  without  the  chest;  but  all  these  processes  are  unnecessary, 
as  well  as  the  double  plate  of  Lottery,  the  ivory  counter  of  Quesnay,  and  the 
machine  of  Bellocq.  The  tent,  tied  round  its  middle  by  a  very  strong  thread, 
carried  through  into  the  cavity  of  the  pleura,  and  then  placed  vertically,  so 
that  by  drawing  on  it  it  cannot  be  brought  away,  compresses  the  artery,  and  at 
the  same  time  the  edges  of  the  two  adjoining  ribs  no  longer  receives  the 
eulogies  lavished  on  it  by  Bilguer,  Richter,  Desault  and  Sabatier.  Theden 
maintains,  that  to  arrest  the  hemorrhage  it  is  sufficent  to  complete  the 
division  of  the  artery,  bend  back  its  posterior  end,  and  plug  the  wound.  I  add, 
that  the  same  end  may  be  attained  without  bending  back  the  vessel,  as  has  been 
well  observed  by  Hebeinstreit.  It  is  scarcely  explained  how  Laefiler  could 
have  proposed  to  open  the  intercostal  space  a  little  further  behind,  leaving  the 
pleura  untouched,  in  order  to  divide  the  artery  at  this  point,  and  there  apply 
a  tampon,  without  at  all  obstructing  the  flow  of  effused  matters  through  the 
first  opening.  Rejecting  all  these  means,  Bell  found  it  more  convenient  to 
seize  with  a  hook  the  end  of  the  bleeding  vessel  and  tie  it.  There  are  some 
who  have  had  the  courage  to  establish  a  point  of  compression  over  the  wound 
of  the  vessel  for  several  days  by  the  fingers  of  assistants,  who  relieved  each 
other  alternately.  In  a  word  there  is  no  kind  of  useless  or  unapplicable 
resources  which  have  not  been  devised  for  this  occasion.  None  however  have 
remained  in  practice.  Supposing  it  necessary  to  act,  the  hemorrhage  may  be 
easily  arrested,  by  pushing  into  the  chest,  in  the  manner  of  Desault  and  Zang, 
the  middle  of  a  fine  compress.  After  filling  this  species  of  sack  with  charpie 
or  tow,  to  transform  its  internal  portion  into  a  kind  of  ball,  its  external  portion 
will  only  have  to  be  closed  and  drawn  up  so  as  to  compress  from  within  outwards 
until  the  blood  ceases  to  flow.  This  small  apparatus  can  be  fixed  without  the 
least  difficulty,  by  tying  the  free  portion  of  linen  over  a  second  roll  of  charpie. 


OPERATIVE    SURGERY.  515 

This  means,  the  only  one  to  which  M.  Larrey  was  willing  to  give  assent,  if  from 
any  cause  it  is  not  deemed  proper  to  make  immediate  union  of  the  wound,  being 
applicable  in  every  case,  offering  the  advantage  of  being  always  at  hand,  and  of 
being  within  the  reach  of  every  one,  should  take  rank  of  all  the  rest,  and  un- 
questionably deserves  to  be  substituted  for  them. 

Art.  3. — Paracentesis  of  the  Pericardium, 

The  idea  of  opening  the  pericardium  when  filled  with  serosity,  pus,  or  blood, 
at  first  appeared  so  bold  that  many  still  regard  it  as  rash  and  inapplicable. 
Timid  surgeons  have  been  deterred  from  it  through  fear  of  wounding  the  heart. 
Others  reject  it,  because  it  may  provoke  inflammation,  which  in  consequence 
of  its  locality  would  quickly  bring  on  death.  The  difficulty  of  recognizing 
the  disease  with  certainty  during  life,  and  the  danger  of  removing  only  a 
symptom,  is  the  argument  which  the  most  reasonable  have  advanced  against  it. 
None  of  these  different  motives  however  is  sufficient  to  proscribe  it  absolutely. 
With  the  exploring  means  which  the  science  at  present  possesses,  the  expe- 
rienced practitioner  will  rarely  fail  of  establishing  with  all  desirable  precision 
the  diagnosis  of  effusion  in  the  pericardium.  The  heart  can  always  be  avoided. 
By  evacuating  a  morbid  fluid  from  a  serous  membrane  we  free  it  from  a  foreign 
body,  and  in  this  respect  puncture  is  more  calculated  to  diminish  than  to 
excite  inflammation.  With  the  operation,  the  patient  it  is  true  runs  great 
risks;  but  without  it  he  is  devoted  to  a  speedy  and  certain  death.  If  para- 
centesis does  not  cure,  it  may  at  least  afford  temporary  relief.  It  is  to  be 
regretted  that  experience  furnishes  scarcely  any  light,  and  that  on  a  subject 
so  grave  the  ideas  are  purely  theoretical.  Senac,  who  is  considered  as  having 
committed  a  fault  in  first  proposing  puncture  of  the  pericardium,  gives  no 
case  of  it,  and  the  observation  attributed  to  him  by  Sprengel  has  reference  to  a 
true  hydrothorax.  Van  Swieten  and  H.  Welse,  to  whom  M.  Rayer  refers, 
express  themselves  still  more  vaguely.  Riolen  who  treats  it  as  a  common 
proposition,  does  not  however  say  that  it  had  been  performed  in  his  time. 
It  is  known  that  the  pretended  pericardium  which  Desault  opened  was  nothing 
more  than  accidental  cyst.  It  does  not  appear  that  M.  Skielderup  has  given 
any  thing  conclusive  in  support  of  his  advice.  It  is  evident  also  that  the  col- 
lection opened  by  M.  Larrey  had  its  seat  without  the  envelope  of  the  heart. 
The  three  observations  reported  by  M.  Romero,  the  substance  of  which  is  also 
given  by  M.  Merat,  are  too  incomplete  not  to  leave  a  doubt  upon  the  mind. 
That  which  Mr.  Jowet  of  London  has  published  as  a  first  successful  case,  in 
182r,  is  equally  incapable  of  removing  all  difficulty  from  the  subject;  but  if 
it  still  remains  to  be  proved  that  paracentesis  of  the  pericardium  has  ever  been 
performed  on  the  living  subject,  there  are  not  wanting  facts  to  prove  that  per- 
foration of  this  membrane  does  not  necessarily  produce  death.  The  thesis  of 
M.  Sanson  jun.  contains  several.  M.  Larrey  quotes  several;  and  I  myself 
have  met  with  one  very  remarkable.  A  coalman,  who  died  of  pneumonia  at 
the  hospital  of  Improvement  in  1824,  had  received  some  years  beibre  a  stab 
with  a  knife  in  the  left  side  of  the  thorax.  On  opening  his  body,  v/e  found  a 
very  old  cellular  band,  which  ran  obliquely  from  the  wall  of  the  thorax  to  the 
mediastinum,  and  was  continuous  with  the  anterior  edge  of  the  lung,  which 
adhered  like  it  to  the  external  surface  of  the  pericardium.     The  point  of  this 


516  NEW    ELEMENTS    OF 

last  organ,  around  which  were  spread  the  preceding  bands,  was  pierced  with 
a  round  opening  with  thin  edges,  and  capable  of  admitting  the  finger.  The 
corresponding  region  of  the  heart  presented  a  cicatrix  easy  to  be  recognized, 
but  which  we  could  not  trace  into  the  ventricle.  The  part  was  exhibited  to  the 
Academy  by  M.  Bougon  the  next  day,  and  every  member  of  that  body  can 
confirm  the  correctness  of  what  I  say. 

Manual. — In  its  natural  condition  the  pericardium  is  accessible  to  the  sur- 
geon by  a  number  of  points.  By  distending  it  beyond  measure,  effusions  ren- 
der it  still  more  easy  to  be  reached. 

Trepanning  tlve  Sternum, — Riolan  advances,  and  others  agree  with  him,  that 
tiie  sternum  may  be  trepanned  at  an  inch  above  the  xiphoid  cartilage  in  per- 
forming the  puncture  of  the  cardiac  cyst.  This  doctrine,  reintroduced  as  a 
novelty  with  all  its  necessary  details  by  M.  Skielderup,  has  found  some 
followers  among  the  moderns.  Laennec  among  others  adopts  it,  and 
endeavors  to  deduce  from  it  the  advantages  of  avoiding  with  certainty  the 
internal  mammary  artery,  of  reaching  infallibly  the  distended  pouch,  and  of 
not  opening  the  pleura.  Senac  directed  the  fifth  or  sixth  intercostal  space  to 
be  opened  a  little  to  the  left  of  the  sternum,  and  through  this  the  trocar  to  be 
plunged  very  obliquely  downwards,  and  to  the  right  into  the  collection  to  be 
evacuated.  In  order  not  to  wound  the  mammary  artery,  Desault  mkde  his 
incision  more  outwardly,  and  entered  the  morbid  sac  only  after  feeling  the 
fiuctuation  with  his  finger.  This  is  also  the  mode  praised  by  M.  Romero, 
who,  instead  of  the  trocar  like  Senac,  or  the  blunt  bistoury  of  Desault,  preferred 
scissors  for  dividing  the  envelope  of  the  heart,  after  raising  up  a  fold  of  it 
with  the  forceps.  Lastly,  M.  Larrey  says  that  it  is  better  to  traverse  from 
below  upwards  the  space  which  separates 'the  left  margin  of  the  xiphoid  appen- 
dix from  the  cartilage  of  the  last  true  rib  ;  that  the  pleura  is  thus  spared  with' 
out  any  risk  to  the  peritoneum,  the  diaphragm,  or  the  internal  mammary  artery, 
and  that  thus  the  most  depe.nding  point  of  the  pericardium  is  reached. 

Trepanning  of  the  sternum  is  unquestionably  the  most  simple  process  that 
has  been  devised.  The  bone  to  be  penetrated  is  soft,  superficial,  and  devoid 
of  bloodvessels  on  both  its  surfaces.  It  allows  the  pericardium  to  be  seen 
and  touched  before  being  opened,  and  the  last  stage  of  the  operation  to  be 
abandoned  ;  the  only  one  to  excite  apprehension  if  the  surgeon  have  previously 
mistaken  the  seat  of  the  disease.  The  fluid  cannot  be  poured  into  the  pleura. 
I  see  no  other  inconveniences,  than  that  of  occasioning  a  loss  of  substance 
which  renders  immediate  union  of  the  wound  difficult,  and  inevitably  brings 
the  interior  of  the  sac  in  contact  with  atmospheric  air.  But  is  it  not  better  to 
leave  the  puncture  of  the  pericardium  open  than  to  close  it  before  stopping 
the  source  of  the  disorder  ?  In  this  case,  is  not  the  action  of  the  air  more  to 
be  desired  than  dreaded  ?  The  danger  to  the  pleura,  no  matter  what  precau- 
tions are  taken  to  avoid  it,  and  to  the  internal  mammary  artery  in  Senac's 
method  slightly  modified  by  Desault,  llemero,  and  Jowet,  does  not  allow  it  to 
be  brought  in  comparison  with  the  preceding  method.  The  process  of  M. 
Larrey,  which  may  rigorously  conduct  to  the  same  end  as  trepanning  the 
sternum,  is  not  of  so  easy  application  as  its  inventor  seems  to  think,  on  subjects 
in  whom  oedema,  infiltration,  or  natural  embonpoint  is  sufficient  to  prevent  the 
skin  from  immediately  touching  the  external  face  of  the  bones  or  cartilages  of 
the  chest.     Besides,  the  branch  of  the  mammary  artery,  which  crosses  the 


OPERATIVE    SURGERY.  517 

anterior  face  of  the  ensiform  prolongation,  is  sometimes  so  considerable,  that 
a  wound  of  it,  which  is  almost  inevitable,  may  create  a  troublesome  hemorrhage. 
It  seems  to  me,  therefore,  prudent  to  act  according  to  the  advice  of  Riolan, 
repeated  by  M.  Boyer.  The  crown  of  the  trepan  is  to  be  applied  over  the 
left  half  of  the  sternum  immediately  above  the  xiphoid  appendix,  so  as  to  fall 
on  the  widest  point  of  the  anterior  separation  of  the  mediastinum.  The  left 
index  finger  carried  to  the  bottom  of  the  wound  will  then  afford  certainty  of 
the  fluctuation,  and  serve  as  a  guide  to  the  bistoury.  The  pericardium  being 
opened,  it  will  be  proper  to  turn  the  patient  on  his  left  side,  and  more  than 
ever  to  keep  his  chest  in  a  position  almost  vertical,  to  give  issue  to  the  fluid, 
which  should  be  permitted  to  flow  slowly.  The  dressing  consists  of  a  tent  of 
cliarpie  carried  to  the  orifice  of  the  serous  sac,  a  pledget  of  lint  spread  with 
cerate,  compresses,  and  a  body  bandage  to  keep  the  whole  in  place,  as  in,  the 
operation  for  empyema. 

Injectiojis. — The  idea  of  treating  hydrops  pericardii  as  an  hydrocele,  by 
injecting  an  irritating  fluid  into  the  diseased  membrane  to  provoke  adhesive 
inflammation,  has  nothing  in  it  repugnant  to  sound  reason,  though  some  have 
unjustly  made  it  a  crime  in  M.  Richerand  to  have  advanced  the  doctrine. 
If  besides  the  evacuation  of  the  fluid  the  puncture  does  not  itself  produce 
this  adhesion,  it  is  useless  to  rely  on  its  success,  except  as  a  mere  palliative. 
The  radical  cure  of  hydrocardia  without  obliteration  of  the  altered  sac  is  no 
more  possible  than  that  of  hydrocele.  If  it  has  ever  been  obtained,  it  was 
because  the  practitioner  without  intending  it  fulfilled  the  design  proposed, 
first  by  M.  Richerand,  and  since  by  Laennec.  Tlie  contact  of  the  air  might 
perhaps  suffice  to  bring  on  the  necessary  degree  of  inflammation.  When 
there  is  no  organic  lesion,  tepid  water,  or  some  other  gently  irritating  fluid 
should  be  first  tried.  If  there  is  an  effusion  of  pus,  the  injections  should  be 
varied  as  in  the  treatment  of  empyema.  In  every  mode  I  w  ould  direct  the 
opening  in  the  pericardium  to  be  large  and  kept  open  to  the  end.  There 
M^ould  then  be  a  treatment  analogous  to  that  of  hydrocele  by  incision  or  ex- 
cision, and  the  effusion  which  naturally  follows  an  injection  into  the  tunica 
vaginalis  after  puncture,  will  not  endanger  its  result.  However,  these  are 
but  suppositions.  Before  according  them  any  value,  and  applying  them  to 
man,  we  ought  by  experiments  on  animals  to  determine  to  what  extent  they 
are  well  founded.  It  is  a  point  of  practice  which  possesses  considerable 
interest.  The  rarity  of  occasions  which  call  for  their  application,  seems  to 
me  to  be  the  only  plausible  reason  which  diminishes  their  importance. 


i 


*n|ip^Bf'ilfe!P' 


518  NEW    ELEMENTS   OF 


CHAPTER  III. 

Abdomen. 
SECTION    I. 

Effusions. — Cysts. 
Art,  1. — Paracentesis, 


Puncture  of  the  abdomen  in  dropsy  is  one  of  the  oldest  operations  in 
surgery.  To  accidents,  of  which  history  furnishes  examples  without  end, 
is  owing  the  first  suggestion.  Nothing  in  truth  is  more  frequent  in  the 
annals  of  science,  than  cases  of  ascites  cured  in  consequence  of  a  wound  of 
the  abdomen.  A  child  amusing  itself  one  day  with  a  knife  in  the  yard  of  a 
dropsical  peasant,  says  Guyon  de  la  Nauche,  was  thrown  by  one  of  its  play 
fellows  upon  the  wretched  patient,  and  cut  open  his  abdomen.  A  large 
quantity  of  water  flowed  from  the  wound,  and  at  the  end  of  some  weeks  the 
patient  was  radically  cured.  Another  ascitic,  finding  no  surgeon  willing  to 
make  the  puncture  resolved  upon  doing  it  himself.  As  it  had  been  forbid  to 
leave  any  thing  in  his  way,  which  might  enable  him  to  accomplish  his  object, 
he  broke  the  glass  he  used  for  drinking,  and  shaped  a  piece,  which  he  plunged 
below  the  naval.  A  complete  cure  was  the  reward  of  his  temerity.  No  doubt 
the  same  remarks  have  given  rise  to  the  same  ideas  since  the  remotest 
antiquity,  and  that  paracentesis  abdominis  is  as  old  as  medicine. 

Indication. — When  ascites  is  the  effect  of  an  incurable  alFection  of  any 
organ  contained  within  the  abdomen,  it  is  evident  that  puncture  will  not  triumph 
over  it,  and  that  in  such  case  it  can  only  be  used  for  the  temporary  relief  of 
the  patient.  But  if  the  dropsy  is  essential  and  idiopathic,  the  removal  of  the 
eiFused  fluid  cannot  but  favor  the  action  of  the  general  treatment,  and  power- 
fully conduce  to  the  re-establishment  of  health.  In  the  first  case  the  opera- 
tion should  be  deferred  as  long  as  possible,  and  resorted  to  only  to  prevent 
suffocation.  In  the  second,  there  would  probably  be  an  advantage  in  following 
the  advice  of  Duverney  and  Bertrand,  renewed  by  M.  Broussais,  to  give  an 
early  issue  to  the  effused  fluid.  It  is  so  rare  to  see  ascites  terminate  happily, 
that,  after  the  ineffectual  employment  of  the  means  which  experience  seems 
most  to  accredit,  compression  for  example,  which  I  saw  once  succeed  in  a  ladi 
fourteen  years  old,  at  the  hospital  of  Tours  in  1818,  the  advantages  of  which' 
are  praised  by  M.  Godele  of  Soissons,  the  good  effects  of  which  were  experi- j^ 
enced  at  the  Hotel  Dieu  during  the  past  year,  and  the  efficacy  of  which  has^ 
been  placed  beyond  doubt  by  M.  Bricheteau,  it  may  well  be  permitted  to 
appeal  to  the  operation,  however  feeble  the  chances  of  success.  \ 

Examination  of  the  Processes, — Red  hot  iron  which  was  formerly  in  use, 
caustic  with  which  an  escar  was  first  made,  which  it  was  afterwards necessaryi 
to  divide  in  order  to  penetrate  the  peritoneum,  and  the  seton  proposed  by  * 
others,  have  long  since  given  place  to  more  rational  modes.    The  method  of  ^ 


OPERxlTIVE    SURGERY.  519 

Paulus  Egineta  and  Guj  de  Chauliac,  a  method  which  was  still  praised  by 
Pigraj,  and  which  consists  in  dividing  the  integuments  with  the  histoiiry 
between  the  pubis  and  the  umbilicus,  and  then  passing  through  the  aponeurosis 
or  the  muscles  a  little  higher  up,  so  as  to  make  it  possible  to  close  at  pleasure 
the  deeper  opening,  bj  slipping  over  it  the  skin  first  divided, is  also  abandoned, 
as  well  as  all  others  which  require  a  cutting  instrument.  The  needle  of 
Thouvenot  or  of  Barbette,  evidently  pointed  out  by  Rhazes  ;the  instrument  of 
Block  or  Girault ;  the  trocar  canula  of  Sanctorius,  the  invention  of  which 
Camper  refersas  far  back  as  Hippocrates,  variously  modified  by  other  authors, 
particularly  by  J.  L.  Petit,  who  made  of  it  the  very  perfect  instrument  known 
at  present  under  the  name  of  trocar  or  trois-quarts,  render  the  puncture  of  the 
abdomen  so  simple  and  easy,  that  for  a  century  past  there  has  been  no  more 
discussion  of  the  bistoury  or  the  lancet  than  of  the  cautery,  for  penetrating 
the  peritoneum  of  an  ascitic.  Some  modern  surgeons  however  seem  to  have 
revived  the  use  of  the  incision.  Dr.  Physick,  among  others  maintains  that 
the  operation  is  much  less  painful  with  the  lancet  than  with  the  trocar,  and 
Dorsey  says,  that  in  America  this  last  instrument  will  soon  fall  intodisuetude. 
More  recently  Mr.  Calaway,  a  surgeon  of  London,  has  endeavored  to  prove 
that  the  lancet  should  really  have  the  preference  in  puncture  of  the  abdomen. 
Directed  by  the  left  index  finger,  which  serves  it  as  •A.point  t?'  appui,  it  is  plunged 
with  the  right  hand  into  the  linea  alba  above  the  pubis  ;  a  female  catheter  is 
then  introduced  into  the  peritoneum,  and  for  the  rest  there  is  nothing  peculiar 
in  the  operation.  This  process,  recommended  by  Petit-Radel  in  I'Ency- 
clopedia  Methodique,  the  same  moreover  with  that  of  CceHus  Aurelianus,  may 
be  imitated  without  inconvenience,  but  it  is  doubtful  whether  it  has  in  reality 
any  real  advantage  over  the  method  adopted  among  ourselves.  If  the  instru- 
ment come  in  contact  with  any  vascular  branches,  it  infallibly  divides  them  ; 
and  all  the  organs  within  its  reach  must  share  the  same  fate,  while  the  trocar 
turns  aside  and  displaces  rather  than  cuts  the  movable  organs  which  present 
themselves  before  it.  The  wound  which  results  from  its  passage  closes  as 
soon  as  it  is  withdrawn.  That  made  by  the  lancet,  on  the  contrary,  remains 
open,  and  offers  no  obstacle  to  the  serosity  which  tends  to  lodge  in  it.  The  flat 
trocar  of  Wilson,  that  of  Andre,  which  according  to  the  advice  of  B.  Bell 
many  practitioners  of  Great  Britain  prefer  to  the  instument  of  Petit,  because 
say  they,  it  scarcely  differs  from  a  cutting  instrument,  is  altogether  unworthy 
of  tliis  predilection.  The  jointed  trocar,  those  with  a  conical  point,  or  like  a 
serpent's  tongue,  or  more  or  less  flattened  instead  of  being  triangular,  and  the 
fifty  other  forms  recommended,  scarcely  deserve  to  be  mentioned.  That  which 
has  received  the  approbation  of  French  surgeons  leaves  something  to  be 
desired,  and  the  modifications  of  which  it  has  been  the  subject  since  J.  L.  Petit 
are  only  calculated  to  injure  it. 

Place  of  Election. — All  points  of  the  abdomen  are  not  equally  proper  for 
paracentesis.  The  left  flank  would  be  the  most  favorable  when  the  spleen 
is  sound,  if  the  epiploon,  more  extensive  on  this  side,  did  not  oppose  an 
obstacle  to  the  flow  of  the  liquid.  On  the  right  the  presence  of  the  liver  is 
to  be  feared.  Too  near  Foupart^s  ligament  is  found  the  sigmoid  flexure  of  the 
colon  or  the  coecum.  Posteriorly  is  the  last  false  rib  or  the  crista  of  the 
OS  innominatum  and  it  would  be  easy  to  reach  the  lumbar  colon.  The  sub- 
umbilical  zone  corresponds  to  the  transverse  portion  of  the  large  intestine 


520  NEW  ELEMENTS  OF 

Quite  loiv  on  the  median  line  is  found  the  bladder.  However,  it  is  necessary 
to  act  on  a  depending  point.  The  linea  alba  preferred  bj  the  ancients,  and 
even  now  by  most  English  surgeons,  has  no  advantage  in  this  respect:  it  is 
far  from  being  as  free  from  liability  to  hemorrhage  as  is  imagined.  A  large: 
vein  sometimes  courses  along  its  anterior  face,  Mr.  S.Cooper  mentions  a 
case  in  which  more  than  a  pint  of  blood  flowed  from  the  wound  he  made  in 
this  place  with  a  bistoury.  In  the  female  there  is  between  the  uterus  and  the 
rectum,  a  cul  de  sac  in  the  bottom  of  the  pelvis,  which  maybe  easily  reached 
through  the  posterior  and  superior  part  of  the  vagina.  This  point,  the  most 
depending  of  all,  would  also  be  the  most  proper  perhaps,  if  the  peritoneum 
was  always  free  through  its  whole  extent,  if  a  change  of  relation  of  the;, 
bladder  of  the  uterus  on  the  intestines  did  not  expose  some  of  these  organs 
to  be  perforated.  We  should  therefore  choose  and  conform  to  the  precept  of 
H-enckel,  of  Watson,  of  Bishop,  of  Nosthig,  only  after  being  assured  by  the 
touch  that  the  serosity  descends  into  the  pelvic  cavity,  and  tends  to  depress 
the  roof  of  the  vagina.  By  penetrating  through  the  rectum  above  the  vesiculse 
seminalis  as  some  other  practitioners  direct,  there  would  be  still  more  danger 
of  wounding  the  bladder.  The  fear  of  then  finding  stercoracious  fluids  to 
pass  into  the  peritoneum,  will  always  be  reason  enough  to  reject  this  mode, 
although  by  way  of  exception  it  may  be  adopted  in  some  subjects.  Eveiy 
mode  of  emptying  tiie  peritoneum  of  ascitic  collections,  even  by  puncturing  the 
bladder  itself  has  been  occasionally  resorted  to. 

Berard  gives  a  case  of  this  in  his  thesis.  There  was  thought  to  be  an 
ischury.  The  sound  was  carried  forcibly  through  the  urethra.  Several  pints 
of  serosity  escaped. — The  patient  died.  The  autopsis  proved  that  the  subject 
had  been  ascitic,  and  that  the  instrument  had  entered  the  abdomen.  A  Lon- 
don surgeon,  Mr.  Watson,  has  seriously  proposed  to  enter  by  this  passage,  and ' 
what  is  no  less  surprising,  Mr.  Buchanan,  one  of  his  countrymen,  is  said  to 
have  performed  it  three  times  with  success,  but  I  do  not  think  that  among  us 
this  precept  will  ever  require  a  serious  refutation.  The  scrotum  which 
answers  best,  as  proved  by  the  observations  of  Ledran  and  Morand,  when 
together  with  ascites  there  exists  congenital  hydrocele,  can  only  be  used  in 
this  circumstance.  If  there  be  found  a  part  of  the  abdominal  parietes  thinner 
than  the  rest,  in  such  a  degree  as  to  be  formed  of  the  skin  alone,  and  having 
acquired  a  kind  of  transparency,  it  is  there  that  we  should  act,  however 
unfavorable  it  may  be  in  other  respects.  The  umbilicus,  which  often  presents 
this  peculiarity,  and  was  recommended  by  Lanfranc  and  the  two  Fabricii,  is 
the  point  wherein  M.  Ollivier,  founded  on  an  observation  entirely  his  own, 
^nd  another  of  M.  Bigat  of  Angers,  proposes  to  perforate  in  pregnant  women, 
M.  Scarpa,  and  after  him  M.  Cruch  direct,  on  the  contrary,  that  during  preg- 
nancy the  puncture  be  performed  in  the  left  hypochondria ;  that  is,  a  little 
below  the  third  false  rib.  I  have  several  times  had  recourse  to  paracentesis 
on  women  in  a  state  of  gestation ;  among  others,  three  times  in  the  course  of 
one  pregnancy ;  and  the  whole  extent  of  the  left  side,  all  the  points  of  this 
side  where  the  trocar  is  usually  inserted,  appeared  to  me  separated  from  the 
uterus  by  a  sufficient  interspace  to  leave  no  great  importance  to  the  precepts  of 
Ollivier  and  Scarpa.  A  little  without  the  linea  alba,  where  the  operation  was 
formerly  performed  according  to  the  advice  of  Celsus,  the  epigastric  artery 
runs  some  risk.    The  middle  of  the  space  between  the  margin  of  the  ribs  and 


OPERATIVE    SURGERY.  521 

the  crista  of  the  ileum,  indicated  bj  Sabatier,  would  have  the  inconvenience 
of  being  too  near  the  chest,  when  the  spleen  and  liver  are  the  seat  of  an 
engorgement;  so  that  as  a  general  rule  the  middle  of  a  line  drawn  from  the 
umbilicus  to  the  anterior  spine  of  the  ileum  is  still  the  best.  The  instrument 
cannot  touch  either  the  bladder  or  uterus,  unless  it  be  very  much  developed; 
or  the  epigastric  arterj  which  runs  within ;  nor  the  anterior  iliac  artery  which 
is  without ;  nor  the  colon  which  is  found  below  and  behind.  This  place, 
which  the  majority  of  operators  have  prescribed  since  Palfin  suggested  the 
idea,  is  then  the  true  place  of  election,  and  each  of  the  others  the  place  of 
necessity.  In  ordinary  ascites  a  wound  of  the  intestines  or  their  arteries  is 
almost  impossible,  the  serosity  naturally  throws  them  towards  the  diaphragm 
or  the  spine.  Even  when  they  remain  free  and  floating,  the  mesentery  is  not 
long  enough  for  the  trocar  to  reach  them.  But  if  adhesions  fix  a  part  of  it 
to  the  parietes  of  the  abdomen,  no  doubt  the  instrument  may  open  them  and 
give  passage  to  fecal  matter;  cases  of  which  have  been  reported.  Encysted 
dropsy y  which  has  its  seat  in  an  ovary,  in  the  cavities  of  the  omenta,  in  a  por- 
tion of  peritoneum  bounded  by  adhesions,  or  in  a  peculiar  accidental  sac, 
will  also  render  the  same  tiling  likely  to  occur.  Surrounded  by  thicker  walls 
it  obliges  us  to  penetrate  deeper  before  arriving  at  the  cavity,  and  consequently 
requires  us  to  distinguish  it  if  possible  before  commencing  the  operation. 

Position  of  the  Patient. — No  one  now  advises  the  patient  to  be  kept  standing 
during  the  operation.  The  sitting  posture  is  not  more  proper  except  under 
particular  circumstances.  He  should  be  placed  on  his  side  near  the  edge  of 
the  bed.  While  the  liquid  flows,  an  assistant  on  the  opposite  side,  with  both 
hands  spread  out,  moderately  compresses  the  parietes  of  the  abdomen. 
Without  this  precaution,  which  the  ancients  neglected,  the  viscera  and  the  large 
vascular  trunks  being  suddenly  relieved  from  the  pressure  to  which  they  had 
been  accustomed,  occasion  syncopes,  lipothymiie,  and  convulsions,  which  it  is 
important  to  avoid.  The  bandage  or  corset  invented  by  Monro  to  supply  the 
place  of  the  assistant's  hands,  and  serve  as  dressing  after  the  operation,  only 
imperfectly  fulfill  the  intention,  and  does  not  deserve  the  preference  given  it 
by  some.  To  apply  it  beforehand,  to  tighten  it  in  proportion  as  the  abdomen 
is  emptied,  to  keep  opposite  the  proper  place  the  hole  which  is  in  it  for  the 
passage  of  the  trocar,  and  then  to  fill  the  hollows  that  may  be  left  in  the  iliac 
regions,  &c.,  are  aiiairs  too  minute  for  surgeons  to  be  confined  to  without 
necessity.  The  cloth  passed  around  the  abdomen,  its  two  extremities  drawn 
gradually  by  assistants  while  the  water  flows,  as  recommended  by  Mr.  S.  Cooper, 
is  still  more  improper.  If  the  effusion  has  its  seat  in  the  peritoneum,  it  is 
possible  that  the  epiploon,  a  knuckle  of  intestine,  a  flake  of  albumen,  or  a 
hydatid,  may  present  at  the  extremity  of  the  canula,  and  close  it  before  the 
complete  extraction  of  serosity.  A  stylet  or  blunt  staff  carried  through  the 
instrument  is  always  sufficient  to  remove  these  obstacles,  and  clear  the  passage 
for  the  fluid  to  run  with  its  original  freedom.  Serous  cysts,  containing  scarcely 
ever  any  thing  but  limpid  serosity,  are  generally  free  from  this  kind  of  incon- 
venience ;  but!  dropsy  of  the  ovary,  which  almost  constantly  forms  an  oily  or 
gelatinous  substance  more  or  less  thick,  rarely  very  fluid,  presents  sometimes, 
and  requires  a  canula  of  considerable  size. 

Extraction  of  the  Fluid. — Many  authors  are  of  opinion  that  the  whole  of 
the  fluid  ought  not  to  be  removed  at  once ;  that  it  would  be  better  only  to  take 


522  NEW    ELEMENTS    OF 

it  Awaj  gradually.  With  this  intention,  Pauliis  Egineta,  Guj  de  Chauliac, 
&c.,  avoided  piercing  the  skin  and  the  peritoneum  on  the  same  level  j  in  the 
time  of  Hippocrates  they  placed  a  small  canula  in  the  v^^ound,  which  has  been 
modified  a  thousand  times  since,  and  which  they  employed  as  a  kind  of  spigot 
to  stop  and  unstop  at  pleasure ;  others  drew  off  at  first  but  a  certain  quantity 
of  the  morbid  fluid,  repeating  the  same  operation  successively  a  greater  or 
less  number  of  times ;  and  after  opening  the  abdomen  with  a  lancet  it  has  been 
proposed  to  let  the  matter  issue  of  itself  slowly  and  insensibly.  But  expe- 
rience having  obtained  nothing  very  positive  as  to  the  value  of  such  a  mode, 
it  appeai^s  more  reasonable  to  leave  in  the  abdomen  only  what  cannot  be 
extracted.  Exhaustion  and  syncope,  which  the  ancients  hoped  thus  to  prevent, 
are  more  certainly  avoided  by  a  bandage  properly  applied ;  and  patients  would 
be  only  half  satisfied,  if  their  abdomen  was  but  half  emptied  after  they  have 
♦submitted  to  be  tapped. 

Dressing. — The  compressing  bandage  after  tapping  has  not  only  the 
advantage  of  supporting  the  viscera,  but  is  also  a  powerful  means  of  determining 
a  definite  cure.  The  authentic  cases  adduced  in  support  of  this  asser- 
tion are  now  of  sufficient  number  to  induce  us  to  multiply  them  more  and 
more.  Last  spring  I  was  requested  by  Doctor  Rousseau,  physician  at  Bating- 
noUs,  to  tap  a  child  five  years  old,  who  had  been  affected  with  ascites  for 
eight  months.  We  drew  six  pounds  of  limpid  fluid  from  the  abdomen.  No 
alteration  of  the  viscera  could  be  detected  through  the  parietes  of  the  abdomen. 
An  exact  and  moderate  compression  was  immediately  established.  The 
effusion  was  not  reproduced  and  the  little  patient  soon  recovered  his  former 
health.  The  mode  of  effecting  compression  in  these  cases  should  be  left  to 
the  invention  of  the  operator.  Whether  it  be  made  with  a  flannel  bandage 
as  directed  by  Mr.  S.  Cooper  after  Bell,  the  bandage  of  Monroe,  a  kind  of 
lozenge  terminating  above  in  a  shoulder  strap,  and  below  by  straps  for  the 
thighs,  and  so  as  to  be  properly  fastened  across,  or  quite  simply,  with  a  body 
bandage  and  compresses,  or  other  pieces  variously  folded  over  the  epigastrium 
and  the  sides,  provided  that  it  be  exact  and  regular  the  rest  is  of  little 
importance. 

Injections^ — Some  think  that  the  radical  cure  of  ascites  may  be  obtained  by 
another  method  after  tapping.  By  inference  from  what  happens  in  hydrocele 
they  dreAv  the  idea  of  throwing  into  the  peritoneum  irritating  fluids  to  produce 
adhesive  inflammation.  Brenner,  who  seems  to  have  started  the  idea,  and  who 
only  wished  to  strengthen  the  viscera,  proposed  a  mixture  of  camphorated 
•spirits,  aloes,  and  myrrh.  W^arrick  tried  it  with  Bristol  water  and  cured  his 
patient.  Repeated  with  red  wine  and  tar  ivater  the  experiment  had  not  the 
same  success.  The  two  patients  died.  After  making  trial  of  the  process 
of  Hales,  who  directed  a  canula  to  be  placed  each  side  of  the  abdomen,  so  that 
the  fluid  might  return  by  one  as  it  was  thrown  in  at  the  other,  Warrick  in  the 
end  gave  the  preference  to  the  Bristol  waters  and  simple  puncture.  Although 
since  directed  by  Heuermann,  Bossu,  and  some  others,  injections  in  ascites  were 
entirely  proscribed  until  two  years  since,  when  the  Annals  of  Broussais  brought 
forward  in  d\eir  favor  two  cases  of  success  obtained  by  the  vapor  of  wine. 
Emboldened  by  their  example  M.  Lhomme  attempted  the  same  means  on  an 
adult  who  had  already  been  tapped  several  times.  The  result  surpassed  his 
expectations.    His  patient,  like  the  one  of  M.  Gobert,  continued  to  do  well.  A 


OPERATIVE    SURGERY.  523 

subject  so  grave  requires  more  conclusive  facts  to  produce  a  decision.  No- 
thing proves  that  M.  Lhomme  really  caused  the  vapor  of  ivine  to  pass  into  the 
abdomen.  He  filled  a  syringe  with  it,  as  he  says ;  but  the  cloths  wet  with  cold 
water  with  which  he  thought  it  necessary  to  wrap  the  canula  through  which  it 
was  obliged  to  pass,  must  necessarily  have  condensed  it  immediately ;  so 
that  very  probably  it  was  the  air  and  not  the  wine  that  was  forced  into  the 
abdominal  cavity.  The  observations  of  Huermann,  of  Litre,  of  Garengeot, 
o-f  Bossu,  seem  only  to  relate  to  encysted  dropsy,  and  those  of  Warrick  or 
Warren,  are  too  incomplete  to  deserve  great  confidence.  Yet  it  is  not 
improbable  that  important  practical  data  may  one  day  be  drawn  from  these 
attempts.  Reasoning  founded  on  several  facts  induces  me  to  think  that  the 
cure  of  ascites  takes  place  only  by  the  adhesion  of  the  parietal  peritoneum 
with  the  abdominal  viscera.  The  colics  which  are  habitually  felt  by  those 
who  have  escaped  this  disease,  and  the  obstruction  which  they  meet  with  in 
their  digestive  functions,  are  proof  of  the  fact.  A  man  about  fifty  years  of 
age,  who  had  been  cured  of  ascites  fourteen  years  previously  and  who  died  of 
pneumonia  in  the  hospital  of  Tours,  in  1817,  a  girl  nineteen  years  old  suc- 
cessfully treated  at  fourteen  years  of  age  for  a  similar  dropsy  at  the  Paris  hos- 
pital for  children,  and  who  died  in  consequence  of  cerebral  lesion  in  1824 
at  the  hospital  of  Improvement,  had  all  the  intestines  glued  to  each  other  and 
to  the  parietes  of  the  abdomen  by  innumerable  cellular  lamellas  and  fila- 
ments. Such  being  the  fact  the  question  remains  whether  prudence  and 
humanity  may  be  allowed  in  these  cases  to  attempt  to  imitate  the  process  of 
nature.  For  the  purpose  of  elucidating  this  fact,  M.  Bretonneau  made,  in 
1819,  some  experiments  upon  dogs.  He  first  injected  pure  water,  brandy 
and  water,  and  then  a  strong  solution  of  muriate  of  soda,  into  the  perito- 
neum, but  no  inflammation  could  be  produced  in  these  animals,  and  all  the 
injected  fluids  were  absorbed  after  several  days.  A  patient  whose  condition 
aftbrded  no  hope  of  success  from  the  use  of  ordinary  means,  and  who  was 
"threatened  with  near  death  was  submitted  to  the  same  experiment.  He  sunk, 
but  it  was  under  the  progress  of  his  disease,  and  because  a  part  of  the  fluid 
was  infiltrated  into  the  substance  of  the  abdominal  parietes  and  there  produced 
gangrenous  erysipelas.  M.  J.  Cloquet  has  several  times  mentioned  to  me  a 
patient  in  whom  the  vinous  or  alcoholic  injection  for  a  congenital  hydrocele 
passed  against  his  intention  into  the  abdomen,  and  who,  after  some  trouble- 
some symptoms,  was  finally  restored  to  health.  Without  wishing  to  draw  from 
these  various  trials  consequences  which  do  not  follow,  I  still  think  them  wor- 
thy of  exciting  attention.  They  tend  to  prove  at  least,  that  injections  into 
the  peritoneum  are  not  necessarily  as  dangerous  as  they  are  generally  supposed; 
and  that  before  rejecting  them  absolutely,  it  would  be  well  to  make  them  the 
subject  of  varied  experiments  and  of  profound  and  impartial  examination. 
This  question  is  also  presented  under  a  new  aspect  by  M.  J.V.  Roosbroeck  of 
Louvain,  who  being  struck  with  the  eminent  diuretic  and  sudorific  properties 
of  the  oxidulous  gas  of  Azote,  resolved  upon  injecting  it  into  the  abdomen  of 
dropsical  patients  after  tapping.  Three  patients,  one  male  and  two  females, 
thus  treated  by  him,  derived  such  advantage  therefrom,  that  M.  Broussais  did 
not  hesitate  to  attempt  it  in  turn,  but  on  a  subject  whose  condition  was  so  de- 
sperate that  it  occasioned  surprise  that  he  should  survive  eight  days.  The 
author  puts  two  drams  of  nitrate  of  ammonia  into  a  glass  vial  to  which  he 


524  NEW  ELEMENTS  Of 

adapts  a  bladder  and  stopcock ;  lutes  the  apparatus,  and  places  it  over  the 
flame  of  a  spirit  lamp ;  when  the  bladder  is  full  of  gas  from  the  decomposition 
of  the  salt,  unlutes  it  and  lets  the  whole  cool ;  he  then  fixes  the  end  of  the 
stopcock  into  the  trocar  canula  and  makes  the  injection.  If  no  error  has 
glided  into  the  statement  of  M.  V.  Roosbroeck,  practitioners  should  un- 
doubtedly be  eager  to  repeat  his  experiments. 

Sac  of  goldbeater^ s  skin. — Will  a  bladder  of  this  material,  as  applied  to  the 
radical  cure  of  hernia,  proposed  by  M.  Belmas,  carried  empty  into  the  peri- 
toneum or  cavity  of  the  cyst,  and  then  blown  up  or  filled  with  any  appropriate 
fluid,  and  fastened  without  by  its  extremity,  have  the  advantage  as  this  author 
presumes  of  graduating  the  irritation  at  pleasure,  or  discontinuing  it  if 
necessary  by  removing  the  foreign  body  which  occasions  it  ?  1  cannot 
think  so. 

Supposing  nothing  of  this  to  be  done,  and  that  the  effusion  reappears,  tapping 
is  to  be  repeated  as  often  as  it  becomes  necessary,  by  the  rules  laid  down 
above.  There  are  patients  whose  life  is  thus  prolonged  for  several  years,  in 
whose  cases  we  are  obliged  to  have  recourse  to  tapping  every  two  or  three 
months*  Dropsy  of  the  ovary,  a  disease  purely  local  in  the  greater  number 
of  cases,  supports  best  these  repeated  operations.  Partial  or  encysted  dropsy 
may  also,  under  some  circumstances,  admit  of  it ;  but  is  doubtful  whether 
general  ascites  may  be  ranked  in  the  same  class,  or  continue  long  after 
paracentesis  v/ithout  becoming  fatal.  Thus  when  it  is  asserted,  that  tapping 
was  performed  nine  times  on  the  same  woman  by  Saviard,  eleven  times  by 
Litre,  twenty-nine  times  by  Grew,  fifty-seven  times  by  Cheselden,  forty- 
seven  times  by  Laub,*  eighty -six  times  in  the  course  of  twenty-six  years,  by 
Martineau,  fifty-two  times  by  Schmucker,  sixty -five  times  by  Mead,  one 
hundred  times  by  Callisen,  and  even  six  hundered  and  fifty-five  times  by 
Bezard,  and  that  the  fatal  term  of  this  disease  has  thereby  been  put  off,  it  is 
almost  certain  that  they  were  cases  of  ovarial  dropsy,  and  not  of  ascites,  in 
the  proper  acceptation  of  the  term. 

Manual. — The  apparatus  is  composed  of  a  trocar  and  canula  of  proper  size, 
smeared  with  cerate,  a  tub  or  any  large  vessel  to  receive  the  fluid,  a  smaller 
and  shallow  vessel  which  may  be  held  quite  close  to  the  abdomen,  unless  the 
serosity  flows  with  sufficient  force  to  render  it  unnecessary,  a  piece  of  cere- 
cloth, various  compresses  folded  several  times,  a  napkin  to  serve  as  a  shield, 
another  folded  treble  and  furnished  with  straps  for  the  thighs  and  shoulders. 
One  assistant  remains  near  the  head,  another  near  the  feet  and  on  the  side 
upon  which  the  patient  is  laid,  in  order  to  support  the  chest  and  thighs.  A 
third,  placed  on  the  opposite  side,  and  even  on  the  bed  for  fear  of  being  other- 
v/ise  too  much  fatigued,  holds  himself  in  readiness  to  place  his  extended 
hands  over  the  whole  surface  of  the  abdomen  to  compress  it  gently  as  the 
water  flows.  The  surgeon  takes  the  trocar  and  plunges  it  with  his  right 
hand  through  the  abdominal  wall,  the  integuments  of  which  are  kept  stretched 
with  the  left.  AVhen  inserted  briskly  and  suddenly,  the  instruments  create 
scarcely  any  pain  to  the  patient.  Many  authors,  fearing  it  may  go  too  deeply, 
and  touch  some  of  the  viscera,  prefer  entering  it  slowly,  turning  it  on  its  axis, 
and  contend  that  in  this  way  the  arteries  are  more  certainly  protected  from 
wound.  These  reasons  have  no  foundation.  The  organs  of  the  abdomen,  as 
I  have  already  said,  are  too  remote  from  its  parietes,  in  ascites,  for  the  trocar 


OPERATIVE  SURGERY.  525 

to  reach  them,  although  carried  in  as  far  as  its  handle.  Making  a  point 
d^appuion  the  skin  with  the  two  last  fingers  during  the  insertion  is  not  much 
more  necessary.  Moreover,  so  many  precautions  only  render  the  operation 
more  long  and  fearful.  The  index  finger  held  alongside  the  trocar  while  the 
handle  is  held  firmly  in  the  palm  of  the  hand,  leaves  uncovered  only  as  much 
as  desired,  and  only  what  is  necessary  to  arrive  at  the  region  of  the  fluid,  and 
is  sufficient  for  tlie  security  of  the  viscera.  If  the  parietes  of  the  abdomen  or 
the  cyst  are  one,  two,  or  three  inches  in  thickness,  sufficient  in  fine  to  cause 
embarrassment,  of  which  Saviard  is  said  to  liave  met  with  a  case,  if  they  are 
so  flabby  as  to  yield  under  the  pressure,  another  instrument  is  to  be  employed, 
and  it  is  in  this  case  that  the  lancet  or  bistoury  may  with  some  advantage  be 
preferred.  The  want  of  resistance  announces  when  it  has  entered  the  peri- 
toneum. The  canula  which  is  to  remain  in  its  place,  its  head  turned  down- 
wards, is  held  by  the  left  thumb  and  forefinger  while  the  trocar  is  w  itlidrawn. 
The  liquid  gushes  out  immediately  with  more  or  less  force,  and  by  a  jet  very 
easy  to  conduct  into  the  bucket  designed  for  this  purpose.  The  buttoned 
stylet,  the  chest  probe,  &c.,  are  only  used  when  some  foreign  body  stops  up 
the  canula.  After  all  the  water  has  been  drawn  off*,  the  operator  removes 
the  tube,  rotating  it  and  supporting,  at  the  same  time  with  the  first  two  fingers 
of  the  other  hand,  the  periphery  of  the  orifice  he  has  made,  to  prevent  the  skin 
from  being  pulled ;  he  then  applies  the  plaster  and  compresses  over  this  point, 
covers  thus  the  whole  front  of  the  abdomen  and  the  sides,  fixes  the  body 
bandage,  and  immediately  replaces  the  patient  in  bed  in  the  least  fatiguing 
posture. 

Occidents. — Hemorrhage  from  tapping,  although  rare,  is  yet  the  inconveni- 
ence which  has  the  most  occupied  practitioners.  Mr.  C.  Smith  has  collected 
ten  instances.  It  is  easily  remedied  when  it  arises  from  a  wound  of  the 
epigastric  artery  or  any  other  vessel  of  the  abdominal  parietes.  For  this 
there  are  several  means,  one  of  them,  used  in  the  last  century,  recommended 
by  Petit  Radel,  and  recently  employed  with  success  by  M.  Cruveilhier,  con- 
sists in  including  the  whole  course  of  the  trocar  in  a  large  fold  of  the  soft 
parts,  in  compressing  or  even  bruising  it  a  little  with  the  thumb  and  forefinger 
until  the  blood  ceases  to  flow.  A  small  plug  of  wax,  an  end  of  bougie,  shaped 
into  a  faucet,  as  devised  by  Bellocq,  or  still  better  a  piece  of  gumelastic  or 
plastic  bougie,  such  as  used  for  the  urethra,  pushed  into  the  wound  so  as  to 
fill  it  exactly,  is  a  resource  which  seems  quite  sufficient  in  this  respect.  I  am 
not  certain  however  that  a  piece  of  prepared  sponge  would  not  do  better. 
By  imbibing  the  liquid  at  the  bottom  of  the  wound,  this  substance  will  evi- 
dently exercise  an  eccentric  compression  most  advantageously,  but  it  may  also 
happen  to  break  when  it  becomes  necessary  to  remove  it.  If  instead  of 
escaping  without,  the  blood  accumulates  within,  it  will  be  difficult  to  perceive 
it  before  death.  Besides;  supposing  the  contrary,  the  surgeon  would  be 
scarcely  better  off.  What  then  is  to  be  done  in  such  a  case  ?  or  where  must 
we  look  for  the  deep-seated  vessel,  which  supplies  the  hemorrhage  ?  For  the 
rest,  we  must  not  be  imposed  upon  by  appearances.  There  is  sometimes 
observed  on  the  surface  of  serous  membranes,  a  sanguineous  exudations© 
abundant  as  to  give  to  the  dropsical  fluid  the  dark  color  of  venous  blood,  so 
that  at  first  sight  we  might  suppose  it  blood  and  not  serosity  that  flows  through 
the  wound.     There  was  a  beautiful  example  of  this  in  an  adult  affected 


526  NEW    ELEMENTS    OF 

with  hydrothorax  at  the  hospital  St.  Antoine,  under  the  care  of  M.  Rayer, 
while  I  performed  the  surgical  duty  of  that  establishment,  and  no  doubt  the 
same  phenomena  may  be  met  with  in  the  peritoneum.  The  hemorrhage,  in 
consequence  of  tapping  in  the  median  line,  mentioned  by  Mr.  S.  Cooper,  may 
have  belonged  to  this  species.  Supposing  that  the  case  observed  at  La  Cha- 
rite  in  1824,  is  not  to  be  referred  to  pure  and  simple  wound  of  the  epigastric 
artery,  it  may  be  better  explained  in  this  way  than  by  a  pretended  lesion  of  a 
mesenteric  vessel.  M.  Piedagnel  however  relates  a  case  of  abundant  effusion 
produced  by  puncture  of  an  epiploic  artery. 

Art,  2. — Humoral  Tumors  of  the  Liver. 

Abscesses,  hydatiferous  cysts,  and  encysted  dropsy  of  the  liver,  have  for  a 
long  time  been  regarded  by  many  persons  as  above  all  surgical  resources. 
The  difficulty  of  recognising  them  during  life,  the  fear  of  producing  effusion 
into  the  peritoneum,  and  of  the  action  of  the  air  upon  the  parietes  of  the  cyst, 
!iave  generally  caused  artificial  opening  to  be  rejected.     However,  cases  are 
quoted  of  cures  obtained  by  means  of  tapping  with  the  trocar  or  with  caustic 
potass.     Again  ;  incision  having  of  late  been  the  subject  of  special  research, 
and  ?.!.  Hecamier  having  arrived  at  the  happiest  results  by  combining  these 
several  means,  I  have  concluded  to  make  it  the  subject  of  a  separate  article. 
Tapping  alone  will  be  insufficient  when  the  cyst  contains  any  thing  besides 
limpid  serosity.     Moreover,  it  would  cause  effusion  of  a  certain  quantity  of 
fluid  into  the  abdomen,  if  the  protecting  adhesions  have  failed  of  being  esta- 
blished around  its  course.     The  use  of  the  bistoury  renders  this  last  accident 
much  more  likely,  and  it  can  only  be  proper  in  cases  where  the  diagnosis 
leaves  no  doubt  of  the  anatomical  relations  of  the  cyst.     Caustics,  it  is  said, 
acting  too  slowly,  are  apt  to  produce  general  peritonitis  in  consequence  of  the 
local  inflammation  resulting  from  their  application.     In  the  process  of  M. 
Recamier,  potass  is  first  applied  on  several  points  very  near  the  morbid  pro- 
tuberance, so  as  to  produce  by  their  union  a  large  eschar,  which  is  divided 
after  some  days  with  a  cutting  instrument.    Another  dose  of  caustic  is  applied 
to  the  bottom  of  the  wound,  which  is  to  act  more  in  depth  tlian  width.     Re- 
peated thus  successively,  cauterization  determines  with  certainty  adhesion  of 
the  hepatic  peritoneum  with  the  peritoneum  of  the  abdominal  parietes,  and 
even  places  the  part  in  condition  for  the  trocar  or  bistoury  to  enter  the  cyst 
as  soon  as  fluctuation  is  perceived  by  the  finger  beneath  the  divided  eschar. 
After  extracting  all  the  fluid,  M.  Recamier  replaces  it  by  medicated  injec- 
tions, which  he  renews  every  day,  and  retains  in  the  morbid  cavity  from  one 
dressing  to  the  other  by  closing  the  wound  with  a  plug  of  lint  or  sponge.  By 
this  .means  the  action  of  the  air  is  prevented,  the  pus,  diluted  as  soon  as  pro- 
duced, cannot  stagnate  nor  pass  into  a  putrid  state  in  the  interior  of  the  cavity, 
and  the  sac,  closing  by  degrees  upon  itself,  in  the  end  transforms  the  whole 
into  a  simple  fistula,  which  generally  is  not  long  in  cicatrizing.     It  is  hardly 
necessary  to  add  that  the  same  treatment  is  applicable  to  tumors  of  the  gall 
bladder,  whenever  they  are  found  in  the  conditions  established  and  so  well 
described  by  J.  L.  Petit.    To  make  clear  the  diagnosis  in  every  affection  of 
which  we  have  just  been  treating,  it  is  often  necessary  to  make  an  exploring 
puncture  with  a  very  small  trocar  or  a  cataract  needle,  as  for  distinguishing 


OPERATIVE  SURGERY.  52T 

with  certainty  an  aneurism  from  an  abscess.  M.  Recamier  remarks  with  jus- 
tice, that  in  this  case  the  instrument  should  I5e  very  fine,  and  withdrawn 
briskly  from  the  tissues.  Otherwise  there  will  be  a  wound  through  which 
the  fluid  may  become  extravasated  in  the  abdomen,  or  the  neighboring  organic 
tissues.  From  these  united  precautions,  successes,  numerous  and  beyond  all 
expectation  have  been  obtained  at  the  Hotel  Dieu  of  Paris,  within  a  certain 
number  of  years. 

Another  mode  of  opening  morbid  collections  in  the  liver  or  abdomen, 
proposed  in  1827  by  Mr.  Graves  of  Dublin,  merits  a  place  beside  the  preceding. 
This  surgeon  uses  only  the  bistoury.  After  cutting  freely  through  all  the  tissues 
to  within  one  or  two  lines  of  the  collection,  he  stops,  fills  the  wound  with 
lint,  and  waits  until,  in  a  fit  of  coughing,  &c.,  the  tumor  opens  spontaneously  at 
the  bottom  of  the  wound.  Mr.  Begin  has  since  proposed  for  all  purulent 
abdominal  collections  to  go  thus,  layer  by  layer,  as  far  as  the  peritoneum,  and 
rest  here  if  there  is  no  adhesion,  but  if  there  is  to  penetrate  at  once  into  the 
cyst.  If  the  tumor  be  still  free,  the  wound  of'the  peritoneum,  which  it  imme- 
diately tends  to  fill,  promptly  adheres  to  it  by  its  anterior  face,  and  three  or  four 
davs  after  the  instrument  may  be  plunged  in  without  fear  of  any  effusion  into 
the  abdomen.  Facts  sufficiently  conclusive  have  been  reported  in  England 
and  France  in  favor  of  this  ingenious  method. 

^rt.  3. — Cysts  and  Tumors  of  the  Interior  of  the  Abdomen. 

The  ovary  is  often  the  seat  of  a  degeneration  which  authors  of  every  age 
have  noticed,  but  relief  of  which  has  scarcely  been  thought  of  except  within 
a  century.    Le  Dran,  Housson,  Garengeot,  had  already  remarked  that  tapping 
scarcely  ever  removed  it,  while  it  was  sometimes  cured  by  largely  incising  the 
cyst.     Morand  even  advances  that  extirpation  of  the  diseased  organ  ought  to 
be  performed  from  the  beginning  to  arrest  its  development.  Observations, 
communicated  by  Delaporte  and  Lieutaud,  were  summoned  in  support  of  this 
operation,  of  which  Thumin  already  gives  the  process,  and  which  two  English 
physicians,  Darwin  and  Power,  warmly  defended  ;  but,  notwithstanding  the 
efforts  of  M.  d'Ischier,  the  success  obtained  by  Laumonier,  the  cure  of  Madame 
de  Choiseul,  and  the  three  cases  reported  by  Kapser,  the  idea  of  Morand 
remained  without  application,  when  in  1825  Mr.  Lizars  undertook  to  invite 
attention  to  it,  and  on  their  part  Messrs.  McDowell,  Nathan  and  Alban  Smith, 
put  it  in  trial  in  America,  and  MM.  Dieffenbach,  Chrysmer,  and  Martini,  en- 
deavored to  introduce  it  in  Germany.     At  present  a  sufficient  number  of 
cases  are  extant  to  enable  us  to  put  a  just  estimate  upon  extirpation  of  the 
ovaries.     Laying  aside   the  operation  formerly  practised  by  Lemman,  that 
published  by  M.  Lafflize  of  Nantes,  another  of  M.  Delpech  of  Montpelier,  I 
will  confine  myself  to  the  enumeration  of  the  most  important — those  which 
have  been  reported  from  ten  to  twenty  years  since  in  the  scientific  journals. 
The  tumor  removed  by  Dr.  McDowell  in  1809  weighed  fifteen  pounds,  the 
cure  was  effected  by  the  thirty-fifth  day.     In  another  patient.  Dr.  McDowell 
finding  both  ovaries  effected  made  an  incision,  a  quantity  of  blood  flowed 
into  the  abdomen,  yet  the  operation  was  attended  with  full  success.     A  negress 
was  relieved  by  liim  in  1816  of  an  ovary  weighing  six  pounds,  and  was  also 
cured.    Two  other  women  whom  he  treated  in  the  same  manner  were  not  so 


5£8  NEW   ELEMENTS  Or 

fortunate;  in  one  the  disease  remained,  the  other  died.  M.  Dzondi  of  Halle 
succeeded  once  by  means  of  incision,  the  use  of  tents,  and  subsequent  extir- 
pation of  the  mortified  cyst.  Pure  and  simple  extirpation  performed  in  1821 
by  Mr.  Smith  was  not  followed  by  any  accident.  The  tumor  removed  by  M. 
Lizars  the  Srth  February  1825,  was  as  large  as  the  uterus  at  full  term.  It 
was  necessary  to  prolong  the  wound  of  the  abdomen  from  the  xiphoid  car- 
tilage to  the  pubis.  The  other  overy  was  equally  affected,  and  yet  the  patient, 
thirty-six  years  old,  was  finally  restored  to  health.  Dr.  Chrysmer,  in  the  case 
of  a  woman  thirty-eight  years  old,  had  every  reason  to  congratulate  himself 
for  having  decided  on  the  operation ;  at  the  end  of  six  weeks  the  patient  was 
able  to  return  home.  On  the  6th  May,  1822,  Dr.  A.  Smith,  operating  on  a 
young  woman,  extracted  the  cyst  after  removing  six  pints  of  fluid,  and  stran- 
gulating it  at  its  base  with  a  strong  ligature  which  came  away  in  a  month  and 
a  half  afterwards.  In  1824  this  lady  enjoyed  the  most  perfect  health.  To 
these  cases  of  real  extirpation  attended  with  success,  must  be  added  others  in 
which  the  tumor  has  not  been  wholly  removed,  or  the  operation  has  not  been 
finished  as  proposed  before  commencing.  In  this  manner  for  instance.  Dr. 
Lizars,  finding  *  simple  adherent  mass  in  front  of  the  sacro-iliac  symphysis, 
instead  of  an  enormous  cyst  as  he  had  anticipated,  thought  proper  to  confine 
himself  to  the  first  stage  of  the  operation,  viz,  the  incision  of  the  abdominal 
parietes ;  closing  the  wound  immediately,  he  was  so  fortunate  as  to  save  his 
patient.  Mr.  Grenville  seeing  in  another  case  that  it  would  be  with  difficulty 
that  the  cyst  could  be  separated  from  the  surrounding  parts,  contented  him- 
self with  incising  it  largely  and  emptying  it  carefully.  This  conduct  gave 
him  complete  success.  M.  Dieflfenbach,  startled  at  the  size  of  the  base  of  the 
tumor  and  the  vessels  it  contained,  seeing  moreover  that  nothing  but  blood 
flowed  from  puncture  of  its  centre,  did  not  dare  to  remove  it,  but  immediately 
closed  the  wound,  and  the  patient  was  also  cured.  Mr,  Galenzowski  of 
Wilna  discovering  that  the  tumor  was  too  adherent  to  be  removed,  emptied  it 
by  a  large  orifice,  tore  down  its  different  cells,  passed  a  thread  through  its 
deeper  wall,  drew  it  towards  the  wound,  to  prevent  all  effusion  into  the  perito- 
neum, closed  in  the  best  manner  he  could  the  division  of  the  abdominal  pari- 
etes, and  obtained  by  this  means  an  entire  cure  in  the  course  of  several  weeks. 
Other  attempts  have  been  less  fortunate. 

A  woman  forty  years  old,  treated  the  20th  September  1 822  by  Dr.  McDowell, 
died  on  the  morning  of  the  24th.  Dr.  A.  Smith,  arrested  by  intimate  and 
very  extensive  adhesions  of  an  ovarian  tumor  in  a  patient  who  had  tapped 
herself  more  than  twenty -four  times,  confined  himself  to  incision  of  the  pari- 
etes of  the  abdomen,  and  did  not  venture  to  finish  his  operation.  He  had  how- 
ever the  misfortune  to  see  this  woman  die  on  the  forty-second  day.  The 
patient  operated  upon  by  Mr.  Lizars  on  the  22d  March  1825,  died  the  next 
day.  The  one  operated  upon  by  M.  Hopper  and  Chrysmer  survived  only 
thirty-six  hours.  Another  by  M.  Chrysmer  alone  was  not  more  fortunate. 
Lastly,  the  young  woman  whose  case  is  given  by  M.  Martini  also  died  after 
thirty-six  hours.  Although  dangerous,  extirpation  of  the  ovary  does  not  the 
less  constitute  a  resource  worthy  of  examination.  The  ovary  is  not  so  in- 
dispensable to  the  support  of  life  but  that  the  woman  may  be  deprived  of  it 
without  too  much  danger.  The  gelders  of  beasts,  who  travel  round  the  coun- 
try exercising  their  profession,  remove  them  without  the  least  fear  in  the  first 


OPERATIVE    SURGERY.  529 

weeks  from  all  the  female  pigs,  and  I  can  affirm  that  in  their  hands  the  opera- 
tion is  seldom  followed  by  bad  results.  Diemerbroech,  relates,  from  Athe- 
naeus,  that  Adrametes,  and  fromSuidas,  that  Gyges  king  of  Syria  thus  treated 
the  women  of  their  kingdom.  Alexander  ab  Alexandro  says  the  same  of  the 
Creophasji  and  the  Egyptians.  Wierus  relates,  that  a  gelder  suspecting  the 
virtue  of  his  daughter  opened  her  abdomen,  drew  out  the  uterus  to  excise  the 
ovaries,  and  that  this  barbarous  operation  had  full  success..  Franckenau,  Pott, 
Lassus,  M.  Deneux  cite  each  a  case  of  extirpation  of  the  ovary  which  did 
not  prevent  the  woman  from  doing  well  afterwards.  The  operation  is  of  itself 
neither  delicate  nor  difficult.  The  occasions  of  performing  it  are  but  two  fre- 
quent. The  diseases  which  require  it  if  left  to  the  resources  of  the  system, 
almost  constantly  cause  death.  But  for  it  to  offer  a  chance  of  success,  the 
tumor  should  be  movable,  not  adhering  to  the  intestines,  easily  separable 
from  all  the  abdominal  organs,  with  a  root  or  pedicle  not  too  large,  and  not 
exposing  too  many  large  vessels  to  be  wounded.  Moreover  it  must  be  known 
and  distinguished  from  every  other  disease,  which  is  far  from  being  always 
easyi  At  first  how  are  we  to  avoid  confounding  it  with  any  tumor  whatever 
adjoining  the  uterus,  the  iliac  fossae,  &c.?  Besides,  who  will  then  be  bold 
enough  to  propose  the  operation  ?  Later,  when  it  occupies  a  great  part  of  the 
abdomen,  the  new  relations  contracted  by  the  organs  surrounding  it  and  the 
almost  inevitable  adhesions  of  its  periphery,  render  its  dissection  and  removal 
if  not  impossible  at  least  extremely  dangerous.  In  fine,  although  incurable 
from  its  nature,  it  ordinarily  brings  on  death  but  very  slowly.  As  a  medium 
term  it  allows,  not  as  Mr  Corbin  believes  twelve  years,  but  five  or  six  to 
women  affected  with  it.  However,  if  as  it  generally  happens  in  this  case  the 
general  health  is  preserved  in  a  manner  to  contrast  with  the  diseased  condition 
of  the  abdomen,  if  the  issue  of  an  unctuous  or  gelatinous  fluid  obtained  by  an 
exploring  puncture,  demonstrates  that  the  disease  is  in  the  ovary,  if  the  tumor 
does  not  exceed  in  size  the  head  of  an  adult,  and  if  the  patient  desires  it 
earnestly,  we  should  attempt  the  operation.  It  only  remains  to  be  determined 
if  simple  incision  according  to  the  principles  laid  down  in  the  preceding  article, 
with  which  M.  Portal,  Denman,  Ray,  and  Ransden,  arc  said  to  have  been  suc- 
cessful, ought  not  to  be  preferred  to  extirpation. 

Manual. — Laid  on  her  back,  the  pelvis  members  moderately  extended  and 
fixed  by  assistants,  the  woman  ought  to  be  placed  so  that  the  most  prominent 
part  of  the  cyst  may  naturally  present  to  the  operator.  He  first  makes  an 
iiicision  parallel  with  the  axis  of  the  body,  four,  six,  or  eight  inches  long,  on 
the  niost  proper  part  of  the  abdomen,  using  the  index  finger  of  the  left  hand 
to  direct  the  bistoury  as  soon  as  the  peritoneum  is  opened,  and  then  engages 
with  the  tumor.  Is  it  free,  movable,  easily  insulated,  and  its  pedicle  narrow, 
tlie  surgeon  has  only  to  tie  its  root  firmly,  and  excise  it  outside  of  the  ligature 
v/ith  the  bistoury  or  scissors.  Are  the  adhesions  uniting  it  with  the  surround- 
ing tissues  small  and  easily  destroyed,  he  removes  them  by  careful  dissec- 
tion, and  acts  as  to  the  rest  as  in  the  former  case.  If  it  be  fungous,  with  a 
broad  base,  with  large  blood  vessels,  it  will  be  better  not  to  touch  it,  but  to  close 
the  wound.  If  the  adhesions  to  the  parietes  of  the  abdomen  dp  not  permit  its 
removal,  we  should  plunge  a  bistoury  into  it  and  open  it  largely,  so  as  to 
empty  it  entirely,  and  act  so  that  the  cyst  may  be  gradually,  drawn  through 
the  wound  of  the  abdomen.  Position,  adhesive  plasters,  or  the  suture  should 
67 


530  NEW    ELEMENTS   OF 

be  employed,  according  to  the  case,  to  unite  the  division ;  which  should  in 
other  respects  be  dressed  as  simply  as  possible.  When  the  solution  of  con- 
tinuity is  very  extensive,  the  intestines  have  such  a  tendency  to  escape  that 
the  suture  is  then  quite  indispensable.  It  is  nearly  tha  same  when  in  the  re- 
moval of  the  tumor  it  was  not  necessary  to  open  n  r  to  occasion  a  great  waste 
in  the  interior  of  the  abdomen.  It  is  quite  the  reverse  when  the  cyst  only  is 
opened,  or  when  it  has  not  been  possible  to  remove  all  that  it  had  been  in- 
tended to  destroy.  Supposing  that  we  wished  to  confine  ourselves  to  incision, 
we  must  first  guard  against  eftusion,  and  produce  in  the  first  place  protect- 
ing adhesions,  if  they  do  not  already  exist,  between  the  morbid  mass  and  the 
parietes  of  the  abdomen ;  and  act  in  short  as  for  an  abdominal  abscess  or  a 
hepatic  collection. 


SECTION   II. 
Hernia. 

A.    HERNIA  IN    GENERAL. 

Jlrt,  1. — Radical  Cure, 

Whatever  be  the  seat  of  hernia,  it  forms  always  an  infirmity  if  not  a 
disease  so  troublesome,  as  to  require  our  efforts  not  only  to  palliate  but  to 
permanently  cure  it. 

The  strange  idea  of  the  ancients  in  ranking  it  among  the  shameful  disor- 
ders, an  idea  still  entertained  in  such  a  manner  that  the  resident  in  the  coun- 
try often  opposes  secretly  the  symptoms  to  which  it  gives  rise,  rather  than 
complain  to  a  physician,  presented  a  bait  too  tempting  not  to  be  turned  by 
cmpyricism  to  the  best  advantage.  Thus  in  the  days  of  Hippocrates,  Galen, 
and  Celsus,  and  in  the  present,  were  there  pretended  curers,  herniary  physi- 
cians, occupied  singly  with  the  treatment  of  this  disorder.  It  would  be  un- 
just however  to  blame  without  exception  the  numerous  attempts  that  have 
been  made  to  obtain  a  permanent  cure,  even  since  the  art  possessed  excellent 
means  of  retaining  it.  Laborers,  who  are  the  most  generally  afiected  with  it, 
derive  but  little  advantage  from  palliatives.  The  most  perfect  bandages  are 
far  from  producing  for  them  the  success  obtained  to  persons  of  a  higher  class. 
The  cushion  leaves  the  ring  nearly  always  after  several  days  or  weeks,  and 
often  the  whole  of  the  truss  soon  proves  a  new  source  of  danger. 

§  1.  Topical  Remedies^  Compression y  Position. 

The  emplastrum  contra  rupturam  of  the  ancients,  the  brick  cerate  of  J.  Fa- 
bricius,  Verduc's  vinegar  bags,  sandal  wood,  tormentilla,  turpentine,  the 
topical  applications  of  Babynet  and  Mdlle.  Devaux ;  the  famous  remedy  of 
the  prior  of  Cabriere,  which  consists  in  red  wine  being  applied  to  the  hernia, 
and  muriatic  acid  taken  internally,  the  cataplasm  of  iron  filings,  while  load- 
stone is  taken  internally,  advised  by  A.  Pare  ;  the  decoction  of  dogs^-grass 
and  of  were-wolf  used  by  Arnaud ;  the  carbonate  of  ammonia  mentioned  by 
M.  Bel  mas,  and  a  thousand  other  means  of  the  same  description,  at  present 


OPERATIVE   SURGERY.  531 

find  no  defenders  except  among  quacks  and  old  women.  It  is  otherwise  witli 
compression,  recommended  by  Celsus,  Norsia,  Blegnj,  Trecourt,  J.  L.  Petit, 
Juville,  &c.  Maintained  with  perseverance,  and  properly  applied,  it  has  fre- 
quently produced  a  definitive  cure  without  requiring  to  be  raised  to  the  point 
of  determining  gangrene  as  was  advised  in  Germany  more  than  half  a  cen- 
tury since.  Quite  recently  M.  Beaumont,  in  a  particular  treatise,  and  M. 
Duplat  of  Lyons,  in  a  memoir  addressed  to  the  academy,  have  endeavored 
to  reinstate  it  in  the  good  opinion  of  practitioners,  by  maintaining  that  com- 
bined with  astringents  it  can  cure  nearly  every  hernia.  A  surgeon  of  Pro- 
vence, M.  Ravin,  states  also  as  a  certainty,  that  topical  astringents  and  com- 
pression can  radically  cure  hernia  at  every  age.  These  means  with  him 
however  are  only  secondary,  the  foundation  of  his  method  being  the  horizon- 
tal position  of  his  patient  for  whole  months.  The  observations  of  Riviere, 
F.  de  Hilden,  Reneaume,  Arnaud,  and  Hey,  and  the  thesis  of  Rieck,  show 
all  the  benefit  to  be  derived  from  the  treatment  proposed  by  M.  Ravin — a 
treatment  which  is  said  to  have  been  generally  used  in  Denmark  in  the  time 
of  Winslow;  but  besides  the  uncertainty  of  success,  what  patient  would 
consent  to  remain  in  bed  six  months  or  a  year  for  a  tumor  which  is  so  easy 
to  retain  by  means  of  a  simple  bandage  ^  The  examination  of  these  various 
resources  belonging  properly  to  pathology,  I  can  only  give  them  a  passing 
notice,  without  pretending  to  fix  their  value  or  disadvantages. 

§  2.  Various  Operations, 

The  principal  operations  which  have  been  put  in  practice  for  obtaining  the 
radical  cure  of  ruptures,  are  cauterization,  the  ligature,  the  suture,  incision, 
excision,  scarifications,  dilatations,  and  closing  of  the  ring. 

1.  Cauterization. — If  it  were  sufficient  in  order  to  cause  an  operation  to 
be  proscribed,  to  point  out  its  dangers  and  cruelty,  and  demonstrate  its  inu- 
tility, cauterization  so  frequently  employed  in  tlie  times  of  Albucasis,  Rogei-, 
and  Guy  de  Chauliac,  had  not  been  extolled  by  so  many  practitioners  at  dif- 
ferent epochs.  But  by  denying  the  success  it  has  really  procured,  in  holding 
as  nought  whatever  of  advantage  it  may  offer,  its  antagonists  have  more  than 
once  given  the  victory  to  those  who  were  endeavoring  to  spread  its  practice. 
Avicenna  speaks  of  surgeons  who  laid  bare  the  hernia,  raised  up  its  internal 
envelope  without  opening  it,  and  cauterized  deeply  the  ring  with  red  hot 
iron.  Others,  Franco  for  example,  opened  the  sac  and  merely  touched  its 
neck  with  fire.  A  number  of  chymical  caustics  have  been  employed  for  the 
same  purpose.  The  escharotic  oil,  mentioned  by  J.  Fabricius;  the  sulphuric 
acid  of  the  empiric  Littleton,  and  which  another  quack  found  means  to  pro- 
pagate in  Paris  in  the  time  of  Arnaud ;  the  muriate  of  antimony,  potassa, 
essence  of  euphorbia,  ranunculi,  &c.,  have  each  in  turn  been  tried.  It  was 
with  the  oil  of  vitriol  that  Maget,  supported  by  Gauthier,  soon  after  unmasked 
by  Bordenave  in  the  academy,  obtained  in  1773  the  pretended  cures  which 
induced  him  to  solicit  the  favor  of  government,  and  v/hich  caused  the  death 
of  the  celebrated  Condamine.  The  potential  cautery  was  applied  on  the  skin 
in  the  form  of  a  train,  or  on  a  circumscribed  point  towards  the  neck  of  the 
hernia,  for  the  purpose  of  there  producing  an  eschar,  and  causing  the  sac  to 
suppurate  after  perforating  it.     It  appears  however  that  Monrp  and  the  naval 


532  NEW    ELEMENTS    OF 

surgeon  spoken  of  by  Sabatier,  applied  their  escharotic  also  to  the  interior  of 
the  sac.  Thus  considered,  cauterization  includes  two  quite  distinct  methods,, 
one  M'hich  relates  to  the  herniary  tunics,  the  other  which  attacks  on  the  con- 
trary the  orifice  through  which  the  organs  are  displaced.  The  first  has  the 
disadvantage  of  being  liable  not  to  penetrate  sufficiently  deep  at  first,  or  in 
the  opposite  case,  of  injuring  the  intestine  itself;  the  inflammation  it  deter- 
mines cannot  be  limited  to  the  sac,  may  reach  the  peritoneum,  and  thus  cause 
tlie  death  of  the  patient.  The  second,  which  is  not  more  entirely  free  from 
this  last  danger,  offers  at  least  the  resource  of  saving  with  more  certainty  the 
viscera,  since  the  operator  commences  by  exposing  them  and  pushing  them 
back  into  the  abdomen.  It  must  be  added  that  this  alone  offers  any  chance  of 
success.  It  is  in  this  way,  when  the  eschar  formed  at  the  opening  of  a  hernia 
has  been  occasioned  by  actual  cautery  or  any  chemical  substance,  it  leaves, 
as  a  consequence,  an  ulceration  which  can  be  cauterized  only  by  the  second 
intention.  But  as  every  cicatiix  which  is  not  the  effect  of  an  immediate 
coaptation  of  the  tissues,  is  soon  converted  into  a  firm  and  elastic  layer,  it  is 
readily  understood  what  kind  of  barrier  may  be  opposed  to  the  reproduction 
of  hernia ;  whereas  the  method  which  may  be  termed  mediate,  admitting  even 
the  most  complete  success,  will  have  no  other  effect  than  the  closure  or  oblite- 
ration of  the  sac. 

2.  Ligature. — The  manner  of  applying  a  ligature  around  hernias  when  radi- 
cal cure  is  intended,  is  by  no  means  the  same  with  all  authors.     Some  apply 
it  immediately  on  the  sac,  others  on  the  skin  without  any  previous  incision. 
Pare  saw  some  who  made  a  circular  incision,  at  the  bottom  of  which  they  tied 
a  thread.     Since  the  time  of  Paul  many  practitioners  had  also  recourse  to 
the  furrow,  but  many  of  them  afterwards  opened  the  whole  sac  to  be  certain 
that  no  organ  was  included,  in  the  ligature.     Guy  de  Chauiiac  says,  that  the 
sac  is  first  to  be  laid  bare,  in  order  to  be  seized  and  strangulated  more  surely 
at  its  base.     Among  those  who  were  content  with  the  mediate  ligature,  there 
were  some,  like  Thevenin,  who  traversed  the  whole  pouch  with  a  double  thread 
and  tied  its  two  halves  separately.     J.  L.  Petit,  who  has  slightly  modified  this 
process,  pretends  to  have  derived  great  advantages  therefrom.     Others,  men- 
tioned by  Celsus,  placed  the  integuments  between  two  plates  of  wood,  and 
compressed  them  as  with  pincers  until  they  became  gangrenous.     In  fine,  the 
oldest  process,  that  adopted  by  Saviaixl  and  Desault,  consists  in  tying  circu- 
larly the  neck  of  all  the  herniary  envelopes  so  as  to  produce  mortification 
more  or  less  promptly.     This  method,  less  barbarous  and  terrible  than  cau- 
tery, has  evidently  had  a  certain  degree  of  success.     If  Lassus  had  better 
understood  its  mechanism,  he  would  not  have  called  in  question  the  instances 
given  by  Bichat,  from  the  practice  of  Desault.     There  is  every  reason  to 
suppose  that  the  medical  societies  of  I^yons  and  Paris  would  not  so  formally 
have  proscribed  it  in  1812,  when  M.Martin  addressed  to  them  his  work 
with  a  view  to  revive  it,  if  they  had  fixed  their  attention  on  the  nature  of  the 
inodular  tissue,  which  ulceration  produced  by  the  thread  leaves  in  its  course. 
No  doubt,  after  the  destruction  of  the  integuments,  it  forms  in  front  of  the 
ring  a  cicatrix  so  firm  as  to  render  the  escape  of  the  viscera  very  difficult,  and 
thus  affords  some  chance  of  a  complete  cure.     However,  as  it  does  not  fail 
to  be  very  painful  at  times,  to  create  danger  of  peritonitis,  and  pinch  some 
portion  of  the  viscera,  unless  very  great  attention  has  been  given  to  it,  and 


OPERATIVE    SURGERY.  533 

as  on  the  other  hand,  umbilical  hernia  of  infancy,  to  which  it  is  peculiarly 
applicable,  is  often  cured  without  any  assistance,  or  under  the  influence  of  a 
simple  bandage,  this  operation  scarcely  deserves  to  be  recalled  from  the  obli- 
vion into  which  it  is  fallen,  and  the  success  recently  obtained  from  it  by  M. 
Bal,  does  not  more  enhance  its  valufe  than  the  constant  success  which  it  is 
said  to  have  upon  colts. 

3.  Suture,  The  suture  which  is  limited  to  sewing  up  the  sac  after  it  has 
been  incised,  or  simply  emptied,  is  at  first  much  more  dangerous  than  the 
ligature  as  practised  by  Desault,  since  it  requires  a  dissection  sometimes  very 
tedious  before  it  can  be  effected — and  thpndoes  not  necessarily  cause  the  for- 
mation of  an  elastic  cicatrix,  since  it  is  not  accompanied  with  loss  of  substance, 
and  has  no  other  end  than  the  obliteration  of  the  sac — it  is  evident  that  it  must 
have  less  efficacy  than  the  first  against  the  return  of  the  disease.  Besides  it  is 
not  a  generaf  method  ;  it  belongs  specially  to  inguinal  hernia  in  men  the  same 
as  castration,  consequently  it  is  unnecessary  for  me  to  dwell  longer  upon  it 
at  present. 

4.  Incision,  Incision  has  been  long  considered  as  an  excellent  means  for 
the  radical  cure  of  ruptures.  It  is  only  siAce  the  beginning  of  the  last  century 
that  surgeons  have  abandoned  it.  All  the  tunics  and  the  sac  itself  were 
divided  as  for  strangulated  hernia.  The  viscera  being  reduced,  the  dressings 
were  applied,  and  the  wound  brought  to  cicatrization  as  in  the  last  case.  The 
obliteration  of  the  sac  was  to  be  the  result  of  the  manoeuvre,  and  the  operator 
hoped  by  this  to  render  tlie  patient  secure  against  all  further  escape  of  the  in- 
testines from  the  abdomen.  Practitioners  soon  discovered  that  the  question, 
had  not  been  presented  in  its  proper  light.  J.  L.  Petit,  yielding  to  the 
advice  of  Arnaud  against  his  own  conviction  afterwards  seriously  repented  it. 
One  of  his  patients  died  on  the  fifth  day.  He  was  witness  of  another  similar 
case,  and  it  was  only  after  running  the  greatest  risk  that  a  third  was  restored 
to  health.  Acrel,  Sharp,  Richter,  Abcrnethy,  &c.,  in  pointing  out  the  same 
dangers,  have  also  shown  that  incision  of  hernia  is  of  itself  much  more  formi- 
dable than  Lieutaud  and  Leblanc  imagine.  Huermann  and  a  great  number  of 
other  practitioners  after  him,  having  remarked  on  the  other  hand  that  it  does 
not  even  succeed  in  preventing  a  return  of  the  disease,  that  persons  operated 
upon  for  strangulated  hernia  are  nevertheless  obliged  to  wear  a  truss,  it  is  not 
astonishing  that  tliey  have  banished  this  surgical  resource  from  practice. 

5.  Excision.  If  incision  could  not  be  retained  in  practice,  with  much 
more  reason  should  excision  be  proscribed.  We  cannot  in  truth  dissect,  insu- 
late, and  remove  the  sac  after  opening  it,  as  Bertrandi  advises,  without  in- 
creasing still  more  the  difficulties  of  herniotomy.  In  merely  excising  opposite 
the  ring,  a  disk  including  the  whole  thickness  of  the  envelopes  of  the  tumor 
previously  reduced,  as  also  directed  by  Lanfranc,  we  may  equally  produce 
peritonites  and  moreover  wound  the  viscera  if  they  adhere  to  the  interior  of  ■ 
the  sac.  The  excision  of  the  w^hole  herniary  sac,  it  is  plain,  would  be  attended 
with  still  greater  dangers.  It  is  truly  painful  to  find  the  detail  of  opera- 
tions of  this  kind  in  the  works  of  Arnaud,  Schmucker,  and  other  mope 
modern  surgeons. 

6.  Dilatation. — Scarifications.  Instead  of  excising  the  sac,  after  incising 
it  largely,  Leblanc  conceived  the  idea  of  applying  to  the  radical  cure  of  hernia 
dilitation  of  the  ring,  already  praised  by  the  older  surgeons,  but  particularly  by 


534  NEW  ELEMENTS  OF 

Arnaud,  for  removing  the  stricture.  Such  a  design  if  ever  seriously  proposed 
would  refute  itself.  The  idea  of  scarifying  the  ring,  an  idea  which  is  referred 
to  Leonidas,  is  less  strange ;  and  Richter  did  not  perhaps  feel  the  full  value 
of  his  assertion  when  he  said  that  small  incisions  increase  greatly  the  adhe- 
sions which  naturally  follow  the  operation.  The  eiFusion  of  lymph  which  is 
almost  the  necessary  result,  procures  effectually  the  chance  of  seeing  all  the 
tissues  mingle  at  the  opening  of  the  sac,  and  the  ring  definitively  closed.  If 
J.  L.  Petit  and  Heister  had  made  this  remark,  they  could  not  certainly  have 
maintained  that  scarifications  are  more  proper  to  relax  than  to  strengthen  the 
canal  or  hernial  opening.  It  is  evidently  to  the  same  omission  that  must  be 
attributed  the  contempt  of  Lassus  for  this  process,  and  the  silence  on  this 
subject  of  the  greater  part  of  modern  authors.  The  principal  reproach  that 
attaches  to  it  is  its  presenting  the  same  dangers  as  incision,  of  which  after  all 
it  is  but  a  simple  modification.  As  to  the  chances  of  success,  it  is  assuredly 
one  of  those  which  offer  the  most.  In  this  respect  it  is  therefore  as  worthy 
and  even  more  worthy  of  attracting  attention  than  any  other. 

7.  Br,  Jameson^s  method.  The  radical  cure  of  hernia  has  always  been 
sought  for  with  such  avidity  by  patients,  that  the  need  of  obtaining  it  has 
never  ceased  to  torment  surgeons,  and  in  our  days  many  means  are  still  pro- 
posed for  this  end.  That  of  Dr.  Jameson  of  Baltimore  deserves  particular 
mention,  as  much  on  account  of  its  originality  as  of  its  real  importance.  A 
woman  operated  upon  with  success  by  this  surgeon  for  strangulated  hernia, 
being  much  troubled  at  seeing  her  disease  return  after  several  months,  com- 
plained to  him  and  desired  to  be  freed  from  it  at  any  cost.  The  hernia  was 
crural.  Having  exposed  the  ring,  Dr.  Jameson  cut,  at  the  expence  of  the 
neighboring  integuments,  a  lancet  shaped  flap,  two  inches  long  and  ten  lines 
wide,  having  its  root  on  the  side  of  the  first  wound,  carefully  dissecting  it,  to 
invert  and  introduce  its  floating  portion  into  the  hernial  opening ;  fixed  it  in 
this  place  by  uniting  the  solution  of  continuity  which  he  had  just  made  by 
several  stitches,  and  supported  the  whole  with  an  appropriate  bandage.  The 
patient  was  completely  cured,  and  there  is  every  reason  to  believe  that  the 
stopper  engaged  in  the  crural  canal  became  engrafted  there  as  in  rhinoplas- 
rnus,  &c.  At  first  view  we  discover  nothing  but  what  is  ingenious  in  the  me- 
thod, and  can  comprehend  all  its  elements.  If  on  the  one  part,  it  is  more 
complicated,  more  painful,  and  at  least  as  dangerous  as  incision  and  scarifi- 
cation, on  the  other  it  seems  capable  of  giving  much  more  certain  results, 
since  by  this  means  we  are  sure  of  entirely  preventing  the  egress  of  the 
viscera.  However,  to  appreciate  its  value  from  a  thorough  knowledge  of  the 
case,  facts  are  necessary,  and  science  as  yet  possesses  but  the  one.  I  will 
even  add  that  this  case  has  not  all  desirable  authenticity;  that  we  can 
scarcely  understand  how,  through  respect  for  the  wishes  of  his  patient,  Dr." 
Jameson  could  have  consented  to  have  but  a  chambermaid  for  assistant  and 
witness  of  the  operation.  So  much  mystery  would  be  capable  of  raising 
doubts  in  the  mind  of  the  least  suspicious  reader. 

8.  Method  of  M.  Belmas.  More  recently,  in  1829,  and  by  a  chain  of  ideas 
with  which  I  have  nothing  to  do  here,  M.  Belmas  arrived  at  the  invention  of 
a  new  metliod,  whicli  seems  to  him  easier,  more  certain,  and  less  dangerous 
than  all  others.  He  directs  a  small  pouch  of  goldbeater's  skin  filled  with  air 
to  be  cai'rieil  in  and  fixed  to  the  superior  part  of  the  hernial  sac.    The  plastic 


OPERATIVE    SURGERY.  535 

matter  which  is  not  long  in  being  eftused,  penetrates  the  parietes  of  this  foreign 
body  and  in  some  measure  combines  with  it.     The  whole  becomes  organized, 
contracts  adhesions  with  the  ring  or  the  neck  of  the  sac,  is  transformed  by 
degrees  into  a  solid  lump,  and  in  the  end  opposes  an  almost  insurmountable 
barrier  to  the  viscera.    Numerous  experiments  upon  dogs,  support  the  asser- 
tions of  M.  Belmas.    It  remained  to  make  application  of  it  upon  man;  which 
first  took  place  upon  M.  Plessys,  a  gentleman  fifty-four  years  old  who  had  had 
an  inguinal  entero-epiplocele  for  about  thirty-four  years.    The  operation  per- 
formed by  M.  Belmas  was  followed  by  no  accident  but  by  perfect  success. 
Encouraged  by  so  splendid  a  result  the  author  communicated  his  process  to 
M.  Dupuytren,  requesting  him  to  try  it  on  a  lad  fourteen  years  old  who  was 
then  at  Hotel -Dieu  for  a  congenital  hernia  combined  with  hydrocele.    Vari- 
ous incidents  rendered  the  operation  long  and  fatiguing.    Alarming  symptoms 
followed  and  caused  much  apprehension  for  ten  days,  so  as  to  induce  M.  Bel- 
mas to  have  the  patient  removed  to  his  own  house  that  he  might  watch  him  the 
better.     However  his  health  was  gradually  restored,  and  towards  the  end  of 
the  second  month  the  hernia  as  well  as  the  hydrocele  were  radically  cured. 
A  third  attempt,  made  by  M.  Belmas  assisted  by  M.  Jaquemin  at  the  Madelo- 
nettes,  on  a  prostitute  affected  with  syphilis  and  umbilical  hernia,  was  not  so 
regular  as  to  allow  any  strict  conclusion  to  be  drawn  from  it.     A  solid  and 
permanent  cure  was  nevertheless  the  consequence  of  this  attempt,  in  other 
respects  so  incomplete.     In  a  fourth  subject  fifty-seven  years  old  afiiicted 
with  a  hydro-sarcocele,  M.  Belmas  wished  to  see  if  his  method  would  succeed 
at  least  in  closing  the  ring  and  curing  the  hydrocele.     The  pouch  became  so- 
lidified about  the  summit  of  the  tunica  vaginalis  which  was  inflamed,  and 
which  it  was  necessary  to  empty  of  a  sero  purulent  matter  with  which  the  in- 
flammation had  filled  it.     In  fine,  a  fifth  trial  was  made  by  myself,  assisted  by 
M.  Belmas  at  La  Pitie,  in  the  month  of  November  1830,  upon  a  man  about 
sixty  years  old,  who  had  had  two  inguinal  hernias  for  a  long  time,  and  who  at 
his  entrance  into  the  hospital  showed  some  symptoms  of  strangulation,  and  died 
in  consequence  of  gangrenous  erysipelas.     But  various  circumstances  unne- 
cessary to  relate  at  present  are  sufficient  to  cause  this  essay  not  to  be  reckoned. 
The  first  of  these  cases  seems  to  confirm  all  the  hopes  of  M.  Belmas.    The 
fourth,  that  of  hydro-sarcocele  has,  in  my  opinion  but  little  value  with 
respect  to  the  principal  question,  and  hardly  deserves  to  be  noticed.    The 
other  three  alone  truly  complicate  this  problem ;  still  it  must  be  confessed 
that  one  of  them,  that  of  the  prostitute,  of  itself  proves  nothing  for  or  against 
the  method.     The  child  operated  on  by  M.  Dupuytren,  seems  to  have  been 
seized  with  inflammation  of  the  gastro -intestinal  passages  and  not  peritonitis. 
In  the  case  which  I  observed,  very  strange  symptoms  were  manifested,  and 
the  material  remote  cause  of  death  was  the  gangrenous  phlegmasia  of  the  scro- 
tum.    It  is  not  clear  that  the  symptoms  met  with  in  these  two  patients  were 
to  be  referred  more  to  the  operation  in  question  than  to  any  other.     The  most 
trifling  puncture  has  sometimes  produced  them,  and  it  is  not  rare  to  see  them 
occur  spontaneously.     The  accident  to  be  apprehended  in  the  process  of  M. 
Belmas  is  peritonitis ;  but  this  phlegmasia  was  not  observed  in  the  patient 
who  died  under  my  care,  and  I  do  not  perceive  that  it  existed  in  the  little 
patient  of  M.  Dupuytren.     The  natural   conclusion  to  be  drawn   from  all 
this  is,  that  in  such  a  condition  a  puncture  or  incision  would  probably  have 


536  VEW  ELEMENTS  OF 

produced  the  same  fatal  results,  and  that  in  reality  these  facts  are  bj  no  means 
conclusive  against  the  idea  of  M.  Belmas,  if  in  other  respects  it  has  sufficient 
foundation.  This  last  question  brings  us  naturally  to  consider  the  absolute 
and  relative  value  of  the  various  methods  wc  have  already  discussed. 

§  3.  /s  itjjossihle  to  obtain  a  permanent  Cure  of  Hernia^  and  ought  it  to  he 

attempted? 

After  having  long  believed  in  tlie  efficacy  of  the  thousand  means  succes- 
sively boasted  of  as  producing  it,  the  profession  has  arrived  at  the  conclusion 
that  the  radical  cure  of  hernia  is  almost  impossible.  The  openings  through 
which  the  viscera  escape,  being  surrounded  with  bone  or  fibrous  bands  have 
not,  it  is  said,  any  tendency  of  themselves  to  close;  and  the  mind  does  not 
in  the  first  place  perceive  how  the  operations  proposed  could  determine  their 
obliteration.  Besides,  what  is  indicated  by  theory  has  often  been  confirmed 
by  experience,  for  every  body  agrees  that  the  operation  for  strangulated  her- 
nia does  not  relieve  the  patient  from  the  necessity  of  wearing  a  bandage,  if 
he  would  prevent  a  relapse.  It  remains  to  know  if  in  both  these^-espects  we 
are  not  imposed  on  by  prejudice.  If  it  is  true  that  herniotomy  does  not  al- 
ways prevent  a  return  of  the  disorder,  it  cannot  be  denie4  that  it  does  so 
sometimes,  and  even  very  frequently.  I  could  cite  many  examples ;  among 
others,  that  of  a  young  student  of  medicine  upon  whom  I  operated  in  1827; 
a  second  more  remarkable,  inasmuch  as  it  concerns  a  man  thirty  years  old 
affected  with  congenital  hernia,  upon  whom  also  I  operated  in  1824,  at  the 
hospital  of  Improvement ;  and  a  third  of  an  adult  with  an  entero-epiplocele 
of  several  years'  standing,  on  whom  Dr.  Payen  operated  in  my  presence 
about  the  beginning  of  183 1 .  The  operation  for  hernia  leaves  a  wound  which 
almost  necessarily  suppurates,  and  the  whole  extent  of  which  must  be  covered 
with  cellular  granulations  as  far  as  the  ring.  Hence  results  a  new  tissue ;  the 
base  of  the  cicatrix,  which,  by  its  great  elasticity  and  the  adhesions  which  it 
contracts  with  the  surrounding  parts,  will  certainly  tend  to  close  solidly  the 
hernial  passage.  To  understand  the  whole  action  of  the  cicatrices  in  this 
case,  it  is  sufficient  to  call  to  mind  the  displacement  caused  by  those  usually 
produced  by  burns,  variola,  &c.  But  to  arrive  at  this  result  (he  wound  must 
suppurate — its  union  must  not  be  immediate;  in  a  word,  the  whole  surface  of 
the  sac  and  the  interior  even  of  its  neck  must  have  time  to  form  cellulo-vas- 
cular  papillae.  If  the  art  has  the  power  of  radically  curing  certain  hernias, 
the  means  of  arriving  at  it  is  to  close  their  passage  by  an  inodular  cicatrix. 
Cauterization  is  evidently  calculated  to  produce  it ;  for  example,  when  it  acts 
on  ^  whole  substance  of  the  scrotal  tunics  and  reaches  the  internal  face  of 
the  neck  of  the  sac.  Ligature,  mediate  or  immediate,  offers  less  certainty, 
because  it  acts  only  from  without  inwards,  and  under  its  influence  the  interior 
of  the  ring  may  remain  free  from  all  morbid  action.  The  loss  of  substance 
from  excision  is  a  guaranty  of  success  which  cannot  but  be  appreciated.  Even 
simple  incision  no  doubt  frequently  succeeds,  iT  we  are  content  to  close  the 
wound  by  the  second  intention.  Scarification  must  excel  all  other  processes ; 
first,  because  it  does  not  expose  the  chord  to  lesion  as  much  as  cauterization, 
nor  tljc  vessels,  as  excision  ;  and  then  because  it  is  followed  with  a  cicatrix 
mttch  more  firm  than  incision  strictly  so  called,  to  which  it  adds  scarcely  any 


OPERATIVE   SURGERY.  »  537 

difficulty  and  complication.  As  to  Dr.  Jameson's  method,  if  new  cures  should 
confirm  what  has  b^en  said  by  its  inventor  I  would  consider  it  preferable  to 
every  other.  The  tegumentary  stopper  which  he  places  in  the  ring,  would 
admirably  supply  the  place  of  the  strongest  cicatrix,  at  the  same  time  allow- 
ing the  im^iediate  union  of  the  wound.  That  of  M.  Bel  mas  would  probably 
do  equally  well  if  inflammation  and  suppuration  of  the  whole  surface  of  the 
sac  did  not  often  complicate  it,  and  sometimes  render  it  dangerous.  Until 
experience  has  more  amply  tested  the  value  of  the  two  last  methods,  I  would 
accord  the  preference  to  scarifications  in  an  attempt  at  a  radical  cure  of 
hernia. 

As  a  possible  result  I  do  not  think  that  this  cure  can  hereafter  be  con- 
tested.    The  only  question  is,  at  what  price  can  it  be  obtained  r     In  itself  the 
operation  is  in  reality  neither  difficult  nor  very  delicate.     Injury  of  the  tes- 
ticle, the  chord,  the  vessels,  and  the  various  local  symptoms  it  may  bring  on, 
are  not  inevitable.     General  symptoms  and  peritonitis,  which  have  more  than 
once  been  the  consequence,  constitute  therefore 'its  principal  dangers ;  but 
will  the  few  cases  related  by  J.  L.  Petit,  Richter,  Abernethy,  &c.,  suffice  to 
settle  this  question.     The  removal  of  a  cancer,  the  operation  for  congenital 
hydrocele,  have  also  caused  death,  and  still  no  one  concludes  it  necessary  to 
proscribe  these  operations,  although  applied  to  less  serious  disorders  than  her- 
nia.    Who  will  pretend  to  say  that  accidents,  sometimes  so  serious,  produced 
by  phlebotomy,  should  be  a  cause  for  rejecting  bloodletting  ?    Is  there  a  single 
operation,  even  a  simple  puncture,  which  may  not  become  fatal  under  more 
than  one  combination  of  circumstances  ?    If  such  possibilities  always  stopped 
the  surgeon,  would  he  ever  have  occasion  to  open  a  bistourj^  or  empty  an 
abscess  ?     For  myself,  I  cannot  see  that  up  to  this  time,  observation  has  de- 
cided on  this  subject  witliout  appeal.     On  the  contrary,  I  am  disposed  to  think 
that,  justly  intimidated  by  fatal  exceptions  or  inexplicable  coincidences,  mo- 
dern surgeons  have  been  biased  in  the  examination  of  so  important  a  remedy, 
and  that  it  deserves  to  be  subjected  to  new  trials  before  it  should  be  entirely 
renounced.  But  supposing  a  desire  to  attempt  the  radical  cure  of  hernia,  it  must 
not  be  supposed  to  be  applicable  to  all  cases  without  distinction.    In  youth  it 
offers  less  danger  and  greater  c/iance  of  success.     The  two  extremes  of  life 
are  less  favorable,  on  account  of  indocility  of  children  and  the  rigidity  of  tlie 
tissues  in  advanced  life.     Old,  voluminous,  and  irreducible  hernias,  compli- 
cated with  extensive  adhesions,  are  generally  ill -adapted  to  it.    Nevertheless, 
it  may  be  employed  wifn  advantage  if  the  enterocele  and  epiplocele  are  kept 
in  the  bottom  of  the  sac  only  by  a  band  that  may  be  easily  divided  with  a 
cutting  instrument.    It  is  clearly  indicated,  for  example,  when  in  a  congeni- 
tal hernia  filamentous  adhesions  expose  the  testicle  to  painful  tensions,  and 
to  being  drawn  towards  the  ring  whenever  the  viscera  return  or  reduction  is 
attempted.     The  risk  run  by  Zimmermann  after  this  operation,  was  probably 
owing  to  the  difficulties  experienced  by  the  surgeon  rather  than  to  the  ope- 
ration itself,  and  is  of  no  weight  against  it.    In  fine,  herniotomy  will  succeed 
best  with  adults  or  persons  approaching  the  adult  state  in  enteroceles,  free 
from  adhesions,  of  small  size,  and  of  recent  occurrence.    When  the  operation 
is  to  be  performed,  the  patient  is  to  be  treated  and  placed  as  for  removing  a 
strangulation,  whatever  in  other  respects  be  the  method  adopted. 
68 


«; 


538  NEW    ELEMENTS    OF 

§  4.  Inguinal  Hernia, 

Besides  the  preceding  methods,  which  are  applicable  to  it  in  common  with 
every  other  kind  of  hernia,  inguinal  hernia  has  caused  the  invention  of  a  great 
number  of  others  which  can  only  be  mentioned  in  discussing  it  particularly ; 
such  are  in  particular  castration,  the  golden  stitch,  and  the  royal  suture. 

1.  Castration,     Some  advocates  of  excision,  of  the  ligature  or  compression 
of  the  sac,  finding  dissection  of  the  peritoneal  elongation  too  difficult,  cut  the 
knot,  by  including  the  spermatic  chord  and  tlie  sac  in  the  same  ligature. 
Hence  arose  castration^     To  perform  it,  Paul  directs  a  T  incision  to  be  made 
on  the  anterior  face  of  the  scrotum.     The  transverse  wound  serves  for  apply- 
ing the  ligature,  the  other  permits  the  extirpation  of  the  testicle.     There  are 
some  who  with  Franco  laid  bare  the  genital  gland  at  its  inferior  part,  dissected 
the  chord  and  sac  from  bejow  upwards,  tied  the  whole  near  the  ring  and  cut  it 
below  the  ligature.     In  the  last  century  some  constricted  the  chord  and  sac 
separately  before  excising  them.  Others  went  so  far  as  to  include  the  chord,  the 
sac,  and  the  scrotum  in  the  same  ligature.     This  criminal  operation,  practised 
with  a  sort  of  mania  by  the  old  surgeons,  is  novv^  forbidden  by  our  laws.     To 
suppress  the  custom  in  his  states,  Constantine  was  obliged  to  attach  to  it  the 
penalty  of  death.     Dionis  speaks  of  a  charlatan  who  fed  his  dog  with  testicles 
removed  in  this  manner.     In  1710,  Housse  v/as  sent  to  the  galleys  for  the 
same  act.     Castration  was  performed  not  only  to  cure,  but  to  prevent  hernia. 
With  this  idea  thousands  of  children  have  been  mutilated.     Women  them- 
selves had  the  temerity  to  undertake  it.     M.  A.  Prosse  was  whipped  in  1735 
at  Rheims  for  similar  misdeeds.     Since  that  period,  in  the  same  diocese,  there 
was  a  wretch  who  boasted  she.  had  performed  it  on  more  than  five  hundred 
subjects.     Some  of  our  provinces  have  been  the  theatre  of  similar  scandalous 
acts  within  a  few  years  past.     To  explain  hcv/  it  happens  that  even  at  this 
time  certain  beings  outrage  morality  and  the  laws  by  practising  this  operation 
v/ould  not  be  very  easy.     I  am  not  sure  however  if  the  fault  is  not  as  much 
ith  the  surgeons  as  with  the  public.     To  do  it  away,  gentlemen  of  the  pro- 
fession have  represented  castration  in  suth  cases  as  excessively  dangerous, 
and  capable  of  frequently  producing  death.    On  the  other  hand,  according 
to  them,  it  never  produces  a  permanent  cure,  a^d  is  always  useless ;  but  there 
is  in  these  assertions  an  exaggeration  which  over^pots  the  mark.     The  atten- 
tive perusal  of  the  old  authors  proves  that  the  imhvense  majority  of  patients 
who  submitted  to  it  did  very  well,  and  that  many  of  them  were  thus  freed  of 
their  hernia.     The  mass  of  the  community  renounce  these  errors  and  their 
prejudices  only  when  clear  and  defined  truths  are  offered  in  their  stead,  and 
not  when  an  attempt  is  made  to  oppose  them  by  other  errors.     We  must  not 
hope  to  do  away  castration  by  maintaining  that  it  is  fatal  and^eldom  succeeds, 
but  by  speaking  truly  and  showing  the  people  that  it  is  frequently  dangerous, 
that  it  does  not  always  succeed,  and  that  it  deprives  man  of  ^n  important 
organ,  and  that  it  may  bo  advantageously  supplied  by  an  operation  unattended 
with  these  inconveniences.     The  only  cases  which  permit  its  application  are 
those  of  sarcocele  and  an  incurable  degeneration  of  the  testicle  coincident 
with  bubonocele.     Notwithstanding  what  Sharp  says,  I  do  not  see  how  adhe- 
sions, whether  epiploic  or  intestinal  can  require  it,  when  at  the  time  of  celo- 
tomy  they  prevent  the  reduction  of  the  displaced  viscera.     At  the  moment 


OPERATIVE    SURGERY.  539 

of  terminating  an  operation  of  strangulated  hernia,  it  is  not  sufficient  that 
the  testicle  be  a  little  more  or  less  in  size  than  usual,  that  it  appear  a  little 
diseased,  but  it  should  be  extensively  altered  for  a  surgeon  worthy  of  the 
name  to  decide  on  its  removal ;  and  it  was  not  without  extreme  surprise  that 
I  found  recorded  in  the  most  recent  work  of  one  of  our  great  masters,  two 
cases  of  quite  an  opposite  character. 

2.  Point  Bore. — A  process,  traced  as  far  back  as  Oribasius,  which  was  in- 
tended to  avoid  the  loss  of  the  testicle,  and  at  the  same  time  produce  the 
effects  of  castration,  is  the  golden  stitch.  It  consists  in  passing  a  gold  wire 
around  the  chord  and  the  sac,  and  then  applying  compression  in  such  a  man- 
ner that  only  the  latter  shall  be  constricted;  and  then  uniting  the  wound 
without  regard  to  the  presence  of  the  foreign  body,  which  the  patient  is  to 
wear  during  the  remainder  of  his  life.  This  method  was  used  in  Denmark 
by  Bucliwall,  and  in  France  by  Berrault.  It  is  not  described  precisely  in 
the  same  manner  by  A.  Pare,  who  directs  a  wire  of  lead  instead  of  gold,  and 
tliat  it  be  removed  after  a  certain  period.  The  absurdity  of  such  a  practice 
is  sufficiently  striking  without  any  comment.  Everyone  perceives  at  first 
sight  tliat  a  ligature  so  applied  cannot  save  the  chord  more  than  the  sac,  and 
that  it  will  oftener  produce  atrophy  of  the  testicle  than  the  cure  of  the  bubo- 
nocele. 

3.  Royal  Suture.  The  suture  called  royaly  because  according  to  J.  Fabri- 
cius  its  intention  is  to  preserve  to  kings  useful  subjects,  is  far  from  deserv- 
ing the,  same  reproach  as  the  point  dore.  To  perform  it,  the  ancients  first 
dissected  the  sac,  insulated  it  from  the  surrounding  tissues,  and  then  sewed 
it  for  its  whole  length  v.ithout  touching  the  chord.  This  appears  to  have  been 
the  practice  of  the  Turks  at  the  period  when  Cantemer  wrote  his  History  of 
the  Ottoman  Empire.  But  Sharp  thought  to  improve  it  by  proposing  to  sew 
at  the  same  time  the  sac  and  tiie  integuments  near  the  ring.  In  any  way  it  is 
seen  not  to  require  the  sacrifice  of  the  testicle,  and  that  it  must  offer  greater 
probability  of  success  than  the  golden  ligature.  However,  as  this  is  in  reality 
but  the  suture  applied  to  scrotal  hernia,  and  as  scarifications  have  in  this 
place  the  same  advantages  as  elsewhere,  I  will  not  dwell  longer  on  the  im- 
portance of  the  royal  suture. 

Art.  2. — Strangulated  Hernia. 

Hernia  is  sometimes  complicated  with  accidents  which  render  it  one  of  the 
most  serious  disorders,  and  one  of  which  operative  surgery  possesses  the  sole 
remedy.  Obstruction  and  strangulation,  the  most  formidable  of  these  acci- 
dents, deserve  for  this  reason  all  the  attention  of  the  surgeon.  A  hernia  is 
said  to  be  obstructed  when  the  substances  destined  to  escape  by  the  anus  are 
arrested  in  the  intestinal  fold  which  forms  it,  so  as  to  interrupt  in  this  place 
the  passage  of  substances  whose  course  is  through  the  digestive  tube.  Stran- 
gulation is  constituted  by  mechanical  constriction  exerted  by  the  surrounding 
tissues  from  without  inwards  upon  a  portion  of  the  alimentary  canal,  so  as  to 
efface  more  or  less  completely  its  calibre,  and  powerfully  disturb  its  principal 
functions.  From  this  definition,  it  is  perceived  that  strictly  considered  there 
may  be  obstruction  without  strangulation,  and  vice  versa.  Nevertheless,  aa 
obstniction  seldom  becomes  dangerous  tut  from  the  strangulation  which  soon 


540  NEW   ELEMENTS   OF 

takes  place,  I  see  no  disadvantage  in  following  the  course  adopted  by  many 
authors,  who  consider  these  two  accidents  but  as  the  cause  and  effect  of  each 
other,  and  only  treat  of  strangulation.     In  fact,  strangulation  may  be  brought 
on  by  various  causes  without  any  change  in  its  nature.     It  sometimes  is 
effected  slowly,  at  others  suddenly ;  it  is  of  various  degrees,  is  attended  or 
not  with  inflammation,  but  it  is  not  the  less  strangulation.     The  term  incar- 
ceration^ which  Scarpa  employs  for  cases  in  which  the  intestine  is  only  dis- 
tended in  the  hernia  without  being  materially  injured,  seems  to  roe  to  be  of 
no  advantage.    Words  are  of  little  importance,  provided  they  give  a  clear 
idea  of  the  thing.     Its  mechanism  is  of  two  kinds ;  a  fibrous  opening  of  the 
abdominal  parietes  may  yield  and  dilate  at  a  particular  time  from  some  effort 
of  the  subject,  and  allow  a  portion  of  the  viscera  to  escape,  and  by  virtue  of 
its  elasticity  contract  again  so  as  to  produce  a  violent  constriction  on  the 
organ  just  passed  through.    In  this  case  there  is  a  strangulation  by  reaction 
of  the  herniary  passage.    In  other  cases  the  contained  parts  swell  and  be- 
come distended  more  or  less  promptly,  and  by  this  eccentric  movement  are 
not  long  in  producing  strangulation,  which  in  this  case  occurs  from  reaction 
of  the  incarcerated  organs.     The  first  §jenerally  appearing  suddenly,  some- 
times with  the  hernia,  or  by  the  addition  of  a  new  portion  of  viscus  in  the 
containing  sac,  being  rapidly  followed  by  inflammationj  has  received  the 
name  of  acute  or  inflammatory  strangulation.     The  second  being  developed 
only  by  degrees,  except  in  hernias,  which  are  not  habitually  reduced,  exciting 
inflammation  only  after  considerable  lapse  of  time,  constitutes  the  slow  stran- 
gulation, or  strangulation  from  obstruction ;  which,  liowever,  does  not  abso- 
lutely prevent  its  being  manifested  at  times  with  great  suddenness.     It  is 
sufficient  to  remark  that  the  openings  through  which  hernias  are  produced  are 
entirely  fibrous,  and  consequently  deprived  of  any  contractile  property  to 
show  that  spasmodic  strangulation  imagined  by  Richter  and  some  others  is 
really  impossible.     Fages  of  Montpelier,  who,  according  to  M.  Delmas,  con- 
tinued to  admit  it,  attempted  in  justification  of  his  opinion  to  transfer  this 
pretended  spasm  to  the  large  muscles  of  the  abdomen,  which  would  then 
react  on  the  hernia  by  giving  more  rigidity  and  tension  to  the  aponeurotic 
bands.    But  in  the  mind  of  any  one  who  understands  the  anatomy  of  the 
abdomen,  such  an  idea  refutes  itself,  and  does  not  require  to  be  opposed. 
However  this  may  be,  strangulation  may  act  on  various  organs  and  have  its 
seat  in  very  different  places,  a  circumstance  not  well  understood,  and  from 
which  no  advantage  can  be  drawn  in  the  treatment  unless  we  remember 
exactly  the  composition  of  hernias. 

§  1.  Anatomical  Remarks, 

Every  hernia  offers  two  things  for  consideration,  its  envelopes  and  the  vis- 
cera which  constitute  it. 

1.  Viscera.  There  is  no  organ  within  the  abdomen  which  may  not  possibly 
form  a  hernia ;  all,  however,  are  not  equally  likely  to  strangulation.  Thus 
the  bladder,  the  ovaries,  the  uterus,  the  spleen,  and  the  liver  have  been  seen 
together  or  separately  in  a  hernial  tumor.  But  with  the  exception  of  the 
urinary  reservoir,  it  can  scarcely  be  conceived  how  these  various  organs  are 
liable  to  strangulation.     The  intestine,  a  large  canal  continually  giving  pas- 


OPERATIVE    SURGERY.  54 1 

sage  to  abundance  of  substances,  must  on  the  contrary  when  its  calibre  is 
effaced,  when  it  becomes  impermeable  in  some  point  of  its  length,  disturb  the 
whole  economy  and  give  rise  to  numerous  distressing  symptoms.  A  constric- 
tion of  the  epiploon  it  is  true  does  not  explain  so  well  these  phenomena  ;^,  but 
whether  it  depends  on  tractions  exercised  upon  the  stomach  and  large  intes- 
tine, or  on  a  sympathetic  reaction  transmitted  by  the  trisplanchnic  nerve,  expe- 
rience proves  that  they  may  then  be  manifested  and  they  must  be  admitted. 
In  order  not  to  confound  these  parts  with  each  other  it  is  important  never  to 
forget  their  principal  characteristics.  The  spleen,  blacker,  softer,  and  more 
easily  torn  if  its  membrane  is  broken,  than  the  liver,  may  be  distinguished  from 
it  besides  by  the  yellowish  tint  and  granulated  appearance  of  the  latter. 
The  small  intestine  differs  from  the  large  in  its  size  and  the  regularity  of  its 
external  face.  Its  fullness  and  the  absence  of  folds  and  muscular  bands  in  the 
stomach  do  not  allow  it  to  be  confounded  with  the  one  or  the  other.  The 
fatty  appendices  of  the  colon  differ  too  much  from  the  spreading  form  of  the 
epiploon,  to  be  mistaken.  As  for  the  epiploon  itself,  as  it  may  lose  its  membrani- 
form  condition,  after  remaining  some  time  out  of  the  abdomen,  and  the  adi- 
pose flakes  which  are  often  found  on  the  external  face  of  the  peritoneum,  and 
sometimes  acquire  sufficient  size  to  simulate  hernia,  may,  if  we  be  not  on  our 
guard,  lead  unto  error  on  this  point.  However,  unless  there  are  morbid  ad- 
hesions the  embarrassment  of  the  practitioner  will  not  last  long,  if  he  call  to 
mind  that  the  omentum  is  prolonged  into  the  belly  while  the  purely  adipose 
lumps  have  their  origin  without  that  cavity.  The  blood  vessels  of  each  organ 
have  here  some  interest.  In  the  intestine  they  form  arches,  arborizations, 
and  fern-leaf  expansions  in  the  bladder,  and  also  in  the  coecum  simple  diver- 
gent arborizations  without  very  evident  arches.  Those  of  the  peritoneum  and 
its  cellular  lining  spread  into  stars  by  layers  and  in  a  very  irregular  manner. 
In  the  epiploon  their  volume  is  enormous  in  comparison  to  the  thickness  of 
the  lamellae  through  which  they  pass,  and  at  a  certain  distance  apart  they  are 
observed  following  a  direction  parallel  with  each  other.  In  the  mesentery, 
certain  venous  branches  sometimes  increase  so  much  in  size  as  to  occasion 
serious  hemorrhage  if  they  happen  to  be  opened,  a  remarkable  example  of 
which  is  related  by  Scarpa;  but  we  shall  have  to  return  to  this  subject  here- 
after. 

2.  Envelopes, — The  envelopes  of  every  hernia  contain,  as  essential  elements, 
the  integuments,  the  peritoneal  sac,  and  the  intermediate  layers.  The  skin 
presents  nothing  remarkable,  except  in  regard  to  varietes  of  thickness,  den- 
sity, and  adhesions.     With  the  sac  it  is  quite  otherwise. 

a.  Sac. — .The  name  of  sac  is  given  to  that  portion  of  the  peritoneum  drawn 
by  the  viscera  out  of  the  abdomen,  and  which  forms  the  most  immediate 
covering  of  the  hernia.  The  older  writers  had  only  confused  ideas  on  this 
subject.  They  imagined  that  descents  or  hargnes  (hernias),  which  they  also 
called  for  this  reason  ruptures  or  breaks,  took  place  through  a  rent  in  the  peri 
toneum.  At  the  time  of  Dionis  it  is  true  the  case  was  otherwise,  and  the  exist- 
ence of  the  hernial  sac  was  admitted  in  the  majority  of  cases,  at  least  it  was 
not  rejected,  except  in  certain  special  hernias,  the  umbilical  for  example ;  but 
it  is  only  since  Mauchart  and  Arnaud,  since  the  middle  of  the  last  century, 
since  the  academy  of  surgery,  that  it  has  been  regarded  as  an  essential  part 
ot  every  kind  of  hernia;  so  that  its  presence  is  now  universally  admitted.     I 


542  NEW    ELEMENTS    OF 

mistake,  the  moderns  agree  that  hernias,  in  consequence  of  penetrating  wounds 
of  the  abdomen,  the  Cassarian  operation,  ligature  of  the  iliac  arteries,  and  gas- 
trotomy,  are  usually  without  it.  When  the  bladder  is  displaced  in  its  anterior 
face,  or  the  ccEcum  in  its  adherent  face,  there  is  no  hernial  sac.  This  is  a 
fact  quite  recently  demonstrated  by  Mr.  Calson  in  opposition  to  Scarpa,  who 
has  gone  to  a  great  length  to  prove  the  contrary.  Let  us  remark  however, 
under  this  last  point  of  view,  that  it  is  more  a  dispute  about  words  than  a  real 
dift'erence  of  opinion.  In  maintaining  that  coecal  and  vesical  hernias  have  a 
sac,  Scarpa  only  meant  that  a  greater  or  less  portion  of  the  displaced  organ  is 
free  within  the  tumor,  and  that  there  is  found  there  a  prolongation  of  the  peri- 
toneum as  in  ordinary  hernia.  Mr.  Colson  does  not  think  of  denying  this 
disposition  ;  he  only  contends,  that  the  hernia  being  adherent  by  the  greater 
part  of  its  surface  the  name  of  sac  cannot  be  given  to  that  portion  of  perito- 
neum that  covers  the  rest.  Some  again  believe  that  hernias  caused  by  trau- 
matic lesions  of  the  abdomen  have  a  sac  like  the  others  unless  they  occur 
before  the  complete  cicatrization  of  the  wound  of  the  peritoneum.  This  is  a 
question  which  appears  not  to  have  been  presented  in  its  proper  light. 
When  a  penetrating  wound  is  closed  and  healed,  there  ordinarily  results  a  cica- 
trix less  thick  and  less  firm  than  the  natural  parietes  of  the  abdomen.  This  is 
explained  not  by  saying  that  the  two  lips  of  the  wound  of  the  peritoneum  are  not 
united,  but  that  instead  of  muscle  and  aponeurosis  there  is  in  this  place  but  a 
fibro-celkrlar  tissue  of  new  formation.  If  therefore  a  hernia  is  formed  through 
it,  whether  it  push  the  cicatrix  before  it  or  m.erely  displaces  by  passing  through 
it,  it  is  not  perceived  how  it  can  fail  of  being  surrounded  on  all  sides  with  peri- 
toneum, and  of  thus  having  a  real  sac.  But  this  cicatrix  may  in  some  mea- 
sure remain  independent  of  the  serous  abdominal  layer,  as  it  is  possible  that 
the  peritoneum  may  be  so  adherent  to  the  margin  of  the  opening  which 
gives  passage  to  the  viscera,  that  the  hernia  shall  receive  no  sac  from  it. 
What  takes  place  in  this  case  is  also  observed  at  tlie  umbilicus.  I  am  possi- 
tively  assured  from  dissection  that  in  general  exomphalos  has  no  internal  tunic 
which  may  be  separated  from  the  other  envelopes.  The  smooth  layer  that  has 
been  taken  for  it  is  intimately  connected  with  the  external  tissues,  and  is  de- 
veloped by  dilatation  like  that  formed  in  cyst,  usually  filled  with  diaphanous 
or  synovial  fluid,  and  not  by  displacement  or  elongation  of  the  peritoneum. 
These  remarks  bring  me  to  admit,  1st,  a  true  sac,  or  sac  by  transfer  of  the 
peritoneum;  2d,  a  false  sac  from  simple  distention  of  this  membrane,  or  any 
other  form  of  cellular  tissue;  3d,  an  incomplete  sac  for  vesical  and  coecal 
hernias,  &c.,  that  is  to  say,  that  the  hernial  pouch  is  covered  entirely  with  a 
true  serous  membrane  in  the  immense  majority  of  cases,  only  partially  in  some 
others,  and  in  the  smallest  number  of  cases  a  simple  surface  instead  of  a  mem- 
brane is  seen  (3n  its  interior;  as  for  instance,  the  uterine  cavity  presents  but 
a  mucous  surface,  while  in  the  intestines  there  is  a  real  membrane  o{  ihh  name. 
The/orm  and  volume  of  the  sac  vary  almost  infinitely.  Henuspherical, 
globular,  pyriform,  irregular,  conical,  cylindrical,  wallet-shaped,  with  a  double, 
triple,  or  guadruple  neck,  &c. — it  may  scarcely  be  larger  than  a  hazel  nut,  or 
equal  in  size  the  head  of  an  adult.  Its  internal  face  is  polislied  and  humid, 
and  does  not  differ  from  that  of  serous  membranes  in  general.  Its  external 
face  demands  a  little  more  attention.  In  the  true  sac  it  is  lined  v/ith  a  cellu- 
lar layer  which  pliiys  an  ixportant  part  in  the  hi^^tory  of  hernia.    Thia  kycr 


I 


OPERATIVE    SURGERY.  543 

is  a  portion  of  wiiat  I  willingly  call  fascia  superjicialis  interna,  or  the  fascia 
propria  of  the  peritoneum,  and  exists  throughout,  but  with  various  degrees  of 
laxity,  thickness,  and  adhesions,  over  the  different  points  of  the  abdominal 
cavity.  It  is  this  through  which  run  the  blood  vessels  generally  attributed  to 
the  peritoneum,  and  which  by  its  induration  and  gradual  condensation  pro- 
duces, what  is  called  the  thickening  of  the  sac;  and  whicli  having  undergone 
a  filamentous  or  semifibrous  transformation  gives  origin  to  that  knotty  appear- 
ance and  those  inequalities  on  the  external  face  of  certain  hernias,  and  which 
may  also  be  the  seat  of  inflammation,  suppuration,  and  morbid  alterations  of 
every  kind.  It  is  from  this  also  that  most  of  the  vessels  come  which  terminate 
beneath  the  skin  after  passing  through  the  muscles  and  aponeurosis,  and  that 
those  small  adipose  masses  arise  which,  passing  little  by  little  the  vascular 
orifices  of  the  fibrous  and  muscular  layer  and  abdominal  parietes,  in  the  end 
sometimes  make  a  projection  beneath  the  skin,  and  are  mistaken  for  real  her- 
nias. Around  the  false  sac  this  layer  intimately  blended  with  the  surrounding 
lamellae,  distinguishes  it  from  the  preceding, and  makes  instead  o^  2i  separable 
membrane,  a  surface  incapable  of  any  motion;  so  that  no  adipose  lumps, 
morbid  deposits,  nor  infiltration  of  fluids  can  possibly  be  between  it  and  the 
rest  of  the  herniary  coverings. 

The  name  of  neck,  which  is  given  to  that  portion  of  the  sac  which  remains 
in  the  herniary  opening,  might  be  advantageously  superseded  by  that  o^  root ; 
for  the  first  brings  with  it  the  idea  of  strangulation,  which  is  far  from  always 
existing,  while  the  second,  which  is  equivalent  to  the  word  origin,  will  express 
exactly  the  object  in  every  case.  However,  as  in  operative  surgery  particu- 
larly the  use  of  it  can  do  no  harm,  I  will  continue  to  employ  it.  The  neck 
of  the  sac  there,  and  I  mean  of  the  true  sac,  is  ordinarily  narrower  than  the 
body  and  fundus  of  this  pouch,  and  often  puckered  like  a  purse  in  the  ring 
that  contains  it.  If  the  hernia  is  of  long  standing,  if  they  remain  long  in 
contact,  it  is  easily  conceived  how  these  folds  may  agglutinate  and  give  to  the 
neck  in  question  a  considerable  thickness  and  power  of  resistance,  which  in 
fact  is  very  frequently  observed.  The  presence  of  several  necks  in  a  single 
hernia,  so  well  explained  by  Arnaud,  and  since  by  Pelletan  and  Scarpa,  has 
nothing  in  it  obscure  or  surprising  to  any  one  since  the  appearance  of  the 
works  of  M.  J.  Cloquet.  If  after  having  been  long  reduced  a  hernia  should 
suddenly  reappear,  the  neck  of  the  first  sack  beiug  too  narrow  to  allow  pas- 
sage to  the  viscera  v/ould  be  pushed  forward  by  them,  at  the  same  time  that 
they  carried  along  a  new  portion  of  peritoneum,  and  form  a  new  neck.  If 
the  same  thing  happen  a  second,  a  third,  and  a  fourth  time,  we  shall  have  a 
sac  with  several  necks.  AVhen  the  first  adheres  powerfully  by  a  part  of  its 
body  to  the  neighboring  tissues,  it  is  possible  tliat  the  other  only  gives  it  a 
valve-like  motion  instead  of  making  it  descend  directly  before  it.  In  this 
zaallet  the  two  pouches  are  in  front  or  at  one  side,  and  not  one  below  the 
other.  The  production  of  these  necks  is  still  possible  without  the  hernia 
having  returned.  Then  it  is  a  new  descent  which  forms  above  the  old  one. 
The  adhesion  of  a  chord  or  epiploic  mass  to  the  bottom  of  the  primitive  sac 
is  most  particularly  favorable  to  the  formation  of  a  second  neck.  Pelletan 
cites  a  case  in  which  the  epiploon  traversed  in  this  way  three  contractions  and 
fixed  itself  at  the  bottom  of  the  lowest  sac.  I  have  seen  one  quite  similar, 
another  in  which  the  superior  sac  enclosed  also  a  coil  of  intestine,  and  yes- 


544  NEW    ELEMENTS   OF 

terday  at  La  Pi  tie,  one  which  hardly  differed  from  the  first.  As  to  the 
numerous  necks  of  knotted  sacs  they  are  formed  in  quite  another  manner. 
These  are  simple  hernias  of  the  sac  between  the  fibres  of  the  fascia  propria, 
or  of  any  fibrous  layer  that  may  have  taken  its  place.  Instead  of  necks,  the 
sac  may  be  divided  by  real  septa,  and  form  one  or  more  independent  cysts 
below  the  portion  which  continues  to  enclose  the  viscera.  The  patient  ope- 
rated on  after  the  manner  of  M.  Belmas  offered  me  a  beautiful  example. 

b.  ^Aponeuroses, — The  tissues  which  separate  the  sac  from  the  cutaneous 
covering  necessarily  vary  with  the  seat  of  the  hernia,  and  cannot  be  usefully 
studied  but  on  occasions  of  each  hernia  in  particular.  I  consequently  shall 
only  for  the  moment  attend  to  the  common  cellular  tissue — the  fascia  superji- 
cialis.  When  there  are  neither  aponeuroses  nor  muscles  interposed,  the/«sc{a 
propria  and  the  fascia  superficialis  are  finally  blended  in  the  thickness  of  the 
herniary  pouch;  that  is,  no  separation  between  the  cellular  lining  of  the  skin 
and  that  of  the  peritoneum  is  distinguished.  Yet  as,  in  its  deepest  part,  it  is 
lamellar,  and  not  filamentous  nor  adipose  as  in  approaching  the  dermis,  it 
sometimes  assumes  the  appearances  of  an  aponeurosis  which  prevents  this 
confusion.  It  is  the  seat  of  the  subcutaneous  veins  and  ganglions,  and  of 
the  infiltrations,  suppurations,  and  indurations  which  are  consequent  upon 
acute  or  chronic  inflammation,  and  may  grow  to  a  surprising  thickness  even 
after  allowing  for  the  fat  naturally  found  in  it,  and  thus  remove  the  hernia 
considerably  from  the  exterior  of  the  body. 

b.  Herniary  Openings — .The  openings  which  permit  the  formation  of  ab- 
dominal hernias  are  of  several  kinds.  Some  being  accidental  frayings,  such 
as  happen  to  individuals  whose  abdomens  have  been  violently  distended  by 
pregnancy,  ascites,  a  tumor  of  any  sort,  &c.,  very  rarely  give  place  to  stran- 
gulation. The  same  remark  applies  in  great  measure  to  those  resulting  from 
penetrating  wounds  of  the  abdomen.  There  are  others  which  are  also  not 
worth  a  long  discussion.  The  orifices  which  are  found  here  and  there  in  the 
several  fibrous  layers  of  the  oblique  or  transverse  muscles  for  the  passage  of 
vessels  of  the  third  order  are  of  this  description,  and  offer  besides  this  re- 
markable fact,  that  the  masses  or  fatty  tumors,  the  pedicle  of  which  they  sur- 
round, which  enlarge  beneath  the  skin,  and  adhere  besides  to  the  peritoneum, 
may  dilate  them  and  drag  through  by  degrees  a  portion  of  that  membrane  in 
the  form  of  a  sac  or  the  finger  of  a  glove,  in  which  the  intestine  may  in  turn 
be  lodged  and  even  stratigulated,  and  constitute  a  species  of  hernia  very  em- 
barrassing to  a  practitioner  who  had  had  no  previous  notion  of  it.  Those  of 
which  it  remains  for  us  to  speak,  may  be  referred  to  two  orders :  these  are 
simple  openings  which  are  called  rings;  and  passages  of  greater  or  less 
length,  more  or  less  oblique,  and  generally  known  at  present  under  the  name 
of  canals.  At  the  umbilicus,  for  example,  the  opening  is  always  a  ring,  while 
at  the  bend  of  the  groin  it  is  always  a  canal. 

Rings. — The  first  species  is  only  met  with  on  the  points  of  the  abdomen 
where  the  aponeuroses  and  the  muscles  do  not  form  distinct  layers,  as  for 
instance  at  the  linea  alba,  or  the  flank,  the  vagina,  the  rectum,  &c.  These 
parts  being  in  fact  not  separable  into  laminae,  but  only  opened  to  allow  the 
passage  of  the  viscera,  the  hernia  arrives  under  the  skin  immediately  after 
passing  through  them,  and  has  only  to  pass  through  a  mere  circle  to  become 
formed. 


OPERATIVE    SURGERY.  545 

Canals. — The  second  is  more  complicated.  Its  entrance  and  termination 
represent  two  distinct  circles,  two  rings  sometimes  at  quite  a  considerable 
distance  apart.  It  can  only  occur  where  the  several  layers  of  the  abdominal 
parietes  are  commonly  separable.  Vascular,  nervous,  or  other  chords  occupy 
it  in  its  normal  state.  Its  passage  may  be  said  to  have  parietes,  and  depends  on 
muscles  or  other  tissues  keeping  its  two  orifices  more  or  less  apart,  and  on  its 
two  rings  belonging  to  difterent  aponeuroses.  If  its  entrance  and  exit  are 
exactly  opposite  to  each  other  the  canal  is  straight  or  perpendicular,  on  the 
contrary  it  is  oblique  when  they  are  situated  at  unequal  distances  from  tlie 
median  line,  which  is  more  frequently  the  case.  Let  us  add,  however,  that 
when  of  long  standing  hernias  tend  to  efface  the  obliquity  and  the  length  of 
their  passages  and  to  transform  them  into  simple  rings ;  and  this  by  a  mechan- 
ism easy  to  be  explained.  Pressed  in  inverse  directions  by  the  portion  of  the 
organ  that  has  come  through  and  by  that  which  tends  to  escape,  the  deep 
seated  and  superficial  aponeuroses  gradually  diminish  the  interspace  which 
naturally  separates  them,  and  finally  come  in  contact.  Taken  in  its  whole,  an 
oblique  hernial  canal  represents  pretty  much  the  shape  of  a  Z  elongated.  But 
it  is  evident,  that  the  viscera  occupying  such  a  canal,  would  from  their  own 
gravity  continually  tend  to  straighten  it  to  bring  its  openings  opposite  to  each 
other;  and  that  then,  as  in  the  preceding  case,  they  might  reduce  it  to  the  state 
of  a  ring  almost  perpendicular.  But  whether  it  be  circle  or  canal,  the  hernial 
opening  is  almost  constantly  widened  into  a  funnel  at  the  abdominal  ex- 
tremity, in  some  persons  more  than  in  others.  As,  on  the  other  hand,  the 
bloodvessels  which  border  on  the  neck  of  the  hernia,  commonly  run  in  the 
substance  of  i\\e  fascia  propria,  that  is,  between  the  peritoneum  and  the  deep- 
seated  aponeuroses,  it  results  that  they  are  generally  found  removed  from  two 
to  three  lines  at  least  from  the  fibrous  edge  which  causes  the  strangulation, 
or  upon  which  we  are  obliged  to  use  the  bistoury  to  effect  a  relaxation. 

§  2.  Seat  of  Strangulation, 

Although  it  is  commonly  at  the  neck  that  hernias  are  strangulated,  it  also 
sometimes  takes  place  in  their  body.  In  this  case  the  strangulation  is  pro- 
duced either  by  a  rupture  of  the  sac  which  has  allowed  the  organs  to  escape 
into  the  surrounding  tissues  through  an  incomplete  partition,  a  contraction,  or 
the  orifice  of  a  lateral  cell  of  this  envelope,  whether  from  an  abnormal  disposi- 
tion of  the  displaced  viscera,  or  from  bands  or  morbid  tumors.  The  twisting  of 
the  intestinal  loop  upon  itself,  for  example,  may  produce  it ;  and  so  may  an  epi- 
ploic band,  which  may  pass  in  front  of  the  intestine  as  if  to  divide  it  into  two 
portions,  before  fixing  itself  at  the  fundus  of  the  rupture ;  and  also  an  opening 
torn  in  this  membrane  in  the  middle  of  the  sac,  through  which  part  of  the 
intestine  shall  have  passed.  The  epiploon  may  also  be  rolled  into-  a  cord, 
and  fix  itself  first  to  one  side,  then  to  the  other,  so  as  to  form  a  kind  of  bridge, 
and  even  a  second  one  by  attaching  itself  again  to  the  first  wall  of  the  hernial 
cavity.  Two  of  its  prolongations  sometime  approximate  after  contracting 
adhesions  laterally,  and  unite  a  little  low'er  down ;  leaving  between  them  a  space 
which  is  also  apt  to  cause  strangulation.  All  kinds  of  bands  may  do  the 
same  as  the  epiploon.  Hey  gives  a  drawing  of  one,  which  fixed  by  its  extre- 
mities to  the  two  sides  of  the  sac  formed  a  complete  circle  in  the  middle 
69 


546  NEW    ELEMENTS    OF 

through  which  the  intestine  passed.     A  hard  epiploic  mass,  of  the  size  of  a 
large  hen's  eg^,  had  produced  strangulation  in  a  patient  whose  body  I  had  an 
opportunity  to  examine.     An  enormous  tumor  of  the  mesentery  had  produced 
the  same  result  in  a  man  operated  upon  by  Pelletan.     The, appendix  of  the 
coecum  would  also  produce  it,  if  it  should  get  into  the  hernia  and  adhere  at  its 
point.     It  is  the  same  with  the  thousand  pathological  alterations  capable  of 
compressing  the  digestive  tube  and  interrupting  the  course  of  its  contents. 
Even  inflammation  of  the  sac,  caused  by  external  violence,  may  bring  on  stran- 
gulation, as  is  proved  by  the  case  of  a  patient  published  in  tlie  Strasburgh 
collection  of  theses  (1803),  who  had  received  a  spent  ball  upon  the  scrotum. 
At  its  root  the  hernia  may  be  strangulated  at  first  in  the  manner  just  described, 
and  afterwards  by  the  opening  through  which  it  necessarily  escapes.    But 
this  opening  we  now  know  includes  several  objects,  the  constricted  portion  of 
the  peritoneal  elongation,  and  the  circle  Or   fibrous  canal  which  contains  it. 
At  first  view  it  appears  difficult  for  the  neck  of  the  sac  to  produce  strangula- 
tion of  itself.     Nothing  however  is  more  common ;  the  adhesion  of  its  folds  to 
each  other  very  much  increases  its  thickness.     Cellular  lamellae  are  then 
successively  Applied  to  its  external  face.     The  plastic  lymph  deposited  there, 
at  the  same  time  unites  the  whole,  and  insensibly  gives  to  the  part  great  den- 
sity, and  a  thickness  which  may  become  considerable ;  for  Arnaud  says  that 
it  was  more  than  half  an  inch  in  one  of  his  patients,  and  M.  Graefe  has 
noticed  the  same  fact.     A  lardaceous  and  even  semi-cartilaginous  appear- 
ance is  also  manifested  there  in  certain   cases ;  in  such  a  w  ay,  that  being 
arrested  from  without  by  the  assistance  of  the  ring,  the  thickening  is  affected 
at  the  expense  of  its  own  calibre  by  a  concentric  reaction,  the  whole  force  of 
which  bears  upon  the  intestine.     Strangulation  therefore  is  sometimes  so  far 
independent  of  the  opening  in  the  abdominal  parietes,  that  this  remains  en- 
tirely free,  and  sufficiently  large  to  allow  an  easy  movement  to  the  neck  of  the 
sac,  so  that  we  may  succeed  without  difficulty  in  making  it  repass  into  the  abdo- 
men without  diminishing  the  constriction  at  all,  if  it  has  not  been  previously 
incised.     Arnaud,  Le  Dran,  &c.,  were  the  first  to  insist  on  this  disposition, 
of  which  Riviere,  Schenck,  Littre,  and  Nuck  had  given  but  an  imperfect 
glimpse,  and  the  knowledge  of  which  has  been  made  general  by  Scarpa,  after 
Pott,  Wilmer,  Hey,  and  Sandifort.    In  France,  M.  Dupuytren  is  one  of  those 
who  have  most  frequently  met  with  it,  and  pointed  it  out  with  the  greatest 
emphasis.     Mr.  Lawrence,  who  at  first  refused  to  believe  in  it,  admits  its 
existence  in  the  last  edition  of  his  works ;  and  at  present  this  mode  of  stran- 
gulation is  no  longer  called  in  question.     It  presents  even  several  distinct 
gradations,  may  be  altogether  annular,  very  circumscribed  for  example,  and 
occupying  but  the  entrance,  the  termination,  or  the  middle  part  of  the  neck,  or 
invading  the  whole  of  this  prolongation,  and  transforming  it  into  a  kind  of  case 
or  sheath  more  or  less  compact.    The  aponeurotiq  opening,  the  part  to  which  the 
strangulation  was  formerly  almost  exclusively  attributed,  also  produces  it  in 
a  considerable  number  of  cases.     But  since  the  difference  has  been  acknow- 
ledged between  the  simple  ring  and  the  hernial  canal,  a  distinction  as  to  the 
neck  of  the  sac  has  become  indispensable  ;  that  is,  in  openings  in  form  of  a 
canal,  so  far  from  being  always  situated  at  the  external  orifice  as  was  supposed, 
it  is  equally  developed  at  the  internal  orifice,  on  an  intermediate  point,  and 
sometimes  on  these  several  parts  at  once. 


OPERATIVE    SURGERY.  547 

The  most  difficult,  and  at  the  same  time  the  most  important  point  in  stran- 
gulation, is  to  distinguish  it  clearly  from  every  other  affection.  If  the  tumor 
is  small  and  had  not  fixed  the  attention  of  the  patient,  a  too  superficial  ex- 
amination may  lead  to  the  belief  of  the  existence  of  a  violent  phlegmasia,  of 
volvalus,  poisoning,  &c.  These  mistakes  are  by  no  means  rare,  even  when 
the  hernia  is  not  very  small.  Some  days  since  a  surgeon  in  the  neighborhood 
of  Paris,  was  called  to  a  patient  whom  he  thought  aft'ected  with  gastritis,  and 
treated  accordingly.  The  symptoms  continued.  A  second  surgeon  was 
called  in  who  found  it  strangulated  hernia !  A  domestic  of  a  dignitary  of 
state  died  last  year  of  what  was  considered  intestinal  inflammation ;  after 
death  it  was  discovered  to  be  strangulated  hernia !  A  strong  and  hearty  man 
was  seized  with  violent  colics,  and  convulsive  motions ;  it  was  thought  to  be 
gastritis.  Leeches  to  the  epigastrium,  &c.,  were  ordered  for  three  days.  He 
was  carried  to  La  Pitie.  He  had  a  bubonocele  which  I  was  able  to  reduce 
forthwith.  A  little  more  knowledge  or  precaution  in  such  cases  would  easily 
prevent  error,  though  not  always,  for  the  most  skillful  are  sometimes  mistaken. 
In  1817  a  woman,  directress  of  the  infirmary  in  the  hospital  of  Tours,  was 
seized  in  the  night  with  colic,  vomiting,  &c.  I  questioned  her;  she  had 
never  had  a  rupture.  The  next  day  M.  Bretonneau  examined  her;  there 
was  no  sign  of  tumor  in  the  abdomen  or  the  groins.  However,  pain  was  in- 
creased by  pressure  in  the  hollow  of  the  thighs,  and  from  this  spot  the  colic 
seemed  to  arise.  A  strangulation  was  suspected,  but  what  was  to  be  done  ? 
Death  took  place  the  following  night.  A  portion  of  intestine  of  the  size  of 
a  walnut  was  strangulated  in  the  left  crural  ring,  and  made  no  prominence 
externally. 

Peritonitis. — A  number  of  circumstances  may  be  mistaken  for  stricture  of 
the  intestine  in  persons  affected  with  hernia — peritonitis,  for  example,  when  it 
is  accompanied  with  constipation  and  vomiting.  L^pon  the  advice  of  two  gen- 
tlemen in  consultation,  and  against  his  own  opinion,  Pott  operated  upon  a 
young  man  whose  hernia  seemed  to  be  strangulated.  There  was  no  lesion  in 
the  tumor.  The  patient  died,  but  it  was  of  intense  peritonitis.  Being  called 
to  another  case.  Pott  would  not  operate.  The  death  of  the  patient  allowed 
him  to  establish  that  the  hernia  was  not  strangulated,  and  that  inflammation 
of  the  peritoneum  had  caused  all  the  symptoms.  Mr.  Earle  was  no  less  unfor- 
tunate in  1828.  The  operation  proved  that  an  enteritis  had  led  him  into 
error,  and  that  no  strangulation  existed.  Let  us  observe  however  that  in  this 
case  the  disease  is  generally  ushered  in  by  a  chill  more  or  less  violent,  that 
the  pains  are  much  more  acute  in  the  belly  than  in  the  tumor,  that  the  vomit- 
ings are  glairy,  greenish,  and  not  stercoraceous,  and  that  the  face  tends  to 
shrink,  but  not  to  become  hippocratic. 

Inflamed  Sac. — A  no  less  difficult  case  is  the  following  :  the  sac  of  an  irre- 
ducible hernia,  or  the  intestine  which  forms  it  may  become  inflamed,  hence 
all  the  signs  of  acute  strangulation.  Hernia*  without  adhesionfe  are  liable  to 
the  same  accident.  Sometimes  however  the  ring  remains  free,  and  in  no 
manner  compresses  the  organs  passing  through  it.  To  suspect  this  condition 
the  pain  must  have  commenced  at  the  body  or  the  base,  and  not  at  the  root 
of  the  tumor ;  the  skin  itself  must  have  partaken  of  the  inflammation  from 
the  begini:ir.gj  and  it  must  be  possible  to  feel  with  ihe  ^*ger  the  laxity  of  ,i^e 


548  NEW    ELEMENTS    OF 

hernial  openings.  This  is  in  fact  sometimes  the  case.  But  when  the  hernia 
is  not  of  any  considerable  size,  how  al*e  we  to  profit  from  these  circumstances  ? 
Happily  in  this  case,  as  in  real  strangulation,  the  operation  is  the  best  remedy 
to  be  employed.  The  viscera  have  been  reduced — the  tumor  reappears — 
symptoms  of  strangulation  manifest  themselves.  The  operation  is  performed, 
and  the  surgeon  finds  only  a  pouch  full  of  fluid,  either  purulent  Or  fiocculent, 
serous  or  sanious.  This  pouch  is  the  inflamed  sac,  the  orifice  of  which  has 
been  closed  by  the  inflammation.  Numerous  cases  of  it  have  been  reported 
latterly  by  MM.  Dupuytren,  Duparcque,  Sanson,  and  Janson.  Mr.  Key 
has  also  been  deceived,  and  the  error  could  not  be  avoided  if  it  were  not  that 
it  is  almost  always  possible  to  procure  some  stools,  or  that  the  stercoraceous 
vomitings  do  not  take  place  as  in  real  hernia. 

Certain  Hydatoid  Tumors  m'dj  be  ranked  in  the  same  class,  as  appears  from 
a  case  recently  published  by  M.  Pigeotte  of  Troyes,  and  from  those  given  by 
Desault,  Dupuytren,  and  M.  Roux.     A  simple  imposthumated  lymphatic 
tumor,  an  indolent  abscess,  and  a  common  abscess  enter  with  equal  propriety 
into  this  list.     M.  Baud  of  Lou  vain,  thinking  to  operate  for  strangulated 
hernia  found  only  a  lymphatic  tumor,  the  pedicle  of  which  he  tied.     The 
symptoms  were  aggravated,  the  patient  sunk ;  and  it  appeared  from  the  au- 
topsis,  that  the  thread  applied  round  the  elongation  of  the  morbid  gland,  con- 
tained a  portion  of  intestine.     The  same  mistakes  may  arise  from  tumors 
purely  fatty,  and  have  b.een  caused  by  them  more  than  once.     Suspecting  a 
strangulation,  Scarpa  laid  bare  the  supposed  hernia,  and  found  only  a  pedun- 
culous  adipose  mass,  which  he  excised.     After  running  great  risk,  the  woman 
in  the  end  recovered.     M.  Cruveilhier  cites  a  case  in  which  the  operator,  less 
fortunate,  lost  his  patient.     A  woman  in  the  ward  of  M.  Parent  at  La  Pitie, 
was  seized  with  colics,  vomiting,  constipation,  &c.     She  had  an  old  tumor  at 
the  umbilicus.     Being  called  to  her,  I  observed  all  the  symptoms  of  strangu- 
lated hernia  and  threatened  peritonitis.     Before  proceeding  to  the  operation, 
I  thought  proper  to  prescribe  a  bath,  leeches,  cataplasms  over  the  abdomen, 
and  enemata  of  various  kinds.     They  forgot  to  transfer  her  to  my  ward,  and 
death  took  place  on  the  third  d^^y.     There  existed  an  intense  peritonitis 
having  its  point  of  departure  on  an  old  lesion  of  the  sexual  organs,  and  the 
supposed  hernia  was  nothing  more  than  a  pcdunculous  fatty  tumor.      An 
epiploic  lump  may  be  transformed  into  ^  hydatid,  or  a  hard  and  immovable 
tumor,  become  inflamed,  form  abscess,  and  be  no  less  embarrassing,  especially 
it  an  intestinal  loop  exist  simultaneously  in  the  hernia.     A  reaper  was,  sud- 
denly seized  with  colic  and  nausea,  and  at  the  same  time  perceived  that  a 
tumor  as  large  as  his  fist  had  descended  into  the  scrotum.     He  Avas  admitted 
at  La  Pitie  on  the  seventh  day.     The  hernia  was  formed  of  two  portions ; 
the  superior,  soft  and  not  very  sensible,  which  I  succeeded  in  reducing ;  the 
other  very  hard  and  larger,  which  it  was  impossible  to  return.     The  symp- 
toms, without  being  very  alarming  at  first,  continued  for  three  weeks,  and 
became  so  aggravated  that  the  patient  was  on  the  brink  of  the  grave,  when  a 
purulent  discharge  froni  his  tumor  put  an  end  to  his  sufferings  and  restored 
him  to  health.     In  the  cliivical  observations  of  Pelletan  is  a  case  very  nearly 
similar.     The  epiploon  may  also  occasion  error  in  another  way.     A  patient 
iiffected  with  abdominal  hernia  died  with  symptoms  of  strangulation.     The 


OPERATIVE    SURGERY.  549 

necropsis  showed  that  the  epiploon,  although  scarcely  diseased  without,  was 
violently  inflamed  in  the  interior  of  the  abdomen,  where  it  formed  a  kind  of 
hollow  cone,  of  which  the  base  embraced  a  preparation  of  the  stomach. 

Internal  Strangulations. — Another  species  of  disease  much  more  capable  of 
leading  into  error,  are  the  various  kinds  of  internal  strangulation,  or  obstacles 
to  the  passage  of  substances  through  the  alimentary  canal,  in  persons  who  are 
at  the  same  time  affected  with  hernia.     A  woman  forty-two  years  old,  who  for 
eight  years  had  been  affected  with  omphalocele,  came  to  the  hospital  of  the 
Faculty  in  the  month  of  March  1824  with  symptoms  of  strangulation,  and 
would  have  been  subjected  to  the  operation  if  it  had  not  been  discovered  that 
she  had  in  the  right  iliac  fossa  a  deep-seated  tumor,  hard  and  very  painful. 
This  tumor  opened  externally  and  was  emptied ;  a  stercoraceous  mass  con- 
tained in  the  coecum  constituted  it,  and  had  evidently  caused  the  constipation, 
vomitings,  &c.     Another  woman,  forty-nine  years  old,  received  in  the  same 
hospital  in  July  1825,  vomited  continually  for  twenty-four  hours  without  its 
being  possible  to  obtain  a  stool.     The  abdomen  was  tympanitic  and  exceed- 
ingly painful,  the  pulse  small,  hard,  infrequent,  &c.     There  existed  at  the 
same  time  a  crural  hernia.     On  opening  the  body  I  found  the  commence- 
ment of  the  rectum   transformed  into  a  lardaceous  tissue  and  completely 
closed.     The  merocele  had  not  suffered  at  all.     Every  tumor,  polypus,  fibrous 
or  cancerous,  originating  in  the  intestine,  will  necessarily  produce  the  same 
consequences  if  it  acquire  a  considerable  size.     A  man  about  sixty  years  old, 
a  great  eater,  who  had  remained  a  long  time  in  the  hospital  of  Tours  for 
vomitings  and  a  constipation  which  nothing  could  overcome,  at  length  died. 
The  small  intestine,  largely  dilated  above,  was  closed  about  its  middle  by  a 
cylindrical  mass  more  than  a  foot  long,  and  about  two  and  a  half  inches  in 
diameter,  partly  free  and  partly  adherent,  the  result  of  an  old  degenerated 
invagination.     If  the  hernia  with  which  this  man. had  been  formerly  affected 
had  still  existed,  the  symptoms  observed  during  life-  might  have  been  attri- 
buted to  it,  and  as  the  result  shows  altogether  improperly.     Similar  cases  are 
found  in  numbers  in  the-scientific  compilation.     A  patient  who  was  sent  to  me 
from  the  ward  of  M*  Andral  in  October  1831,  furnished  me  with  one  of  the 
most  remarkable.     The  memoir  of  Hevin,  which  contains  them  all,  proves  at 
the  same  time  that  the  different  gradations  of  invagination  have  often  resulted 
in  the  same  train  of  symptoms.     It  may  also  happen  tliat  these  symptoms  de- 
pend on  a  spiral  twisting  of  a  loop  of  tlie  small  intestine  upon  the  mesentery, 
or  on  its  flattening  against  the  spine,  of  which  the  death  of  Chopart  affords  a 
proof;  or  a  circular  stricture  of  one  part  of  the  organ  reduced  after  having 
been  long  engaged  in  a  hernial  opening,  as  in  the  case  reported  by  Ritsch  ;  or 
the  neck  of  the  sac  being  pushed  into  the  abdomen  with  the  hernia,  as  is  seen 
in  the  observations  of  Le  Dran,  Arnaud,  &c. ;  more  frequently  still  on  the  diges- 
tive tube  being  engaged,  to  the  point  of  strangulation,  in  some  slits,  or  under 
some  bands  or  appendices  of  the  abdominal  organs.     Thus  M.  Berard  has  seen 
it  enter  the  anterior  mediastinum  by  separating  the  xiphoid  fibres  of  the  dia- 
phragm ;  it  has  often  passed  into  either  pectoral  cavity  through  the  body  of 
ihe  diaphragm  itself ;  through  a  slit  in  the  epiploon  as  we  find  in  Arnaud  ;  of  ,. 
the  mesentery  as  Saucerotte  afiirms ;  through  the  foramen  of  Winslow,  and  an 
opening  in  the  transverse  mesecolon  as  observed  by  M.  Blandin  ;  between  the 
bladder  and  the  pubis,  where  an  epiploic  band  fixed  in  an  inguinal  sac  kept  it 


550  NEW  ELEMENTS  OF 

strangulated  under  the  caecal  appendix  attached  by  its  point  to  some  point  or 
other  of  the  abdominal  cavity ;  under  an  accidental  curvature  of  the  intestine ; 
an  epiploic  arch  attached  on  the  one  part  to  the  spine,  and  on  the  other  upon 
the  superior  strait  of  the  pelvis,  as  seen  by  M.  Bonnet  in  the  body  of  a  patient 
who  died  at  the  hospital  St.  Antoine ;  under  an  enormous  band  in  the  form  of 
a  T,  the  horizontal  branch  of  which  extended  from  the  liver  to  the  left  flank,^ 
and  the  vertical  portion  to  the  right  iliac  fossa;  in  fine,  under  the  thousand 
varieties  of  bands  and  chords  which  disease  or  accident  may  produce  in  the 
interior  of  the  abdomen.  The  strangulation  produced  by  these  numerous  causes, 
after  all  only  differing  from  herniary  strangulation  in  having  its  seat  in  the 
interior  of  the  splanchnic  cavity,  may  easily  induce  error  in  subjects  who  have 
also  a  visible  external  rupture.  They  are  to  be  distinguished  however  in  the 
majority  of  cases,  by  remarking  the  point  of  departure  of  the  pains  and  their 
course ;  by  comparing  the  condition  of  the  tumor  with  the  condition  of  the 
abdomen  and  vice  versa.  When  it  exists  alone  there  is  hardly  ever  a  mistake, 
but  we  are  then  to  specify  its  kind,  and  see  if  art  can  afford  a  remedy.  This  is 
a  question  that  cannot  be  discussed  at  present,  but  will  find  a  place  in  a 
subsequent  article. 

§  3.  Indications, 

It  must  be  seen  by  what  has  been  said  that  strangulated  hernia  is  an  extremely 
serious  disorder,  and  one  which  without  the  assistance  of  art  will  almost 
constantly  prove  fatal.  When  once  recognized,  therefore,  it  is  important  to 
remove  it  to  apply  a  remedy.  To  obtain  its  reduction  or  relieve  the  strangu- 
lation is  the  end  to  be  attained.  To  say  with  Richter  and  Callisen,  that  it  is 
first  necessary  to  combat  the  inflammatory  tendency,  the  pain,  &c.,  in  order  to 
diminish  the  constriction  of  the  parts,  would  be  to  take  the.  effect  for  the  cause, 
and  attack  the  consequences  instead  of  destroying  their  origin.  To  arrive  at 
this,  the  operation  is  not  the  only  means  which  the  surgeon  may  employ.  It 
is  but  a  last  resource.  Before  attempting  it,  the  taxis,  hlood-leiting,  baths, 
clysters,  opiates,  and  various  topical  applications  may  or  should  be  tried. 

1.  Taxis, — The  first  idea  that  presents  itself  when  a. patient  is  seized  with 
strangulated  hernia,  is  to  attempt  to  return  it  into  the  abdomen,  and  in  truth 
this  is  the  usual  commencement.  To  perform  the  taxis,  the  patient  is  laid 
so  that  the  muscles  may  be  easily  relaxed,  commencing,  as  Sourdiere  has  well 
shown,  with  the  sterno-mastoid  muscles;  not  as  is  generally  supposed  that 
this  position  favors  the  reduction  by  permitting  the  aponeurotic  openings  to 
yield  and  enlarge,  but  because  the  contrary  position  favors  much  more  the 
expulsion  than  the  return  of  the  viscera,  lessens  rather  then  enlarges  the  ab- 
dominal cavity.  He  is  then  to  make  no  effort,  no  movement,  but  to  remain 
perfectly  relaxed.  The  surgeon  placed  on  the  rights  grasps  the  tumor  with 
one  hand,  draws  it  a  little  towards  him  so  as  to  disengage  it  from  the  ring, 
seizes  it  at  the  neck  with  the  first  two  or  three  fingers  of  the  other  hand,  then 
pushes  it  up  in  small  portions,  commencing  with  those  which  have  last 
escaped,  and  directing  them  in  the  axis  of  the  herniary  opening.  As  soon  as 
one  portion  is  reduced,  the  fingers  of  the  second  hand  retain  it  and  prevent 
its  return,  while  the  right  endeavors  to  reduce  another  portion,  and  so  on 
until  a  .nass  remains  small  enough  to  be  retumed  at  once  under  the  influence 


OPERATIVE    SURGERY.  551 

of  proper  pressure.  When  the  reduction  takes  place  freely,  this  last  portion, 
pushed  by  the  extremities  of  the  five  fingers  of  the  first  hand,  passes  through 
without  stopping,  and  gives  out  a  characteristic  sound  called  gargouillement, 
a  sound  which  is  caused  by  the  fluid  heretofore  imprisoned  in  the  displaced 
intestinal  loop,  quickly  leaving  it  to  restore  an  equilibrium  in  the  whole  canal. 
Epiplocele,  which  is  besides  distinguished  by  its  uneven,  rugged  form,  by  its 
soft,  clammy  consistence,  produces  no  gargouillement,  and  does  not  yield  with 
as  much  facility  as  enterocele.     The  taxis  should  be  performed  according  to 
the  same  rules  in  both  cases,  that  pressure  may  be  carried  much  farther  in  the 
second  than  in  the  first  without  inconvenience.     When  after  some  time  a 
portion  of  the  hernia  disappears  suddenly  and  with  noise,  while  tlie  remain-- 
der  rests  stationary  in  the  sac,  it  may  be  concluded  that  there  has  been 
entero-epiplocele,  and  that  it  is  the  intestine  that  is  reduced.     It  is  propA' 
however  not  to  forget  that  enterocele  strangulated  by  obstruction,  may  easily 
be  mistaken  for  epiplocele,  and  that  its  reduction  is  not  always  accompanied 
with  a  sound  of  gargouillement.     If  the  tumor  is  small,  the  fingers  of  the 
left  hand  may  be  employed  to  support  its  circumference,  while  those  of  the 
right  press  upon  it  in  every  direction.     Even  when  it  is  of  a  considerable 
size  we  may  endeavor  to  restore  it  en  masse  if  the  strangulation  is  not  very 
decided,  and  if  the  hernia  has  passed  through  a  simple  ring.     We  may  also, 
when  it  is  very  large,  grasp  it  with  both  hands  and  compress  its  whole  surface 
at  once,  as  for  emptying  a  bladder  full  of  fluid.     The  gas  and  semi-fluid 
matter  thus  compressed,  sometimes  re-enter  the  abdomen  so  as  to  remove  the 
strangulation,  or  singularly  facilitate  the  after  reduction  of  the  viscera.     This 
process  has  succeeded  with  me  a  number  of  times.     Moreover,  after  vainly 
trying  one  mode  we  should  attempt  another,  and  the  taxis  is,  after  all,  an 
operation  which  practice  and  the  anatomical  knowledge  and  intellectual 
resources  of  every  one  teach  better  how  to  perform,  than  all  the  details  found 
in  the  best  authors.     To  repeat;  put  the  parietes  of  the  abdomen  in  a  state 
of  relaxation ;  support  the  neck  of  the  tumor  with  one  hand  while  pushing  it 
back  with  the  other,  so  as  not  to  let  it  bend  over  the  edges  of  the  ring  instead 
of  going  through  it;  disengage  it  a  little,  lengthen  it,  knead  it  in  a  manner  so 
as  to  spread  its  contents  over  as  great  a  surface  as  possible;  grasp  it  largely 
with  the  hands  or  the  ends  of  the  fingers,  as  its  size  may  admit;  have  it 
grasped  even  by  the  hands  of  an  assistant  if  very  large,  while  the  surgeon 
himself  holds  the  root;  urge  it  back  by  the  same  passage  through  which  it 
has  issued  ;  suspend  the  efforts  and  resume  them  shortly  after ;  vary  their 
direction  and  energy ;  use  them  to  the  best  advantage,  but  be  cautious  of  car- 
rying them  80  far  as  to  create  danger;  these  are  the  only  rules  the  operator 
requires  in  performing  the  taxis.     I  will  add  that  in  large  hernias,  particu- 
larly the  epiploic  or  obstructed  it  is  often  useful  to  continue  the  taxis  by  means 
of  a  methodical  compression,  until  it  can  be  resumed  with  the  hand,  when  it 
has  not  completely  succeeded  at  first.     In  1825,  a  man  forty-seven  years  old, 
affected  with  an  enormous  entero-epiplocele,  was  admitted  into  the  hospital  of 
Improvement.     Attempts  at  reduction  frequently  repeated  on  the  evening  of 
his  entrance,  and  the  next  day  were  attended  with  no  success;  but  as  there 
was  no  sign  of  inflammation,  and  the  symptoms  made  slow  progress,  it  was 
decided  to  wait.    The  second  day  the  action  of  the  hand  was  again  attempted, 
and  the  intestine  was  in  part  reduced.    To  prevent  its  return,  I  forced  the 


552  NEW  ELEMENTS  OF 

whole  tumor  in  a  suspensory  bandage  furnished  with  compresses.  I  thus  suc- 
ceeded in  exerting  an  exact  and  considerable  pressure  upon  it,  which  reduced 
it  one  half  in  the  course  of  the  night,  so  that  the  taxis  then  succeeded  without 
difficulty. 

The  smoothing  iron,  the  piece  of  lead,  and  the  bladder  filled  with  mercury, 
applied  as  weights  upon  the  hernia,  in  which  Wilmer  and  some  other  English 
surgeons  say  they  find  so  much  to  recommend,  are  in  reality  but  compressing 
means,  of  which  an  appropriate  bandage  will  always  advantageously  supply 
the  place.  If  the  taxis  has  the  advantage  of  often  rendering  a  serious  and 
painful  operation  unnecessary,  it  is  itself  far  from  being  entirely  unattended 
with  danger.  The  viscera  in  which  the  circulation  is  badly  conducted,  irri- 
tated by  the  constriction,  and  already  more  or  less  inflamed,  must  become 
still  more  violently  inflamed  under  this  pressure.  It  is  well  known  that 
unless  we  proceed  with  all  possible  care,  it  will  be  very  easy  to  contuse  them, 
to  bring  on  mortification,  or  tear  them  and  expose  the  patient  to  the  greatest 
danger.  Thus  for  a  long  time  it  has  been  remarked  that  the  operation  was  so 
much  the  less  likely  to  succeed  as  the  attempts  at  reduction  had  been  more 
numerous.  There  are  some  persons,  says  Petit,  who  will  succeed  at  any  cost, 
and  boast  of  reducing  every  hernia;  they  compress,  bruise,  and  inflame  the 
intestine,  and  it  is  always  with  repugnance  that  I  perform  the  operation  on 
patients  who  have  undergone  such  trials.  Pott  directs  that  we  should  not 
wait  longer  than  two  hours.  After  he  had  formed  a  custom  of  acting  with 
this  promptness,  nearly  all  his  patients  got  well.  Previously  he  had  lost  half. 
Comparative  trials  made  at  Hotel  Dieu,  had  proved  to  him  that  the  proportion 
of  success  after  celotomy  was  considerably  gi'eater  in  patients  operated  upon 
without  having  been  fatigued  by  the  taxis  than  in  others.  At  the  hospital  of 
Orleans,  where  the  operation  was  performed  from  the  first,  Leblanc  was 
rarely  unsuccessful ;  while  at  Paris,  where  it  was  left  until  very  late,  most  of 
the  subjects  died.  It  was  for  this  reason  that  Richter  attempted  to  proscribe 
the  taxis.  He  declares  that  he  has  rarely  seen  a  hernia  really  strangulated 
reduced  by  this  means,  and  contends  that  those  which  have  yielded  to  it 
would  have  gone  back  of  themselves  a  few  hours  later.  These  apprehensions, 
a  little  exaggerated,  are  only  well  founded  in  the  cases  of  enterocele  and  in- 
flammatory strangulation.  The  attempts  must  have  been  very  awkwardly 
prolonged  to  cause  the  suppuration  of  the  epiploon  noticed  by  Arnaud,  and 
immediate  gangrene  of  the  enterocele  from  obstruction,  &c.;  but  it  is  readily 
conceived  that  in  acute  strangulation  the  taxis  if  unsuccessful  may  become 
dangerous,  and  render  the  operation  infinitely  more  formidable  than  if  it  had 
been  but  feebly  exercised.  However,  in  abandoning  it  too  early  we  are  liable 
to  perform  a  grave  operation  without  necessity.  Sometimes  by  renewing  our 
attempts,  twice,  thrice,  or  even  six  times,  we  succeed  in  reducing  a  painful 
hernia  which  had  resisted  all  previous  endeavors.  In  other  cases  attempts  no 
less  numerous,  although  unsuccessful,  have  not  prevented  herniotomy,  per- 
formed after  the  lapse  of  two  or  three  days,  from  succeeding  completely.  In 
fine,  a  strangulated  hernia  has  been  seen  so  frequently  reduced  by  one  surgeon 
after  having  been  vainly  attempted  by  another,  that  it  is  difficult  not  to  hesi- 
tate when  it  is  proposed  to  abandon  the  taxis.  A  porter  next  door  to  me  had 
an  old  hernia  which  was  strangulated  in  the  morning,  only  in  consequence  of 
a  single  effort,  and  notwithstanding  his  bandage.     During  the  day  there  were 


OPERATIVE    SURGERY.  55S 

three  failures  in  the  attempt  to  reduce  it.  I  saw  him  at  eight  o'clock  at  night. 
His  suiFering  and  agitation  were  extreme.  He  could  not  be  touched  without 
uttering  piercing  cries.  The  whole  pain  was  in  the  tumor,  which  seemed 
unable  to  bear  the  least  pressure.  I  would  not  hazard  an  operation  however 
before  trying  the  taxis  again.  I  obtained  nothing  at  first  but  a  quick  and  in- 
voluntary-motion  in  the  patient,  while  a  second  effort  returned  the  whole  of 
the  intestine.  The  symptoms  disappeared  immediately,  and  the  next  day  this 
man  was  able  to  resume  his  ordinary  occupations.  In  the  month  of  March 
1825,  M.  Demay  requested  me  to  see  with  him  at  the  barriere  de  Sevres,  a 
woman  who  had  been  laboring  under  a  strangulated  merocele  for  thirty-six 
hours.  The  tumor  was  of  the  size  of  a  small  egg,  very  hard,  painful,  and 
evidently  formed  by  the  intestines.  After  subjecting  it  to  the  taxis,  I  thought 
that  it  had  considerably  diminished  and  would  not  operate.  I  returned  there 
the  next  day,  and  attempted  the  reduction  with  no  more  success  than  before. 
However,  as  I  found  it  in  the  end  less  in  size,  I  persisted,  and  the  operation 
was  deferred  a  second  time.  Twenty-four  hours  after,  at  our  third  visit,  we 
were  all  disposed  to  wait  no  longer,  l3ut  to  relieve  the  strangulation  immedi- 
ately; and  when  I  least  expected  it,  this  hernia  disappeared  under  my  fingers, 
and  two  days  afterwards  the  patient  was  in  good  health.  Although  these  cases 
tend  to  prove  that  in  general  we  must  not  take  too  literally  the  advice  of  Pott, 
or  Richter,  and  set  aside  the  taxis  from  the  first,  yet  I  do  not  mean  that  they 
should  give  too  much  boldness  to  the  young  practitioner.  It  is  but  too  com- 
mon to  see  in  our  days  what  Petit  might  exclaim  against,  as  in  his  own  time. 
**  How  often  is  it  seen  that  patients  die  the  same  day  the  reduction  has  been 
made.  In  some  the  gut  is  found  gangrenous ;  in  others  it  is  burst,  and  fecal 
matter  poured  into  the  abdomen."  If  we  are  to  believe  a  medical  journal, 
this  accident  happened  in  the  month  of  x\pril  last  in  one  of  our  great  hospitals, 
the  very  day  on  which  the  surgeon  had  dilated  upon  the  dangers  of  forcible 
taxis.  I  know  besides  that  this  misfortune  happened  a  short  time  after- 
wards in  the  same  establishment.  In  both  cases  the  intestine  was. torn,  and 
The  Lancet  relates  similar  accidents  occurring  in  the  London  hospitals,  one  in 
particular  under  the  care  of  Mr.  Calloway.  The  case  mentioned  by  Lassus 
is  not  at  all  surprising,  since  the  young  man  had  conceived  the  singular  idea 
of  using  a  stick  by  applying  one  end  on  the  tumor  and  the  other  against  a 
wall.  Therefore  the  point  is  not  to  reduce  it  at  any  risk,  but  only  to  know 
how  to  make  use  of  the  taxis  properly.  Small,  recent,  and  painful  hernias 
bear  it  ill ;  because  the  opening  which  gave  them  passage  is  narrow,  and  very 
tight ;  because,  moreover,  the  intestine  thus  bridled,  inflames,  becomes  altered, 
and  often  gangrenes  'with  the  greatest  rapidity.  The  same  may  be  said  of 
hernias  which  reappear  suddenly,  and  become  strangulated  after  having  been 
long  retained  by  a  truss.  It  is  so  much  the  more  dangerous  as  the  subject  is 
younger,  more  robust,  and  more  irritable.  In  chronic  strangulation  it  would 
be  imprudent  to  operate  before  recurring  to  it  several  times,  and  that  even 
with  considerable  force.  The  most  of  old  hernias  are  of  this  class.  The 
presence  of  the  epiploon,  of  a  layer  of  fat,  or  of  a  portion  of  the  large  intes- 
tine in  the  sac,  diminish  its  dangers,  because  these  several  objects  resist  pres- 
sure better  than  the  small  intestine.  For  the  rest  it  is  not  the  time  elapsed 
since  the  appearance  of  the  first  symptoms,  but  rather  the  state  of  the  parts 
which  should  regulate  its  application.  In  some  subjects,  gangrene  or  ulcera- 
70 


554  NEW   ELEMENTS   OF 

tion  supervenes  almost  immediately  upon  strangulation.  M.  Larrey  found  it 
to  occur  in  two  hours,  Richter  after  the  lapse  of  eight,  and  Mr.  Lawrence  at 
the  end  of  twelve;  while  in  other  cases  apparently  similar,  it  had  not  been 
manifested  on  the  fifth  or  sixth  day.  In  1824,  at  the  hospital  of  Improve- 
ment, I  operated  upon Moliere,  who  had  been  four  days  affected  with 

strangulated  hernia.  The  intestine,  although  livid,  was  not  mortified,  and  the 
cure  readily  took  place.  Some  months  afterwards  another  patient  was  car- 
ried to  the  same  establishment,  to  be  there  operated  upon  for  a  similar  accident. 
The  symptoms  which  had  existed  but  twenty -two  hours,  were  exhibited  with 
less  intensity  than  in  the  first.  The  hernia  as  in  that  case  was  crural.  How- 
ever, the  intestine  was  perforated,  and  notwithstanding  its  liberation  the 
patient  died  during  the  night.  On  inspection  of  the  body,  alimentary  sub- 
stances were  found  efiused  in  the  abdomen,  and  gangrene  had  invaded  a  great 
part  of  the  digestive  tube. 

As  long  as  the  skin  is  neither  red  nor  very  sensible,  nor  positively  inflamed, 
while  direct  pressure  upon  the  tumor  does  not  too  much  increase  the  suffering, 
and  while  there  is  no  very  evident  sign  of  a  true  inflammation  of  the  abdomi- 
nal peritoneum,  nothing  obliges  us  to  abstain  from  it  unless  it  has  already 
been  tried  by  experienced  persons.  In  the  contrary  case  it  would  be  best  to 
renounce  it,  unless  no  attempt  whatever  has  been  previously  made.  Every 
thing  is  then  to  be  apprehended,  supposing  even  that  we  succeed,  in  returning 
into  the  abdomen  a  half  mortified  intestine,  if  not  a  perforated  one,  and  the 
dark  putrid  matters,  more  or  less  acrid,  which  usually  surround  the  sac. 
When  it  is  much  inflamed,  the  operation  is  cseteris  paribus  the  most  certain 
means  to  propose  to  the  patient.  It  is  scarcely  more  dangerous  at  this  mo- 
ment than  the  taxis,  and  has  the  advantage  over  it  of  removing  immediately 
every  obstacle,  and  of  not  aggravating  the  condition  of  the  viscera  contained 
in  the  tumor.  If  deferred,  it  will  not  be  the  same.  The  organs,  contused, 
lacerated,  or  gangrenous,  do  not  offer  the  same  hopes  of  success,  and  the  ope- 
ration perhaps  may  only  hasten  the  transmission  of  the  disease  to  the  interior, 
and  consequently  its  fatal  termination. 

Instead  of  placing  the  patient  as  described  above,  some  surgeons,  Winslow 
among  others,  were  in  the  habit,  in  the  last  century,  of  putting  them  on  their 
knees,  the  head  low  and  resting  on  the  elbows,  while  the  taxis  was  performed, 
some  credulous  or  bigoted  souls  took  occasion  from  this  to  induce  the  indivi- 
duals thus  prostrate  to  make  fervent  prayers,  pretending  that  if  in  this  posture 
their  hernia  was  reduced,  that  it  was  to  the  divine  interposition  they  should 
ascribe  it.  A  practice  much  more  ancient,  used  also  by  Louis,  Hey, 
M.  Ribes,  &c.,  and  which  M.  Jobert  says  was  successfully  followed  by 
M.  Girauld,  consisted  in  seizing  the  legs  of  the  patient  and  hanging  him  up  by 
the  hams  upon  the  shoulders  of  an  assistant  who  gently  jarred  him,  while  his 
head  and  back  rested  upon  the  bed,  or  while  another  person  performed  the 
taxis.  It  is  possible  that  this  resource  may  not  be  of  much  value,  but  it  does 
not  seem  to  me  to  deserve  the  neglect  into  which  it  is  fallen,  nor  the  ridicule 
which  has  been  cast  upon  it  at  the  present  day.  Mr.  Lawrence  is  evidently 
mistaken,  when  he  says  that  the  abdominal  viscera  are  too  exactly  supported 
throughout  for  the  simple  position  of  the  patient  to  carry  them  more  in  one 
direction  than  another.  We  may  every  moment  have  proof  of  the  contrary 
by  observing  on  ourselves  that  the  intestines  float  always  to  the  most  depend- 


OPERATIVE    SURGERY.  555 

ing  point  of  the  abdomen ;  in  the  vertical  position  towards  the  hypogastrium, 
and  towards  one  or  the  other  side  when  we  lie  on  the  right  or  left.  I  conceive 
then  that  by  holding  the  patients  by  the  hams  there  is  some  chance  of  the  dis- 
placed organs  leaving  the  hernia  to  be  carried  towards  the  diaphragm,  which 
in  this  case  becomes  the  inferior  wall  of  the  abdomen.  There  would  be  dan- 
ger in  doing  so,  for  the  same  reason,  if  tlie  intestine  or  peritoneum  be  already 
inflamed  or  if  from  any  other  motive  whatever,  we  have  to  dread  all  kind  of 
dragging  on  the  part  of  the  abdomen  or  the  hernia.  For  the  purpose  of  me- 
thodising and  generalising  this  succussion,  Linacier  of  Chinon  invented  in 
1819  a  kind  of  pivot  bed  or  tumbril  covered  with  cushions,  upon  which  he 
fixed  the  patient  so  as  to  shake  him  more  or  less  briskly  by  alternately  letting 
fall  and  raising  the  head  of  this  apparatus.  However  ingenious  it  may  seem, 
this  bed  was  not  adopted  and  should  not  have  been  so.  In  the  first  place  it  is 
not  to  be  found  every  where,  and  is  not  indispensable,  and  then  the  patients 
are  stretched  upon  it  at  full  length,  while  by  suspending  them  by  the  hams 
they  may  be  kept  flexed,  and  greatly  bent  upon  their  anterior  plane.  If  suc- 
■cussion  is  to  be  tried,  this  last  mode  of  operating  ought  to  be  preferred  as  the 
most  simple,  least  dangerous,  and  quite  as  efficacious  as  any  conceivable  ma- 
chine. I  need  not  here  remark  that  the  taxis  ought  to  be  renewed  with  all 
possible  care,  while  the  assistant  or  assistants  keep  the  patient  suspended ;  that, 
as  in  the  case  of  the  young  man  mentioned  in  the  Lancet,  it  would  be  well 
also  to  draw  the  abdominal  wall  upon  the  side  opposite  the  hernia,  and  that  the 
concussions  upon  the  pelvis  are  not  indispensable. 

2.  Baths, — If  the  hernia  is  obstinate,  the  taxis  should  not  be  employed  alone. 
The  bath  is  an  accessory  which  is  then  scarcely  ever  to  be  neglected.  It 
calms  or  diminishes  the  pain,  the  spasm,  the  rigidity  of  the  tissues,  the  tenes- 
mus, and  inflammation  itself  if  exisiing.  It  is  used  of  the  temperature  of  28° 
or  30°  Reaumeur  (100°  Fahrenheit)  or  a  little  lower.  The  patient  remains  in 
it  from  one  to  two  hours.  Desatilt  directs  a  cloth  suspended  at  its  four  corners 
so  as  to  make  a  kind  of  bed  of  the  body  of  the  bathing  tub,  where  the  patient 
may  lie  moderately  flexed  and  be  subjected  to  further  attempts  at  reduction. 
Some  practitioners  repe9<:  it  once  and  even  several  times  during  the  day,  that 
is,  when  the  tumor  is  Piore  urgent  or  the  operation  not  decided  on.  However 
if  more  powerful  means  have  been  employed  it  would  be  useless  to  have  recourse 
to  it,  and  lose  precious  time  in  inefi'ective  efforts.  Although  the  warm  bath  is 
proper  in  almost  every  species  of  strangulation,  it  is  in  acute,  inflammatory, 
intestinal  strangulation,  in  young  and  robusts  subjects,  that  it  ought  particu- 
larly to  be  ased.  As  it  has  not,  like  the  taxis,  the  disadvantage  in  case  of 
failure  of  increasing  the  danger ;  as,  if  the  operation  may  have  become  indis- 
pensable, it  can  only  be  favorable  to  success,  there  is  no  reason  to  neglect  its 
use  except  in  cases  which  will  not  allow  us  to  temporize. 

3.  Bloodletting, — The  unanimity  of  surgeons  in  regard  to  the  utility  of  warm 
batliing  in  cases  of  herniary  strangulation  is  not  so  complete  upon  that  of  blood- 
ietting.  Although  extremely  extolled  by  Dionis,  by  almost  all  the  academy 
of  surgery,  by  Pott  more  than  any  one  else,  and  recommended  by  the  most 
distinguished  authors  of  our  day,  it  has  been  as  it  were  proscribed  by  Wilmer, 
Alanson,  and  Sir  Astley  Cooper.  Dr.  Hey  also  acknowledged  that  it  is  most 
frequently  useless,  and  that  it  was  necessary  to  restrain  its  use.  The  surgeon 
of  Coventry  condemns  it  as  enfeebling  the  patient  without  favoring  th€  reduc- 


556  '         NEW    ELEMENTS    OF 

tion  in  the  least.  It  has,  says  he,  influence  neither  upon  the  aponeurotic 
opening,  nor  on  the  strangulated  viscera;  it  can  no  more  enlarge  the  one  than 
diminish  the  size  of  the  others  ;  in  fine,  it  remains  to  be  proved  whether  blood- 
letting has  ever  removed  a  well  attested  strangulation.  To  these  objections, 
the  principal  fault  of  which  is  their  being  too  absolute,  we  have  first  to  oppose 
the  experience  of  every  age,  which  has  often  demonstrated  that  a  hernia 
resisting  the  taxis  until  then,  has  been  very  easily  reduced  after  copious  bleed- 
ing. By  producing  a  general  shock,  this  means  is  calculated  to  facilitate  the 
return  of  the  displaced  organs,  to  diminish  the  resistance  of  the  muscles,  the 
engorgement  of  the  tissues,  local  congestion,  by  consequence  the  volume  of  the 
strangulated  parts,  and  thereby  all  inflammatory  fluxion.  Carried  to  syncope, 
bloodletting  puts  in  motion  the  peristaltic  action  of  the  intestines,  so  that  after, 
they  return  completely  of  themselves  under  its  influence.  Thus  it  will  be 
well  when  we  wish  to  attain  this  end,  to  open  the  vein  largely  and  keep  the 
patient  erect  during  the  bloodletting.  To  understand  the  importance  of 
bloodletting  it  is  necessary  to  specify  the  cases  that  require  it.  Obstruction, 
epiplocele,  and  every  species  ojp  strangulation  in  the  aged  would  be  rather  ag- 
gravated than  diminished  by  it.  Delicate  subjects  and  old  hernias  do  not 
bear  it  without  inconvenience  unless  it  is  formally  indicated  by  well  marked 
inflammatory  symptoms.  On  the  contrary,  in  young  and  robust  persons  ^vvith 
recent,  acute,  intestinal  strangulation,  it  is  of  incontestible  utility,  and  should 
rarely  be  neglected  were  it  but  to  extinguish  or  lessen  the  phlegmasiac  move- 
ment tending  to  invade  the  abdomen.  It  would  be  improper  however  in  any 
case  to  fix  upon  it,  like  Pott,  an  exaggerated  value.  It  v/ould  not  be  very  ra- 
tional to  depend  on  its  efiicacy  after  repeating  it  two  or  three  times,  even  in 
patients  in  whom  it  is  best  indicated.  It  is  an  accessory  means,  which  like 
the  bath  will  rarely  of  itself  suffice,  and  in  truth  only  deserves  so  much  con- 
fidence, because  it  serves  at  the  same  fniie  as  a  precaution  against  future 
accidents 

4.  Purgatives, — In  the  last  century,  Legrane.,  a  surgeon  of  Aries,  proposed 
the  use  of  Epsom  salts  as  a  kind  of  panacea  in  sti;»ngulated  hernia.  Accord- 
ing to  him  this  medicine  incites  and  titillates  t\ie  htestine,  and  frequently 
causes  it  to  re-enter  the  abdomen  and  discharge  tK<^  niatters  which  may  have 
accumulated  therein.  Most  violent  purgatives,  emetics  m  nauseating  doses, 
ipecacuhanha  for  example,  have  been  also  recommended.  Richter  and  He- 
berden,  who  have  employed  them,  profess  to  have  obtainexl  real  advantages 
from  this  exhibition.  In  France  they  have  never  enjoyed  mu^h.  reputation, 
and  the  medical  ideas  attempted  to  be  spread  for  the  last  twenty  years,  have 
not  been  of  a  kind  to  bring  them  into  favor  among  us.  Although  their  irritating 
action  is  infinitely  less  dangerous  than  some  have  imagined,  yet  in  my  opinion 
it  would  be  hazardous  to  trust  to  them  in  acute  or  inflammatory  strangulation. 
I  would  employ  them  freely,  on  the  contrary,  when  there  is  only  epiplocele, 
or  fatty  hernia,  and  the  course  of.  substances  is  not  mechanically  interrupted 
in  the  digestive  tube ;  and  even  in  entcrocele  w^hich  is  only  strangulated  from 
obstruction  and  does  not  threaten  inflammation.  As  they  solicit  the  secretion  or 
exhalation  of  a  great  quantity  of  fluid  and  a  vernacular  motion  more  evident 
in  the  superior  portion  of  the  canal,  as  they  may  produce  the  re-establishment 
of  the  stools  or  the  softening  of  the  obstructing  substances,  it  is  easily  con- 
ceived how  they  may  have  had  success,  and  still  preserve  partisans,  as  M. 


OPEUATIVE    SURGERY.  557 

Gaussail  gives  proof  quite  recently  in  the  weekly  journals.  But  it  is  a  species 
of  remedy  too  difficult  to  manage,  too  treacherous,  and  too  rarely  useful  for  me 
to  venture  formally  to  recommend  it.  The  following  however  is  a  case  which 
I  cannot  pass  by  in  silence.  A  woman  thirty -two  yfears  old  was  in  the 
fourth  day  of  a  strangulated  hernia.  Every  thing  had  been  tried,  baths,  bleed- 
ing, taxis,  and  clysters  of  all  sorts.  The  belly  was  tympanitic  and  painful. 
The  vomitings,  constipation,  pulse,  and  countenance  left  no  doubt  as  to  the 
dangers  under  which  this  woman  must  sink  if  the  operation  was  not  performed 
without  delay.  The  patient  positively  refused  to  submit  to  it.  Having 
nothing  further  to  hope  I  gave  her  every  thing  she  desired.  At  her  earnest  en- 
treaty some  milk  and  a  purgative  were  administered  to  her.  During  the 
day  she  took  two  ounces  of  castor  oil.  The  symptoms  continued  until  5  o'clock 
p.  M.  but  shortly  afterwards  were  calmed,  and  at  my  visit  the  next  morning, 
the  students  who  had  watched  her  and  myself  could  not  have  been  more  as- 
tonished at  finding  her  out  of  all  danger.     Her  recovery  was  complete. 

5.  Opiates. — Antispasmodics,  opium,  and  other  substances  capable  of  modify- 
ing the  general  economy,  whether  singly,  or  combined  with  purgatives  as 
Richter,  Heberden,  &c.  were  in  the  habit  of  employing  them,  scarcely  deserve 
to  be  called  to  the  notice  of  the  reader.  The  sole  advantage  they  can  promise 
is  to  calm  for  a  time,  to  palliate  the  colics,  nausea,  distress,  in  fine  some  of  the 
symptoms  produced  by  the  strangulation ;  but  to  terminate  the  strangulation 
itself  is  not  in  their  nature.  I  do  not  see  why  belladonna  which  was  for  a  long 
time  extolled,  and  given  in  a  large  dose  as  directed  by  M.  Chevallier,  can  be 
of  more  avail  than  opium.  The  oil  of  turpentine,  given  by  Drs.  Sewall  and 
Mc Williams  in  the  quantity  of  two  ounces  at  a  time,  so  that  the  patient  swal- 
lowed eight  ounces  in  twenty-four  hours,  will  probably  never  be  tried  in 
France,  and  therefore  deserves  merely  a  passing  mention,  notwithstanding  the 
success  attributed  to  it  in  America. 

6.  Enemata. — At  the  same  time  that  one  or  all  of  the  preceding  means  are 
employed,  it  is  customary  to  solicit  the  large  intestine.  The  principal  inten- 
tion being  to  provoke  the  passage  of  matter  situated  below  the  strangulation, 
or  at  most  to  produce  an  anti-peristaltic  motion  in  the  whole  of  the  digestive 
tube,  some  persons  use  simple,  laxative,  or  common  purgative  injections. 
Riviere  thought  that  by  injecting  air  into  the  anus  by  a  bellows  the  displaced 
organs  might  be  returned  into  the  abdomen.  MM.  Hufeland  and  Van  Loth, 
pretend  to  have  cured  several  patients  by  injecting  hyosciamus  or  belladonna 
into  the  passage,  as  is  also  recommended  by  M.  Pauquy  in  his  thesis.  But  in 
this  view  tobacco  is  the  substance  most  employed.  It  is  given  in  smoke  by 
means  of  an  apparatus  that  every  one  can  invent  and  construct;  or,  which  is 
at  once  more  convenient  and  certain,  in  infusion  \\\e,  same  as  any  other  clyster. 
In  this  last  case  a  dram  of  tobacco  to  a  pint  of  water  is  the  proper  dose,  winch 
it  might  be  dangerous  to  exceed.  Sir  A.  Cooper  has  seen  it  cause  a  kind  of 
poisoning,  which  actually  occurred  in  another  case  in  which  two  drams  were 
used ;  and  the  same  accident  has  happened  since  in  the  ward  of  M.  Marjolin. 
Without  believing  with  Heister,  that  it  is  an  infallible  remedy,  or  with  Pott, 
that  nothing  further  is  to  be  hoped  for  after  using  it  in  vain ;  without  giving  it 
the  same  confidence  as  Hey,  Lawrence,  Rose,  and  the  greater  part  of  English 
surgeons,  it  cannot  be  denied  that  the  tobacco  clyster  has  more  than  once, 
removed  the  strangulation  and  rendered  the  operation  unnecessary. 


558  NEW   ELEMENTS    OF 

For  myself  I  have  seen  but  one  case,  but  it  was  a  remarkable  one;  every 
thing  was  ready  for  the  operation,  yet  before  it  took  place  M.  Richerand  had 
occasion  to  send  for  something  out  of  the  hospital.  During  this  time  a  tobacco 
injection  was  administered,  and  when  about  to  expose  the  hernia  we  all  saw 
to  our  great  surprise  that  it  had  been  reduced.  The  symptoms  ceased  at  the 
same  time,  and  the  young  man  left  the  next  day  to  resume  his  ordinary  occu- 
pation. It  is  true  I  have  seen  it  employed  again  in  the  same  hospital,  and  I 
have  used  it  since  in  twenty-five  cases  at  least  without  any  benefit.  The 
oppressio  viriunif  the  deep  colics,  the  cold  sweats,  the  tendency  to  convul- 
sions which  it  usually  produces,  are  evidences  of  the  energy  of  its  action.  As 
it  determines  at  the  same  time  violent  vermicular  contractions  in  the  whole 
length  of  the  intestinal  tube,  nothing  is  easier  than  to  understand  the  effects 
attributed  to  it  in  strangulated  hernias.  For  the  same  reasons  that  render  it 
powerful  and  of  incontestible  utility,  tobacco  may  be  sometimes  dangerous. 
When  the  constriction  is  very  decided,  the  hernia  recent,  purely  intestinal, 
and  complicated  with  inflammation,  and  the  strangulation  acute,  prudence 
opposes  its  employment.  On  the  contrary,  it  is  very  proper  in  every  kind  of 
obstruction,  and  strangulation  of  the  large  intestine  and  of  the  epiploon; 
whenever  in  fine  the  inflammatory  symptoms  are  but  little  developed,  and 
there  is  no  reason  to  fear  the  effect  of  tractions  upon  the  displaced  organs. 
After  trying  it  in  the  dose  of  a  dram,  under  these  circumstances,  we  may 
and  ought,  if  it  produce  nothing  manifest,  repeat  ijt  pnce  or  oftener,  and  throw 
up  two  drams  at  least  provided  no  narcotism  nor  other  general  accidents  are 
to  be  apprehended. 

7.  Topical  ^ipplications. — Leeches.  Cataplasms  which  have  been  advised 
and  used  by  a  number  of  practitioners,  can  be  of  no  real  use  except  in  very 
few  cases.  If  the  tumor  is  neither  hot,  nor  tense,  nor  painful,  nor  really  in- 
flamed, their  usefulness  is  more  than  doubtful  unless  they  act  from  their 
weight ;  and  if  the  contrary  condition  exist,  we  cannot  wait  long  enough  for 
their  emollient  properties  to  produce  any  effect.  For  the  rest,  as  they  do  not 
interfere  with  the  use  of  the  bath,  bleeding,  and  tobacco  clysters,  I  see  but 
little  inconvenience  in  covering  the  hernia  with  them  in  acute  strangulation 
as  long  as  the  operation  is  not  urgently  demanded.  It  is  otherwise  with 
respect  to  leeches,  which  many  apply  upon  or  about  the  tumor.  Experience 
says  nothing  in  their  favor,  and  reasoning  proves  that  they  may  be  injurious 
in  every  hernia  without  inflammation,  and  in  inflammatory  strangulation  itself; 
for  there  they  can  at  best  but  act  against  an  effect,  while  it  is  the  cause  that 
should  be  removed.  The  ecchymoses  which  result  from  them  have  besides 
the  disadvantage  of  increasing  the  thickness  of  the  herniary  envelopes,  of 
deforming  and  deranging  them,  and  thus  rendering  the  operation  more  diffi- 
cult. If  they  are  ever  useful,  it  is  at  most  in  strangulation  of  an  inflamed 
epiplocele  of  some  adipose  tumor  or  other  independent  of  the  intestine.  Re- 
frigerants perhaps  deserve  a  little  more  attention.  Compresses  wet  with  cold 
water,  ice  water,  chloruretted  solution,  vinegar  and  water,  frictions  with  acetic 
ether,  all  the  means  in  fine  which  when  applied  upon  the  tumor  remove  a 
large  proportion  of  caloric,  may  favor  the  reduction  in  three  ways;  1st,  as 
discutients  by  diminishing  the  afflux  of  the  fluids;  2d,  by  condensing  the 
gaseous  fluids  in  the  strangulated  loop  of  intestine ;  3d,  by  soliciting  the 
peristaltic  action  of  the. digestive  tube.     It  is  seen  from  this  simple  enumerar 


OPERATIVE  SURGERY.  559 

tion  in  what  cases  they  would  be  proper,  and  what  it  is  reasonable  to  expect 
from  them.  A  much  more  powerful  mode  of  employing  them  is  one  followed 
by  some  old  women  in  the  country,  and  described  by  J.  L.  Petit.  Being 
called  to  a  young  man  to  operate,  this  author,  accompanied  by  some  of  his 
professional  brethren,  was  ready  to  commence,  when  the  grandmother  of  the 
patient  entering  the  chamber  attempted  to  drive  them  all  out,  and  said  she 
was  going  to  cure  her  child  off  hand.  After  extending  him  naked  upon 
the  floor,  she  ran  to  the  well  and  drew  a  bucket  of  water,  which  she  threw 
suddenly  upon  the  hernia.  The  fact  is,  says  J.  L.  Petit,  who  requested  pei- 
mission  to  be  a  witness  of  the  experiment,  that  the  intestines  returned  almost 
immediately,  and  the  young  man  was  cured  without  an  operation.  Every  one 
understands  the  action  of  these  means,  and  that  they  miglit  be  employed  with 
some  confidence,  if  when  unsuccessful  they  were  not  of  a  nature  to  favor  the 
development  of  the  numerous  phlegmasiae  which  sometimes  follow  hernio- 
tomy. In  order  that  gangrene  from  congelations,  noticed  by  Sir  A.  Cooper, 
be  feared,  ice,  snow,  and  every  other,  even  the  most  powerful  refrigerant, 
must  be  used  with  very  little  precaution,  and  I  doubt  if  such  an  accident  is 
really  to  be  apprehended.  Much  has  been  said  of  the  belladonna  of  late  in 
the  reduction  of  hernias.  M.  Speziani  made  a  pomatum  of  it  with  which  he 
smeared  the  tumor;  MM.  Meale,  Pages,  Faye,  and  Magliari,  did  the  same 
with  success;  M.  Saint- Amand  was  not  less  fortunate,  using  it  in  cataplasms ; 
M.  Riberi  covered  a  bougie  with  it,  which  he  introduced  into  the  urethra,  and 
declares  that  he  has  in  this  way  been  successful.  M.  Guerin  of  Bordeaux, 
long  since  used  opiated  bougies,  daily  introduced  into  the  canal  of  the  urethra 
as  a  remedy  for  herniary  strangulation.  To  say  that  great  confidence  may  be 
reposed  in  such  means  I  cannot ;  but  as  they  are  of  easy  application  as  well 
as  void  of  danger,  I  see  no  reason  why  they  may  not  be  used  when  there  is 
no  need  of  an  immediate  operation.  I  have  employed  them  six  times.  The 
tumor,  greased  morning  and  evening  with  the  ointment  of  belladonna,  was 
covered  with  simple  cataplasms.  Twice  I  introduced  the  same  substance 
into  the  anus  on  a  strong  bougie,  and  I  must  confess  that  several  of  the  pa- 
tients seemed  to  be  relieved.  As  for  explaining  their  mode  of  action,  we 
must  wait  I  think  until  a  greater  number  of  facts  are  given  in  their  favor. 

8.  Acupuncture. — Galvanism.  I  do  not  speak  here  of  astringent  cata- 
plasms, as  the  promegranate  and  decoction  of  walnut  leaves  which  Belloste  so 
much  recommends,  supposing  them  to  have  been  long  since  generally  aban- 
doned ;  but  I  cannot  dispense  with  saying  something  on  acupuncture  and 
electro-puncture.  Since  the  time  of  Pare,  surgeons  have  sometimes  ventured 
to  pass  a  long  needle  or  small  trocar  once  or  oftener  through  the  hernia,  for 
the  purpose  of  giving  vent  to  the  gas  contained  in  the  strangulated  intestine. 
Pott  says  such  a  practice  is  absurd,  and  does  not  require  refutation.  Most 
of  the  moderns  are  of  the  same  opinion.  It  has  nevertheless  been  employed 
in  my  presence  on  a  patient  upon  whom  I  operated  immediately  afterwards ; 
and  I  am  assured  by  a  young  candidate  in  medicine,  that  his  father  has  often 
tried  it  with  success.  I  think  it  ought  to  be  rejected ;  first,  because  it  cannot 
rationally  be  applied  but  to  enterocele  distended  with  aeriform  fluids,  and 
secondly,  because  one  of  these  two  things  occurs ;  either  the  small  wound 
closes  when  the  needle  is  withdrawn,  and  it  is  as  if  nothing  had  been  done, 
or  it  remains  open,  and  in  this  case  it  is  to  be  feared  that  the  intestine  when 


560  NEW    ELEMENTS    OF 

returned  into  the  abdomen  may  allow  the  escape  of  some  particles  of  the 
fluid  usually  contained  in  it.  This  last  accident  however  cannot  easily  take 
place,  for  every  traumatic  perforation  of  the  digestive  tube,  which  is  not  more 
than  a  line  or  two  in  breadth,  seldom  fails  of  being  Immediately  obliterated, 
either  by  the  approximation  of  its  edges,  or  by  a  swelling  of  its  mucous  mem- 
brane. For  the  rest  acupuncture  is  a  bad  means,  and  if  it  is  to  be  tried  at  all 
a  very  fine  canula  should  at  least  be  used,  which  may  give  passage  to  the  gas 
after  being  introduced  into  the  tumor  by  the  needle.  Electro-puncture  with 
which  M.  Leroy  (of  Etiolles)  has  made  experiments  upon  dogs,  has  not  to 
my  knowledge  been  yet  applied  to  man.  It  consists  in  placing  by  means  of 
a  steel  point,  one  extremity  of  an  electric  or  galvanic  circle  in  the  tumor, 
while  the  other  extremity  of  the  same  circle  is  placed  upon  the  tongue  or 
anus,  according  as  the  hernia  is  formed  of  the  small  or  large  intestine.  The- 
ory teaches  that  the  currents  or  discharge  from  a  pretty  strong  pile  or  trough 
thus  directed,  are  calculated  to  create  in  the  displaced  viscera  sufficient  move- 
ments to  sometimes  determine  their  return  intp  the  abdomen.  It  is  for  expe- 
rience to  confirm  these  conjectures.  After  all  the  resource  is  easLily  tried  in  a 
better  way  than  by  electro-puncture,  as  it  may  be  applied  by  means  of  simple 
electric  circle  without  needles. 

Recapitulation. — Let  us  imagine  the  practitioner  supplied  with  these  various 
means,  actually  in  presence  of  an  individual  affected  with  strangulated  hernia. 
Suppose  it  an  old  enterocele  become  all  at  once  irreducible.  If  attempts 
have  already  been  made,  before  renewing  them  he  will  have  the  patient  placed 
in  a  bath,  and  commence  by  a  copious  bleeding  from  the  arm  if  he  is  robust 
and  threatened  with  inflammation.  If  the  taxis  does  not  then  succeed,  the 
large  intestine  is  to  be  emptied  by  means  of  laxative  enemata.  Tobacco 
infusion  will  have  its  turn  two  or  three  hours  after.  If  the  state  of  the  forces 
permit,  the  bleeding  is  to  be  repeated  together  M'ith  the  bath  and  the  taxis  ; 
then  come  the  frictions  with  belladonna,  and  the  bougies,  according  to  the 
method  of  M.  Riberi,  or  M.  Guerin.  If  all  is  insufficient,  and  there  is  no 
urgency,  embrocations,  cold  applications,  compression,  and  lastly,  electricity, 
may  be  tried.  In  cases  of  acute  strangulation,'  of  recent  hernia,  the  taxis, 
bleeding,  baths,  clysters,  cold  or  narcotic  applications  should  rapidly  succeed 
one  another.  If  there  is  already  inflammation  in  the  tumor,  the  tobacco  in- 
jections, electricity  and  compression  are  no  longer  applicable.  The  taxis 
also  should  be  performed  with  the  greatest  precaution.  If  the  pain  and  other 
inflammatory  symptoms  leave  no  doubt  as  to  the  state  of  the  parts,  blood- 
letting and  bathing  can  only  be  considered  as  preparatives;  all  topical  appli- 
cations should  be  neglected,  and  the  operation  performed  as  soon  as  possible. 
Leeches  in  great  number,  and  emollient  cataplasms  will  only  be  proper  when 
the  symptoms  seem  to  depend  on  an  epiplocele  or  tumor  foreign  to  the  intes- 
tine. When  the  hernia  is  formed  by  the  large  intestine,  or  the  progress  of  the 
symptoms  is  tardy,  we  commence  with  the  taxis  or  the  bath,  then  have  recourse 
to  tobacco  clysters,  opiates  or  belladonna,  refrigerants,  and  electricity  itself; 
but  venesection  should  or  may  be  most  frequently  omitted.  The  same  course 
is  followed  when  there  is  only  obstruction ;  and  in  this  case,  in  the  intervals 
between  the  use  of  the  taxis,  compression  by  means  of  a  proper  bandage  may 
be  of  service,  as  in  case  of  epiplocele,  freed  from  adhesions  and  inflammation. 
In  fine,  having  tried  every  thing,  and  modified  our  attempts  according  to  the 


OPERATIVE    SURGERY.  ♦  561 

nature  of  the  symptoms,  if  the  hernia  be  retained  by  adhesions,  or  if  the  ring 
oppose  an  invincible  resistance,  we  must  not  think  of  reducing  it.  If  there 
be  yet  time,  celotomy,  in  which  the  chance  of  success  is  the  greater  and  the 
danger  the  less  the  earlier  it  is  eraployed,  should  no  longer  be  deferred.  As 
the  treatment  required  by  the  patient  is  the  same  after  reduction,  as  after  the 
operation  we  will  not  refer  to  it  at  present. 

§  4.  Herniotomy  or  Celotomy. 

A.  Enterocele. — The  operation  for  strangulated  hernia  was  not  posiiively 
known  before  Rousset.  Maupasius  seems  to  have  been  the  first  to  point  out 
its  advantages.  Until  then  celotomy  was  performed  only  for  the  purpose  of 
protlucing  a  radical  cure  of  ruptures.  It  consists  of  several  stages :  incision 
of  the  integuments,  division  of  the  tissues  situated  between  the  cutaneous  en- 
velope and  the  peritoneum,  opening  of  the  sac,  examination  and  appreciation 
of  the  strangulated  parts,  destruction  of  the  strangulation,  and  reduction  of  the 
displaced  viscera ;  such  are  the  phases  through  which  the  surgeon  proposes  to 
run,  after  arranging  his  apparatus,  the  patient,  and  the  assistants. 

Jlpparatus. — A  fold  of  lint  spread  with  cerate  and  sufficiently  large,  rolls 
and  dossils  of  charpie,  adhesive  strips,  obiong  or  square  compresses,  a  long 
roller  or  rather  a  special  bandage,  a  straight  bistoury,  a  convex  bistoury. 
Pott's  concave  bistoury,  a  straight  probe-pointed  bistoury,  good  dissecting 
forceps,  straight  scissors,  a  director  without  cul-de-sac,  several  ligatures  and 
needles,  in  addition  to  the  accessories  of  every  great  operation,  are  the  various 
objects  necessary,  which  are  to  be  placed  in  order  on  a  large  dish,  or  on  a  shelf. 

Position  of  the  Patients  and  Assistants. — The  table  covered  with  a  mat- 
tress, or  the  bed.  on  which  the  patient  is  laid,  requires  nothing  particular 
except  to  be  properly  protected  by  cloths,  and  of  a  convenient  height  and 
width.  No  one  at  present  imitates  Louis  in  sitting  on-  a  stool  between  the 
legs  of  the  patient  held  on  the  edge  of  his  bed.  They  stand,  kneel,  or  sit  on 
the  right.  The  patient,  in  a  horizontal  position,  and  nearer  the  right  side  than 
the  left,  is  in  a  state  of  complete  relaxation.  An  assistant  watches  the  mo- 
tion of  his  head  and  arms,  anotlier  attends  to  his  inferior  extremities ;  a  third 
stands  opposite  to  the  operator  to  stretch  the  skin,  sponge  the  wound,  &c.; 
the  fourth  is  free,  and  is  charged  with  handing  the  instruments. 

First  Stage. — The  parts  should  be  previously  shaved,  washed,  and  dried. 
If  the  skin  be  too  tense,  too  thick,  or  too  adherent,  the  surgeon  with  a  convex 
bistoury  divides  it  as  in  simple  incision  from  without  inwards,  taking  care  not 
to  go  too  deeply  at  first.  In  the  opposite  case  he  takes  up  as  large  a  fold  a^ 
possible,  one  extremity  of  which  he  gives  to  an  assistant,  and  immediately 
divides  it  either  by  puncture  from  within  outwards,, or  which  is  better,  from 
its  edge  towards  its  base.  This  fold  has  the  advantage  of  less  exposing  the 
viscera  to  be  cut,  but  the  incision  is  less  regular,  and  can  never  be  prolonged 
sufficiently  at  a  single  stroke,  if  the  hernia  is  voluminous ;  so  that  aeteris 
paribus  simple  incision  is  preferable  when  we  are  sure  of  one  hand.  The 
wound  should  be  in  the  direction  of  the  greatest  diameter,  and  of  an  extent 
proportioned  to  the  volume  of  the  tumor.  We  do  not  give  it  the  T  or  crucial 
form  except  in  particular  cases.  When  it  is  not  long  .enough  at  first,  instead 
of  passing  a  director  successively  under  each  of  its  angles,  to  enlarge  the 
71 


i 


562  *  NEW  ELEMENTS    OF 

wound  with  scissors  or  the  straight  bistoury,  the  operator  takes  up  one  of  the 
]ips  and  directs  the  assistant  to  take  the  other,  so  that  the  index  finger  rests 
in  tlie  wound  and  the  thumb  on  the  skin  at  the  inferior  end ;  the  thumb  in  the 
wound  and  the  finger  on  the  integuments  at  the  superior  end  ;  he  separates 
them  a  little,  reflecting  them  outwards,  and  then  with  the  convex  bistoury- 
enlarges  the  wound  as  much  as  he  thinks  necessary.  By  the  other  method 
much  more  pain  is  produced,  the  skin  slips  over  the  director,  puckers,  and  is 
incised  with  difficulty.  The  vessels  opened  during  this  first  incision  are 
rai'ely  large  enough  to  require  the  ligature.  It  is  usually  sufficient  to  rub 
them  a  little,  or  to  have  the  assistant's  finger  applied  over  their  orifice  for  a  time 
to  stop  their  bleeding ;  otherwise  twisting  them  is  a  very  simple  thing. 

Second  Stage. — The  division  of  the  laminae  which  come  after  the  skin 
requires  the  greatest  attention,  and  should  be  m.ade  very  slowly.  In  fact, 
they  are  not  sufficiently  distinct  from  each  other,  nor  sufficiently  uniform  in 
respect  to  thickness  to  insure  us  against  wounding  parts  which  it  is  important  to 
save,  or  to  permit  us  to  proceed  with  extreme  reserve,  feeling  our  way  carefully 
until  we  arrive  at  the  sac.  The  most  certain  way  is  to  take  them  up  with  the 
forceps  as  they  present  on  a  projecting  point  of  the  tumor  by  small  portions 
at  a  time;  to  cut  them  off"  successively  with  the  knife,  and  renew  this  ma- 
noeuvre as  long  as  the  sac  continues  concealed.  The  director  carried  upwards 
and  downwards  through  this  species  of  aperture  as  far  as  the  extremities  of  tlie 
wound,  allows  us  to  incise  them  with  safety  with  the  straight  bistoury  or  scissors. 
No  one  will  now  pretend  to  tear  them  with  the  sharp  pointed  probe  of  Le  Dran, 
or  the  gum  lancet  which  was  used  even  in  the  last  century.  It  is  on  approach- 
ing the  sac  that  the  difficulties  begin.  In  some  subjects,  or  in  certain  hernias 
it  is  separated  from  the  skin  only  by  a  very  thin  layer,  in  others  it  is  found  at 
several  lines  and  even  several  inches  in  depth.  To  arrive  at  it,  we  are  some- 
times obliged  to  pass  through  several  lardaceous  layers,  imposthumated  lym- 
phatic ganglions,  and  circumscribed  or  diffused  purulent  collections;  in  fine,  it 
may  be  immediately  surrounded  with  some  considerable  quantity  of  bhickish 
serosity  (of  which  Mr.  Travers  and  M.  Richerand  each  give  an  example), 
very  apt  to  make  us  think  that  we  have  penetrated  its  interior,  or  with 
diff*erent  kinds  of  adipose  expansions,  which  may  be  easily  mistaken  for  the 
epiploon. 

Interposed  adipose  layers. — It  seems  that  this  last  anomaly  is  by  no  means 
infrequent.  Saviard  reports  a  case  of  it.  It  was  also  met  with  in  a  patient 
operated  upon  by  M.  Lisfranc.  I  have  had  myself  four  cases.  If  it  be  true  that 
the  error  may  often  be  easily  avoided,  it  cannot  be  denied  tliat  it  is  sometimes 
necessary  to  use  the  greatest  caution  not  to  commit  it.  When  the  fatty  layer 
covers  the  whole  of  the  external  face  of  the  sac  In  the  manner  of  a  cloth,  or 
when  it  is  even  surrounded  by  a  humid,  fine,  and  polished  membrane  without 
adhesions,  such  an  arrangement  may  embarrass  even  the  most  skillful.  M. 
Roux  himself  barely  avoided  the  mistake  in  1825,  at  the  hospital  of  Improve- 
ment. After  dividing  the  integuments  and  several  cellulo-adipose  lavers,  he 
came  to  a  brownish  membrane,  very  distinct  from  the  others,  opened  it  with 
precaution,  and  finding  it  smooth  and  covered  with  an  unctuous  serosity  on  its 
interior  he  thought  he  had  opened  the  sac.  Beneath  was  seen  a  yellowish  mass, 
porous,  and  very  flexible,  but  not  an  intestine.  Fearing  that  this  mass  might 
be  the  intestine  covered  with  the  epiploon,  M.  Roux  took  the  nrecaution  of 


OPERATIVE   SURGERY.  563 

dividing  it  layer  by  layer  has  he  had  done  with  the  rest.  Instead  of  the 
intestine,  the  true  sac  shortly  presented  itself,  after  which  there  was  nothing 
remarkable  in  the  hernia.  The  abnormal  production  does  not  always  sur- 
round the  whole  of  the  sac.  In  1829,  a  patient,  inadvertently  placed  in  the 
medical  wards  of  the  hospital  St.  Antoine,  was  sent  the  next  day  to  my  care. 
Strangulation  was  then  of  several  days'  standing.  The  membrane  which  I  took 
for  the  sac  being  opened,  there  appeared  a  mass  composed  of  two  parts,  the  one 
globular,  dark,  and  smooth,  of  about  the  size  of  a  small  egg,  situated  pos- 
teriorly and  inwards  ;  the  other  larger,  less  dark,  knotty,  and  placed  against 
the  anterior  and  external  half  of  the  first.  The  idea  of  an  entero-epiplocele 
immediately  struck  me.  But  in  attempting  to  insulate  the  fatty  portion  in 
order  to  proceed  to  the  reduction,  I  perceived  that  the  intestine  was  not  laid 
bare  and  that  a  semi-transparent  lamina  still  separated  it  from  the  other  tissues ; 
this  was  the  real  sac,  the  neck  of  which  gave  attachment  by  its  external  face 
to  a  true  fatty  hernia  which  I  excised.  A  laundress,  to  wliom  M.  Forget 
called  me,  presented  an  arrangement  not  less  singular.  I  had  also  opened  a 
membrane  which  might  be  mistaken  for  the  sac.  The  tumor  it  contained  was 
trilobed,  and  its  three  lobes  were  of  unequal  size  and  a  very  deep  brown 
color.  We  readily  discovered  that  the  viscera  had  still  another  covering  to 
be  divided.  The  internal  bossehire  alone  belonged  to  the  intestine,  it  had  a 
particular  sac ;  the  two  others  had  also  a  distinct  covering,  were  pedunculous, 
of  an  adipose  nature,  and  fixed  to  the  external  face  of  the  herniary  peritoneum. 
I  excised  them  after  reducing  the  intestine,  and  the  patient  got  well.  I 
operated  at  La  Pitie  in  October  1831,  on  an  old  woman  who  presented  an 
arrangement  exactly  similar  to  that  in  the  first  case.  These  fatty  vegetations 
may  assume  a  thousand  other  forms.  Thus  M.  Tartrie  met  with  a  hard 
oblong  tumor,  which  he  could  not  reduce,  and  which  he  took  for  degenerated 
intestine,  and  cut  off  for  the  purpose  of  establishing  an  artificial  anus.  The 
patient  died,  and  lo  !  the  intestine  had  not  been  touched.  There  was  not  even 
enterocele ;  it  was  an  adipose  hernia  which  had  been  removed. 

A  cysty  resulting  from  an  old  herniary  sac,  or  of  any  other  nature,  empty, 
like  the  one  in  the  patient  operated  upon  at  La  Pitie  by  the  method  of  M. 
Belmas,  or  filled  v;ith  fluid,  as  many  authors  have  observed,  may  occasion 
mistakes  of  another  description  which  every  one  can  conceive ;  mistakes  so 
much  the  more  easily  occurring  as  the  sac  Itself  after  being  inflamed  and 
transformed  into  an  abscess,  may  give  rise  to  most  of  the  symptoms  of  stran- 
gulation, as  has  been  said  above. 

Third  stage. — But  being  once  aware  of  the  possibility  of  so  many  mistakes, 
the  experienced  surgeon  will  almost  always  succeed  in  avoiding  them.  The 
sac  is  unopened  as  long  as  there  is  seen  a  surface  rugose,  tomentose,  uneven, 
a  mixture  of  layers  or  lumps,  adipose,  vascular,  cellular,  or  lamellated;  as 
long  as  the  neck  of  the  tumor  is  not  free  and  does  not  allow  us  to  feel  around 
its  circumference  within  the  ring  with  the  nail  or  the  end  of  a  probe.  Cysts, 
abscesses,  &:c.  are  distinguished  by  their  want  of  communication  with  the  ab- 
domen. It  is  the  same  with  all  morbid  productions  situated  without  the 
peritoneum.  Supposing,  besides,  that  an  adipose  layer  may  be  mistaken  for 
the  epiploon,  what  danger  would  there  be  in  tearing  it  prudently  in  order  to 
see  what  is  beneath  ?  Unless  there  are  peculiar  difficulties,  we  ought  only  to 
lay  bare  the  sac  in  the  direction  of  the  wound  of  the  integuments.    By  trying 


564  NEW    ELEMENTS    OF 

to  dissect  it,  and  separate  it  carefully  from  the  surfoiindlng  tissues,  the 
surgeon  prolongs  the  operation,  increases  the  amount  of  pain,  and  renders 
mortification  of  the  process  of  the  peritoneum  almost  inevitable,  if  its  excision 
is  not  immediately  performed.  In  the  more  simple  hernias,  the  opening  of 
the  sac  is  easy  and  without  danger  to  the  man  possessed  of  exact  anatomical 
knowledge  and  a  little  skill.  The  intestine  constantly  presents  some  inequa- 
lity and  is  not  so  exactly  globular  as  its  peritoneal  covering,  which  besides  is 
usually  separated  from  it  by  a  layer  of  serosity  or  lic[uid  matter  of  more  or  less 
thickness.  In  this  case  we  may  in  some  measure,  as  Louis  did  not  hesitate 
to  affirm,  cut  at  a  single  stroke  the  skin  and  the  principal  layers  which  sepa- 
rate it  from  the  sac,  and  then  with  a  second  stroke  without  hesitation  pene- 
trate this  last  envelope.  In  other  and  rather  complicated  cases,  this  proceeding- 
would  amount  to  rashness,  and  would  truly  deserve  the  blame  which  has 
been  cast  upon  it.  When  there  is  in  the  sac  but  a  small  quantity  of  fluid, 
it  does  not  prevent  us  recognizing  the  presence  of  the  intestine  within.  What 
may  lead  to  error  is  the  entire  absence  or  the  excess  of  fluid  in  this  pouch. 
It  is  readily  perceived  how  easy  it  would  be  on  the  first  hypothesis  to  cut  as 
^eep  as  the  viscera,  and  divide  them  without  perceiving  that  we  had  passed 
the  sac.  The  difficulty  would  be  in  every  respect  much  greater  if  the  various 
parts  were  united  by  adhesions.  In  the  second  case  the  danger  only  lies  in 
the  possibility  of  confounding  it  with  a  large  portion  of  intestine  distended 
with  gas  or  any  liquid  substance,  supposing  here  that  the  sac  could  not  yet 
be  distinguished. 

Dropsy  of  the  Sac. — The  presence  of  a  large  quantity  of  fluid  in  the  sac  is 
too  frequently  met  with  not  to  require  notice  in  this  phace.  An  observation 
of  Saviard  mentions  it.  Merry  found  more  than  a  pint  in  the  case  of  a  woman. 
M,  Liegard  of  Caen,  and  M.  Roux,  have  each  met  with  a  case.  Schmucker 
and  Siebold  arc  said  to  have  been  on  the  point  of  being  deceived,  and  of  sup- 
posing that  they  met  with  a  hydrocele.  Monro  asserts  that  he  found  more 
than  six  pounds,  and  Scarpa  more  than  three  in  a  single  sac.  Pott  several 
times  tapped  for  this  complication,  which  Mr.  Lawrence  appears  also  to  have 
met  with.  In  fine,  in  a  thesis  which  he  lias  just  defended.  M.  A.  E.  Mare- 
chal  has  assembled  several  cases,  picTied  up  by  him  at  La  Charite.  In  order 
that  it  should  occur,  too  conditions  are  necessary;  the  neck  of  the  sac  must 
be  first  closed  by  stricture  or  in  some  other  manner,  and  then  the  peritoneal 
process  must  become  the  seat  of  an  unnatural  exhalation.  The  other  affections 
which  may  to  a  certain  degree  simulate  it,  are  vesical  hernia,  an  hydrocele 
which  shall  have  an  old  closed  hernia  sac  foi  its  seat  as  witnessed  by  Butrandi 
and  Pelletan,  or  large  hydatic  cysts  developed  on  the  strangulated  epiploon, 
like  the  one  nientioned  by  Lamorier.  I  have  myself  observed  a  case  perhaps 
more  extraordinary  still  than  any  of  those  as  yet  related  ;  an  old  man  quite 
robust  was  brought  into  my  ward  at  St.  Antoine  in  October  1828,  to  be  treated 
for  an  enormous  hernia,  attended  for  five  days  with  constipation,  vomiting, 
and  ether  symptoms  of  strangulation.  This  hernia  which  occupied  the  scrotum 
had  double  the  size  of  the  head  of  an  adult,  was  heavy,  tense,  brownish, 
slightly  painful,  covered  with  veins  gorged  with  blood,  and  had  no  crimpling 
on  its  surface.  Fluctuation  in  it  was  obscure,  so  thick  wore  its  parietes,  and 
the  light  of  a  taper  gave  but  very  vague  indication  of  its  nature.  The  patient 
told  us  he  had  carried  it  for  fifteen  years  without  its  being  larger  than  his  fist. 


OPERATIVE   SURGERY.  565 

and  that  several  times  he  had  succeeded  in  reducing  it.  I  did  hot  hesitate  to 
open  it,  proceeding  with  the  same  cautions  as  for  ordinary  hernia,  that  is, 
dividing  its  coverings  layer  by  layer",  and  on  one  point  only.  As  soon  as  it 
was  pierced  there  escaped  with  a  forcible  jet  a  liquid  as  clear  as  wine.  I 
immediately  enlarged  the  opening  and  drew  off  more  than  three  litres  of  a 
slightly  turbid  serosity.  Its  superior  part  contained  besides  an  entero-epiplo- 
cele  about  as  large  as  the  fist,  which  was  powerfully  strangulated,  and  had 
several  gangrenous  spots.  By  calling  to  mind  the  natural  signs  of  simple 
hydrocele  and  cystocele,  there  will  be  but  few  difficulties  on  this  head.  The 
mistake,  besides,  would  not  be  very  serious.  It  is  only  necessary  to  know 
that  such  a  complication  would  render  the  efforts  of  tlie  taxis  nearly  useless, 
since  the  fluid  absorbs  them  before  they  reach  the  intestine ;  and  on  the  otiier 
hand  this  fluid  must  favor  the  strangulation  by  its  reaction  upon  the  viscera. ' 
It  is  then  as  in  every  other  case,  the  intestine  with  which  we  should  be  careful 
not  to  confound  the  sac  thus  filled  with  fluid.  In  order  that  it  shall  be  impos- 
sible, we  must  suppose  an  intimate  adhesion  between  these  two  parts,  a  kind 
of  confusion  of  the  visceral  peritoneum  with  the  parietal  peritoneum  of  the 
tumor,  which  except  in  very  old  or  coecal  hernias  is  quite  rare. 

Provided  there  is  no  sac,  even  when  adhesions  may  exist,  it  does  not  appear 
how  it  can  be  absolutely  impossible  to  recognise  the  intestine  if  proper  care 
be  used.  The  sac  in  its  natural  state  is  but  a  simple  lamella  and  can  only  be 
surrounded  by  lamellse.  Whatever  thickness  it  possess,  whether  depending 
on  the  cellular  tissue  which  covers  its  surface,  or  on  accidental  layers  deposited 
on  its  internal  face,  it  will  always  be  presented  under  the  form  of  con- 
centric layers  unequally  superimposed ;  while  the  meeting  with  a  fleshy 
covering  wdth  a  double  plane  of  fibres  beneath  a  completely  adherent  serous 
expansion  will  not  permit  us  to  mistake  the  intestine,  nor  to  penetrate  the 
interior  of  this  organ  if  we  wish  to  avoid  it.  A  note  by  the  translator  of 
Scarpa,  in  whidi  it  is  said  that  a  provincial  surgeon  divided  the  intestine, 
because  the  adhesions  which  united  it  with  the  sac  did  not  permit  him  to  dis- 
tinguish these  two  parts,  the  accident  which  happened  the  last  year  in  one 
of  the  great  hospitals  of  the  capital  to  the  superintending  surgeon,  who  also 
penetrated  the  intestinal  canal  in  operating  for  a  hernia,  as  well  as  many 
other  mistakes  of  the  same  description,  seem,  it  is  true,  to  ri§e  up  against  the 
opinion  I  have  just  advanced;  but  viewing  it  more  closely,  setting  aside  the 
authority  of  names,  and  with  the  desire  of  coming  exactly  at  the  truth,  we 
shall  not  be  long  in  perceiving  that  the  error  in  these  different  cases  was  not 
inevitable,  and  that  the  blame  should  be  attached  rather  to  the  inattention  of 
the  operators  than  to  the  nature  of  the  case.  The  practitioner  mentioned  by 
M.  Olivier,  for  instance,  says  that  before  arriving  at  the  sac,  he  had  to  pass 
through  a  cyst  filled  with  brownish  serosity.  But  it  seems  evident  to  me  that 
this  pretended  cyst  was  the  sac  itself  which  he  did  not  recognise.  Hence  it  is 
that  he  opened  the  intestine  thinking  it  only  the  herniary  covering.  However 
this  may  be,  we  may  proceed  in  two  ways  to  the  opening  of  the  sac.  The 
first,  and  that  which  is  generally  followed,  consists  in  seizing  it  with  the 
forceps  at  the  point  wliich  seems  most  free,  so  as  to  raise  a  small  flap,  which 
is  excised  by  carrying  the  bistoury  horizontally  beneath  the  beak  of  the  in- 
strument. The  fluid,  if  it  contain  any,  immediately  issues  through  this  open- 
ing, unless  the  intestine  is  immediately  engaged  in  it,  which  is  distinguished 


566  NEW  ELEMENTS  OF 

by  its  greater  pliability,  by  its  more  mellow  appearance,  and  its  other  natural 
characters.  A  conductor,  carried  through  this  opening,  is  then  used  in  enlarg- 
ing it  as  much  as  is  desired,  and  protects  the  viscera  against  the  action  of  the 
probe-pointed  bistoury  or  blunt  scissors  which  are  then  to  be  employed.  The 
other  method  is  apparently  more  dangerous,  and  hence  is  generally  condemned 
by  authors.  But  I  have  constantly  found  it  more  simple  than  the  preceding, 
and  would  therefore  not  hesitate  to  give  it  the  preference  if  we  could  rely 
sufficiently  on  the  hand  of  every  one  who  operates  for  strangulated  hernia. 
While  the  left  hand  stretches  sufficiently  the  sac  or  tumor,  the  right,  armed 
with  a  straight  bistoury  held  as  a  pen,  draws  gently  and  with  small  strokes 
the  point  of  the  instrument  over  the  prominent  parts,  divides  them  layer  by 
layer,  and  thus  allows  us  to  distinguish  all  the  laminae  which  present,  to  stop 
when  we  please,  and  to  penetrate  quite  as  safely  as  by  the  ordinary  process. 
In  every  case,  the  rule  is  to  open  the  sac  as  far  as  the  lower  part  of  the 
tumor,  so  that  its  inferior  portion  may  not  serve  as  a  receptacle  for  pus  or  other 
fluids  that  may  accumulate  in  the  bottom  of  the  wound.  Many  surgeons 
advise  the  same  to  be  done  at  the  superior  part ;  but  others,  of  a  different 
opinion,  direct  the  incision  to  extend  only  to  within  a  certain  distance  of  the 
ring.  They  contend  that  by  this  they  expose  the  patient  less  to  peritonitis, 
or  the  surgeon  to  go  wrong  in  removing  the  stricture,  provided  that  then  it 
becomes  impossible  to  introduce  the  bistoury  between  the  neck  of  the  serous 
tunic  and  the  aponeurotic  opening,  as,  it  is  said,  has  sometimes  happened.  If 
names  such  as  J.  L.  Petit  and  Astley  Cooper  were  not  their  defenders  these 
operative  minutiae  would  not  deserve  notice.  Has  the  question  been  seriously 
discussed  whether  it  is  proper  or  not  to  prolong  a  few  lines  more  or  less  the 
incision  of  the  sac,  in  this  or  that  direction  r  Those  who  have  performed  the 
operation  for  strangulated  hernia  cannot  be  made  to  understand  that  the 
removal  of  the  stricture  can  be  rendered  either  more  or  less  easy,  or  perito- 
nitis either  more  or  less  to  be  dreaded  by  one  or  the  other  of  the  modes  of 
proceeding.  When  the  root  of  the  parts  to  be  reduced  has  been  laid  bare,  the 
object  is  accomplished.  For  the  rest,  it  is  of  little  consequence  whether  the 
incision  of  the  peritoneal  process  extend  into  the  ring,  or  stops  a  few  lines 
short. 

Fourth  Stage. — Freed  from  "every  obstacle  to  their  expansion,  as  soon  as  the 
sac  is  largely  opened  the  viscera  often  suddenly  acquire  a  much  more  con- 
siderable volume  than  had  at  first  been  supposed;  so  as  even  to  lead  to  the 
belief  that  a  new  portion  of  them  has  just  escaped  through  the  herniary  open- 
ing. At  length  they  are  in  view.  Before  going  further,  we  must  appreciate 
their  condition  and  ascertain  the  seat  of  stricture.  When  the  hernia  is  not 
very  large,  inflammation  has  often  united  its  several  folds  together  or  to  the 
sac.  Gentle  traction  or  passing  the  fingers  between  the  parts  is  always  suffi- 
cient to  separate  them  in  such  cases.  If  old  adhesions  organised,  filamentous, 
in  form  of  chords,  or  cellular  prolongations,  prevent  their  complete  insulation, 
a  bistoury  or  scissors  will  soon  despatch  the  business.  General  adhesions,  so 
intimate  as  not  to  permit  us  to  perceive  any  line  of  demarcation  between  the 
sac  and  the  hernia,  should  alone  be  respected.  In  attempting  to  destroy  them 
it  would  be  difficult  not  to  make  some  slips  in  the  direction  of  the  intestine; 
or  if,  to  obviate  this  danger  the  instrument  is  carried  more  outwards,  the 
viscera  remain  loaded  with  too  much  foreign  tissue,  rendering  their  reduction 


OPERATIVE    SURGERY.  567 

doubtful.  If  they  are  strangulated  by  a  rent  in  the  sac,  or  in  the  sac  itself,  by 
a  rupture  or  band  of  epiploon  by  an  accidental  cord,  or  in  any  other  way,  we 
begin  by  setting  them  free  in  order  to  spread  them  out  and  see  if  they  are  not 
the  seat  of  a  degeneration,  whether  ulcerous  or  gangrenous ;  in  a  word,  to  see 
whether  or  not  they  are  in  a  perfectly  sound  state.  Having  thus  spread  out 
and  examined  them,  we  should  replace  them  in  the  abdomen  if  the  stricture  of 
the  ring  offer  no  obstacle.  In  fact,  this  is  possible  in  a  certain  number  of  cases. 
In  the  first  place,  when  the  abdominal  opening  is  not  the  seat  of  strangulation, 
and  when  besides,  the  course  of  the  matters  has  not  been  interrupted  by  a  too 
abrupt  inflexion  of  the  organs  on  the  herniary  orifice,  moreover  when  the 
substances  accumulated  in  the  intestinal  loop,  are  of  sufficient  fluidity  for  a 
methodical  pressure  to  return  them  behind  the  ring.  Nevertheless,  before 
attempting  it,  whatever  be  the  state  of  the  parts,  all  that  portion  should  be 
drawn  out  which  is  found  in  the  aponeurotic  passage.  Without  this  precaution 
we  run  the  risk  of  returning  into  the  abdomen  a  portion  of  intestine,  con- 
stricted, obliterated,  ulcerated  or  more  or  less  extensively  altered,  which 
although  seeming  perfectly  sound  externally,  may  be  absolutely  incapable  of 
performing  its  functions.  Besides,  another  advantage  results,  which  is,  that 
the  loop  being  longer,  the  matter  it  contains  are  spread  over  a  greater  surface, 
distend  it  less,  diminish  the  volume  of  each  of  its  rings,  and  thus  render  its 
reduction  more  easy.  Its  coarction  in  the  ring  is  a  known  fact,  admitted  by 
all  authors,  and  which  the  observation  of  Ritch  has  placed  beyond  doubt.  In 
a  patient  operated  on  by  this  surgeon,  the  symptoms  continued  after  the 
reduction.  Death  was  the  consequence,  and  the  opening  of  the  body  showed 
the  cause ;  the  portion  of  intestinal  tube  which  had  been  strangulated,  was 
found  so  contracted  as  scarcely  to  allow  a  passage  to  a  common  quill.  A 
more  frequent  lesion,  and  one  which  in  my  opinion  has  not  been  sufficiently 
noticed,  is  ulceration  of  the  intestine  on  its  external  face.  It  presents 
the  appearance  of  a  furrow,  one  to  two  lines  broad,  occupying  sometimes 
several  points,  sometimes  even  the  whole  extent  of  the  intestinal  circumference, 
and  corresponds  to  the  fibrous  circle  which  has  caused  the  disorder.  It 
might  be  called  a  wound  produced  by  a  cord  tied  too  tightly.  As  long  as 
the  peritoneal  tunic  alone  is  deceased,  as  the  muscular  membrane  is  not 
entirely  cut  through  or  the  mucous  membrane  preserves  its  thickness,  the 
whole  may  be  replaced  in  the  abdomen  without  danger ;  but  then  the  greatest 
care  will  be  necessary,  for  these  various  tunics  being  at  the  same  time  more  or 
less  softened,  the  least  pulling  may  terminate  in  a  rupture,  as  I  witnessed  in 
the  case  of  a  female  operated  upon  under  the  direction  of  M.  Roux,  and  who 
died  the  next  day.  Mr.  Lawrence  and  M.  Roux,  who  with  more  earnestness 
than  M.  Boyer  have  called  the  attention  of  practitioners  to  it,  might  have 
added  that  this  traumatic  fissure  has  more  than  once  gone  so  far  as  to  perforate 
the  intestinal  tube  and  produce  a  fatal  effusion,  the  origin  of  which  was 
improperly  referred  to  gangrenous  ulceration.  A  woman  fifty-five  years  old, 
was  brought  in  ]  824  to  the  hospital  of  Improvement.  I  operated  immediately 
for  a  strangulated  hernia  of  forty  hours'  duration.  After  removing  the 
stricture,  I  reduced  the  intestine  with  the  exception  of  its  most  projecting  part 
which  was  gangrenous,  the  opening  of  which  I  retained  in  the  ring.  The 
organic  contour  which  liad  supported  the  constriction,  presented  the  above- 
mentioned  ulceration,  and  near  its  mesenteric  border,  there  was  a  perforation 


5G8  NEW    ELEMENTS    OF 

through  whicli  the  fluid  matter  poured  into  the  peritoneum.  The  reduction 
therefore  should  nev^r  be  accomplished  in  any  case  without  previously 
bringing  the  sac,  for  examination,  that  portion  of  the  viscera  which  has 
been  originally  contained  in  tlie  fibrous  circle  of  the  abdominal  wall.  If  it 
resist,  or  any  difficulty  be  experienced  in  returning  it,  we  should  without 
hesitation  enlarge  the  opening  through  which  it  has  passed — we  should  finally 
remove  the  strangulation. 

Fifth  Stage. — ^The  seat  of  this  strangulation,  is  not  in  every  case  the  same. 
In  the  circular  openings  it  may  be.  produced  by  the  neck  of  the  sac,  or  by  the 
fibrous  circle  which  embraces  it.  In  a  canal,  it  is  found,  as  I  have  already 
stated,  sometimes  at  the  external  orifice,  sometimes  at  the  posterior  orifice, 
and  at  other  times  between  the  two.  Strangulation  by  the  neck  of  the  sac 
occurs  only  in  old  hernias,  or  in  those  which  liave  protruded  and  been  reduced 
a  number  of  times.  In  other  cases,  in  fact,  we  cannot  conceive  how  the 
circle  can  be  thickened,  contracted,  and  indurated  so  as  to  interrupt  the  passage 
of  intestinal  matters.  It  is  known  by  the  mobility  of  the  peritoneal  prolonga- 
tion, whicli  is  pushed  back  in  drawing  the  intestine  towards  the  abdomen  by 
the  freedom  of  the  ring,  notwithstanding  the  constriction  of  the  viscera,  and 
by  the  facility  of  introducing  the  finger  completely  or  in  part  between  the 
fibrous  circle  and  the  root  of  the  sac.  If  the  strangulation  is  formed  by  the 
external  orifice  of  the  herniary  canal,  the  nail  carried  on  this  point  will  soon 
give  assurance  of  the  fact.  When  more  deeply  situated,  on  the  contrary,  the 
opening  in  question  is  neither  tense  nor  completely  filled.  In  this  ease,  it 
will  be  known  that  the  entrance  of  the  serous  membrane  is  not  the  cause, 
but  rather  that  of  the  aponeurotic  canal,  if  the  incomplete  reduction  of  the 
intestine  is  not  accompanied  with  a  gliding  of  the  sac. 

Two  different  methods  have  been  proposed  for  removing  the  stricture, 
dilatdtion  and  iiicision.  The  former  was  extolled  by  Thevenin,  and  afterwards 
by  Arnaud,  and  has  been  especially  recommended  by  Leblanc.  Various 
instruments  have  deen  devised  to  accomplish  it.  The  double  gorget,  the  two 
branches  of  which  open  and  close  in  the  manner  of  dressing  forceps,  will, 
certainly  fuUfil  the  intention  better  than  any  crotchets  or  dilators  that  have 
been  contrived,  if  the  method  itself  deserved  to  be  retained ;  but  the  only 
advantage  it  presents,  that  of  defending  the  vessels  from  lesion,  iS'  of  too 
little  value  in  comparison  with  its  disadvantage  to  allow  its  general  adoption. 
The  impossibility  of  applying  it  when  the  strangulation  is  carried  very  far, 
its  insufficiency  in  the  greater  number  of  cases,  the  contusion  of  the  viscera  which 
most  frequently  results  from  it,  the  enlargement  of  the  ring  instead  of  its 
definitive  closure,  which  will  almost  necessarily  be  the  consequence,  sufficiently 
justify,  in  my  opinion,  the  neglect  into  which  it  has  fallen;  and  I  doubt 
whether  M.  Truestedst,  who,  alarmed  by  the  fear  of  opening  the  arteries  in 
removing  the  stricture,  has  just  proposed  it  anew,  will  find  many  imitators 
among  his  contemporaries. 

Incision  or  debridement  consists  in  dividing  more  or  less  deeply,  on  one  pr 
several  points,  the  free  edge  of  tlie  constricting  circle.  This  is  the  delicate 
and  dangerous  part  of  the  operation.  It  exposes  the  organs  within  the  ring 
to  be  wounded,  and  even  those  still  contained  in  the  abdomen,  but  especially 
the  vessels  on  the  contour  of  the  hernia.  On  this  account  a  host  of  diff*erent 
pi'ocesses  have  been  advised  for  executing  it.     The  scissors  curved  on  the 


OPJBRATIVE  SURGERY.  569 

edge,  formerly  used  by  some,  are  proscribed  at  present  and  deservedly.  It 
is  the  same  with  the  bistoury  of  Bienaise,  an  instrument  which  seems  to  have 
given  the  idea  of  the.  lithotome  of  Frere  Come.     The  concave  bistoury  of  Pott, 

^now  supersedes  all  other  herniary  bistouries.  Sir  A.  Cooper  has  so  modified 
it^^.nat  its  cutting  edge  is  not  more  than  six  or  eight  lines  in  extent,  and  stops 

'^'within  two  or  three  lines  of  its  buttoned  extremity.  Thus  constructed,  it 
renders  less  liable  to  lesion  the  parts  which  during  the  cutting  of  the  stricture 
come  before  its  heel.  This  trifling  advantage  should  be  accepted,  but  we 
should  be  cautious  in  exaggerating  its  value,  as  has  been  done  by  some  of  our 
masters,  no  doubt  from  want  of  reflection.  I  will  remark  here,  that  in  certain 
cases  when  the  edges  of  the  abdominal  opening  are  very  thick,  when  move- 
ments backwards  and  forwards,  or  sawing  movements  become  necessary,  it  is 
less  convenient  than  the  bistoury  of  Pott.  The  oval  plate  which  M.  Chaumas 
placed  on  its  convex  edge,  in  order  to  protect  the  intestines,  is  too  much  in 
the  way  and  of  too  little  use  to  require  further  mention.  The  intention  of 
M.  Dupuytren  in  transferring  the  cutting  edge  to  the  convexity,  which  seems 
not  to  have  been  exactly  understood  by  those  who  have  v/ritten  since,  was  to 
render  it  better  adapted  to  the  division  of  the  tissues,  from  before  backwards, 
and  from  the  centre  of  the  ring  towards  its  circumference.  Hence  it  is 
suitable  only  in  some  cases,  and  we  shall  soon  show  that  even  in  these  cases 
the  simple  straight  bistoury,  or  the  ordinary  convex  bistoury,  may  be  used 
advantgeously  in  its  stead.  The  probe-pointed  bistoury,  edged  like  a  file, 
invented  by  J.  L.  Petit,  is  too  coarse  to  divide  the  vessels,  but  will  be  fine  enough 
to  destroy  the  continuity  of  an  aponeurotic  circle,  but  is  of  no  value  notwith- 
standing all  the  eulogies  that  have  been  heaped  upon  it.  The  stricture  is  not 
always  caused  by  the  fibrous  tissues,  and  it  is  not  proved  that  an  instrument 
just  capable  of  cutting  an  albugineous  circle  will  always  spare  the  tissue  of 
an  artery.  As  to  the  common  probe-pointed  bistoury,  it  is  evidently  less 
convenient  than  the  curved  bistoury,  as  we  are  almost  always  obliged  to  follow 
a  passage  more  or  less  tortuous  to  come  at  and  remove  the  stricture. 

The  winged  director  of  Merry  which  the  invention  of  M.  Chaumas  should 
render  useless,  and  which  was  intended  to  fullfil  the  same  indication,  is  no 
longer  found  in  the  apparatus  of  surgery ;  so  that  Pott's  bistoury  is  in  reality 
the  only  particular  instrument  that  has  been  retained  for  relaxing  the  stricture 
in  strangulated  hernia.  When  there  are  no  vessels  in  danger,  the  concave 
bistoury  or  even  the  probe-pointed  bistoury,  if  a  ring  and  not  a  canal  is  to  be 
acted  upon,  sufBces  and  may  be  preferred.  The  nail  of  the  left  index  finger 
is  first  introduced  between  the  intestine  and  the  circle  to  be  divided,  its  pulp 
then  serves  as  a  guide  to  the  instrument  of  Pott,  the  bottom  of  which  is  carried 
into  the  abdomen  before  turning  its  edge  upon  the  resisting  border.  An  assist- 
a.nt  then  takes  charge  of  the  viscera,  and  separates  them  from  the  point  to  be 
divided;  another  assistant  acts  in  the  same  manner  with  respect  to  the  lips 
of  the  wound;  after  which  the  surgeon,  combining  the  movements  of  his  right 
hand  which  holds  the  handle  of  the  bistoury  with  those  of  the  left  index  fin- 
ger which  supports  its  back,  saws  the  ring  until  it  yields  and  is  decidedly  cut, 
which  is  told  by  a  sound  similar  to  the  breaking  of  tin  or  the  rumpling  of 
pacchment.  However,  as  this  noise  comes  from  the  fibrous  tissue  which  is 
br^cn;'it  would  be  useless  to  expect  it  when  the  unbridling  cut  acts  only  on 
the  neck  of  the  sac.  Supposing  the  director  is  to  be  used,  it  will  be  as  a  sub- 
72  "■ 


570  NEW  ELEMENTS  OF 

stitute  for  the  index  finger;  that  is,  after  it  has  been  introduced  into  the  peri- 
toneum the  bistoury  is  passed  upon  it,  and  thus  supported  during  the  cutting 
of  the  stricture.  In  such  cases  it  is  well  for  it  to  have  a  cul-de-  sac  to  serve 
as  a  limit  to  the  point  of  the  cutting  instrument,  and  to  have  it  curved  so  that 
the  concavity  of  its  beak  may  be  well  applied  against  the  internal  face  of  the  ^ 
abdominal  wall,  and  prevent  any  portion  of  the  viscera  from  coming  between, 
and  running  the  risk  of  being  divided  at  the  same  time  with  the  edge  of  the 
herniary  opening.  If  it  is  absolutely  necessary  to  be  content  with  a  straight 
or  sharp-pointed  bistoury,  all  these  precautions  no  doubt  have  their  value ; 
but  with  Pott's,  or  any  probe-pointed  bistoury,  where  can  be  its  importance  ? 
Are  they  not  more  embarrassing  than  really  useful  ?  To  preserve  with  cer- 
tainty the  vessels  about  the  neck  of  the  sac,  Bell  has  recommended  a  very 
ingenious  process,  which  is  this ;  a  convex  or  broad -pointed  bistoury,  as  most 
of  the  English  ones  are,  with  its  back  against  the  pulp  of  the  left  index  finger, 
is  carried  in  front  of  the  ring  and  divides  it  at  short  strokes,  fibre  by  fibre, 
from  below  upwards,  or  from  the  centre  towards  the  circumference,  and  from 
its  cutaneous  face  towards  its  peritoneal,  taking  care  that  the  edge  of  the  nail 
always  goes  a  little  beyond  the  point  of  the  instrument.  The  strangulation 
is  thus  removed  before  arriving  at  the  fascia  propria,  which  contains  tbe  arte- 
rial canals,  and  nothing  forbids  the  incision  to  be  carried  to  all  proper  extent. 
It  was  evidently  to  obtain  an  analogous  result  that  M.  Dupuytren  proposed 
his  curved  bistoury  with  the  edge  on  the  convexity.  This  process,  the  advan- 
tages of  which  I  attempted  to  demonstrate  in  1825,  which  M.Colson,  and  M. 
Dellouey  have  introduced  again  as  belonging  to  themselves,  is  in  the  first 
place  only  adapted  to  a  strangulation  foreign  to  the  neck  of  the  sac ;  secondly, 
it  would  be  impossible  or  dangerous  to  have  recourse  to  it  when  the  circle  to 
be  divided  is  deeply  situated  or  not  well  determined.  For  the  rest,  the  most 
common  convex  or  slender-pointed  bistoury  will  answer  the  purpose  equally 
as  well  as  the  bistoury  of  Bell.  Moreover,  the  danger  of  wounding  the  ves- 
sels is  much  less  than  is  generally  imagined.  Enveloped  in  cellular  substance 
which  lines  the  peritoneum  and  separates  it  from  the  fascia  iransversalis  or 
the  abdominal  parietes,  they  are  constantly  thrown  outwards,  two  lines  at 
least,  upon  the  posterior  face  of  the  ring,  and  this  is  because  the  entrance  of 
-every  hernia  is  widened  into  the  shape  of  a  funnel,  and  by  entering  it  the  vis- 
cera themselves  separate  more  or  less  the  vessels.  On  the  other  hand  they 
are  so  flexible  and  generally  so  movable  as  to  recede  from  the  bistoury  when 
it  touches  them,  rather  than  remain  and  be  divided  by  it.  When  the  stran- 
gulation occupies  a  canal,  and  is  not  located  at  its  posterior  part,  the  neces- 
sity of  carrying  the  point  of  the  instrument  into  the  abdomen  is  not  evident, 
nor  consequently  is  it  evident  in  what  consists  the  danger  of  wounding  the 
blood  vessels.  In  fact  there  is  another  means  of  braving  every  inconvenience 
of  this  sort  with  almost  complete  security  when  we  are  obliged  to  pass  through 
the  whole  of  the  herniary  passage.  This  consists  in  making  two,  three,  four, 
five,  and  even  ten  incisions,  instead  of  one,  upon  the  dense  margin  which 
binds  the  viscera.  By  thus  multiplying  them  we  can  give  to  each  but  a  line 
or  a  line  and  a  half  of  depth ;  the  enlargement  of  the  orifice  will  yet  be  con- 
siderable, and  the  vessels  will  be  absolutely  out  of  danger.  The  idea  of  this 
process,  which  I  shall  call  the  '*  debridement  midtiple,^^  is  already  found  in 
Scarpa,  and  has  long  since  received  its  application  in  vaginal  hysterotomy. 


OPERATIVE  SURGERY.  571 

M.  Manche  of  Lyons  published  it  in  1826.  It  seems  that  M.  Dupuytren 
adopts  it  also  in  some  cases.  But  it  was  by  M.  Vidal  (of  Cassis)  that  it  was 
erected  into  a  rule  in  1827,  and  1831,  at  the  same  time  that  M.  Dellouey  who, 
no  doubt  by  mistake,  gives  the  honor  of  it  to  M.  Amussat,  proposed  to  com- 
bine it  with  the  method  of  Bell.  For  my  own  part,  I  have  performed  it  three 
times,  and  am  led  to  believe  that  it  deserves  the  serious  attention  of  the  ope- 
rating surgeon. 

JViiat  extent  should  be  given  to  the  debridement  ?  If  we  trust  some  authors, 
two  or  three  lines  will  be  sufficient.  According  to  them,  a  more  extensive 
incision,  by  enlarging  the  ring  too  much,  will  most  assuredly  cause  a  relapse, 
even  when  no  wound  of  the  vessels  is  apprehended.  No  doubt  we  should  be 
content  with  a  small  incision  when  the  constriction  is  trifling  and  the  reduction 
does  not  require  more.  On  the  contrary  if  there  seems  to  be  a  necessity  for  a 
larger  incision,  the  practice  of  Sharp,  of  Hey,  of  M.  Dupuytren,  and  the 
observations  recently  published  by  M.  Janson,  prove  that  there  is  no  reason 
for  abstaining  from  it.  The  incision  of  two  lines  in  extent,  repeated  in  several 
places,  the  debridement  multiple  will  leave  no  excuse  on  this  point  to  those 
whom  the  vicinity  of  important  vessels  might  deter.  As  to  relaxation  of  the 
herniary  opening,  it  does  not  appear  how  it  can  be  very  formidable,  unless  on 
the  supposition  that  it  is  one  of  those  long  gashes  which  cannot  be  indispen- 
sable except  in  some  rare  cases  of  deep  strangulation.  If  the  wound  suppurate, 
as  it  almost  always  does,  the  inodular  tissue  which  is  formed  in  front,  or 
even  in  the  centre  of  the  ring,  to  constitute  the  cicatrix,  frequently  offers  to 
the  viscera  a  more  powerful  resistance  than  could  have  been  presented  by  the 
natural  tissues.  In  this  point  of  view  the  debridement  midtiple  should  still 
obtain  the  preference,  because  the  more  numerous  the  scarifications  of  the  ring 
the  more  solid  will  the  cicatrix  become,  and  the  greater  will  be  the  chance  of 
seeing  the  elastic  tissue  in  question  developed. 

Some  authors  have  also  thought,  that  it  would  be  advantageous  and  possible 
to  remove  the  stricture  without  opening  the  sac  ;  that  thus  there  would  be  an 
operation  attended  with  very  little  danger,  as  the  peritoneum  remaining  intact 
would  not  be  so  exposed  to  the  inflammation  which  is  so  frequent  after  the 
common  operation  ;  that  the  viscera  would  by  this  mode  be  out  of  danger  of 
being  wounded ;  in  a  word,  the  opening  of  the  sac,  which  is  ordinarily  attended 
with  so  much  uncertainty  would  be  avoided,  and  celotomy  performed  with 
confidence,  promptitude,  and  very  little  pain.  Of  itself  the  cutting  of  the 
stricture  thus  presents  no  more  difl&culty  in  this  way  than  the  ordinary  process. 
The  bistoury  is  introduced  between  the  fibrous  ring  and  the  neck  of  the  sac 
instead  of  being  passed  between  the  sac  and  the  viscera;  the  root  of  the  hernia 
is  insulated  with  a  little  more  care,  in  order  the  better  to  distinguish  the 
external  face  of  the  serous  prolongation  at  its  exit  from  the  abdominal  aperture, 
and  this  is  all.  J.  L.  Petit,  who  set  himself  up  as  the  defender  of  this  mode 
of  operating,  to  which  Franco,  Rousset,  Pare,  and  some  others,  had  already 
called  the  attention  of  practitioners,  attributes  to  it,  as  has  since  been  done  by 
Garengeot  and  Ravaton,  so  many  advantages  that  no  other  would  at  present 
be  followed  if  they  were  real  and  not  counterbalanced  by  still  niore  numerous 
disadvantages.  It  is  time  in  my  opinion  to  cease  to  attribute  to  the  contact 
of  the  air,  dangers  which  are  so  often  encountered  without  any  plausible 
reference  to  such  a  cause.    The  radical  cure  which  is  pretended  to  be  thus 


57Z  NEW   ELEMENTS    OF 

obtained,  is  certainly  less  probable  than  by  the  opening  of  the  sac.  If  the 
hernia  is  reduced  without  dividing  its  peritoneal  covering,  it  does  not  appear 
how  the  obliteration  of  the  passage  is  a  necessary  consequence,  as  it  is  main- 
tained to  be  by  J.  L.  Petit.  It  is  to  be  feared  that  the  parts  contained  in  the 
the  sac  may  be  the  seat  of  alterations,  which  it  is  important  not  to  mistake. 
To  what  accidents  will  the  patient  not  be  exposed  if  the  intestine  be  gan- 
grenous, ulcerated,  contracted,  twisted,  strangulated  by  a  band,  passed  through 
an  opening  in  the  epiploon,  or  if  several  of  its  parts  adhere  together.  It  is 
evident,  moreover,  that  in  case  of  adhesion,  reduction  would  be  altogether 
impossible,  and  that  this  species  of  liberation  would  be  insufficient,  whenever 
the  stricture  is  caused  by  the  neck  of  the  sac.  Add  to  this,  the  serosity  more 
or  less  turbid  of  a  deeper  or  lighter  red,  which  may  be  found  in  the  hernia  to 
the  amount  of  several  ounces  or  even  pounds,  as  has  been  noticed  above,  could 
not  be  returned  into  the  abdomen  without  creating  apprehensions.  This 
method,  which  may  perhaps  be  successfully  put  in  practice,  for  recent  and 
small  hernias,  presents  therefore  no  real  advantage  over  the  ordinary  method, 
and  deserves  the  neglect  into  which  it  has  sunk,  notwithstanding  the  successes 
brought  forward  in  its  support  in  the  name  of  M.  Beau chene  and  of  some  other 
modern  practitioners,  who  seem  to  consider  it  of  their  own  invention.  Another 
species  of  debridement,  which  seems  to  be  as  old  as  Franco,  is  that  advised  by 
Pigray.  It  consists  in  making  an  incision  in  the  abdominal  parietes  a  little 
above  the  strangulation,  so  as  to  be  able  by  introducing  the  fingers  into  the 
wound,  to  draw  back  the  intestine  and  return  it  into  the  abdomen.  Rousset  who 
wrote  a  little  before  Pigray,  says  that  this  mode  had  been  followed  by  Duval  and 
his  son,  as  well  as  by  Maupas.  Heister  who  refers  it  to  Cheselden,  is  evidently 
mistaken  on  this  point,  as  Sabatier  judiciously  remarks ;  the  process  of  the 
English  surgeon  appears  to  be  the  common  one,  but  with  a  very  large  incision. 
It  is  sufficient,  I  think,  to  mention  the  operation  spoken  of,  to  show  its  dangers 
and  absurdity.  If  after  incising  the  anterior  ring  of  the  herniary  canal  there 
be  any  difficulty  in  the  reduction,  it  will  be  necessary  to  explore  this  canal 
with  the  finger,  and  see  that  no  second  strangulation  exist  on  die  side  of  the 
abdomen.  If  in  this  case  the  stricture  depend  upon  the  sac,  we  may,  by 
drawing  the  two  lips  of  its  external  division,  bring  it  in  the  wound  and  divide 
it  without  danger,  with  blunt  scissors  or  a  bistoury,  to  any  necessary  extent. 
"When  on  the  contrary  this  posterior  strangulation  is  caused  by  a  fibrous  circle, 
the  drawing  out  of  the  neck  of  the  sac  will  be  insufficient ;  the  curved  bistoury 
must  be  introduced,  guided  by  the  finger  or  a  director,  and  be  used  as  in 
external  strangulation. 

Sixth  Stage. — The  obstacle  which  opposes  the  return  of  the  displaced  organ 
being  overcome,  the  next  thing  to  be  attented  to  is  the  reduction.  After 
spreading  equally  all  the  matters  contained  in  the  intestine  which  is  visible, 
the  surgeon  grasps  it  with  the  thumb  and  the  first  two  fingers  near  the  ring; 
the  right  hand  embraces  the  portion  last  issued  and  pushes  it  back,  passing  it 
between  the  fingers  of  the  left,  which  prevents  its  return,  while  a  new  portion 
is  seized  and  reduced  in  the  same  manner,  and  so  in  succession  until  the 
whole  is  returned  into  the  abdomen.  The  fore  finger  is  then  carried  into  the 
canal,  to  be  certain  that  the  intestine  has  resumed  its  natural  place,  that  it  has 
not  turned  through  the  substance  of  the  abdominal  parietes,  that  the  sac  has  not 
followed  it,  and  tliatit  is  really  free  from  all  stricture  or  adhesions  capable  of 


OPERATIVE 'SURGERY.  575 

interrupting  its  functions.  When  there  remains  a  strangulation  at  the  pos- 
terior part  of  the  sac,  whicli  has  formed  but  very  feeble  connections  with  the 
parts  adjacent,  if  the  hernia  is  not  very  voluminous,  it  may  return  en  masse, 
by  pushing  before  it  the  circle  which  strangulates  it.  Le  Dran  was  one  of  the 
first  to  point  out  this  fact,  which  has  been  taught  by  many  surgeons  since. 
The  intestines  then  glide  between  the  peritoneum  and  the  parietes  of  the  ab- 
domen, sometimes  are  arrested  there  and  become  fixed.  The  stricture  not 
being  destroyed  a  fissure  is  at  length  made,  and  then  follows  an  effusion  into 
the  abdomen.  Arnault,  De  la  Faye,  Leblanc,  Bell,  and  Sabatier  have  observed 
cases  of  this  description,  and  M.  Dupuytren  seems  to  have  met  with  several. 
It  is  not  always  in  consequence  of  resistance  of  the  neck  of  the  sac  that  the 
hernia  thus  returns  without  ceasing  to  be  strangulated.  If  the  strangulation 
is  situated  at  the  internal  aperture  of  the  canal,  and  has  not  been  removed,  the 
intestines  may  also  be  engaged  between  the  fascia  transversalis  and  the  mus- 
cles, separating  these  parts,  and  remain  there  quite  as  well  as  it  might  between 
the  aponeurosis  and  the  peritoneum.  An  adult,  twenty-eight  years  old,  upon 
whom  I  operated  for  an  enterocele,  presented  this  peculiarity,  in  1823,  at  the 
hospital  of  Improvement.  After  freeing  the  external  aperture  of  the  canal, 
I  forgot  to  explore  the  posterior  ring,  and  passed  to  the  reduction.  As  I  had 
heard  no  gafgouillement,  and  as  the  abdominal  wall  remained  projecting,  I  de- 
termined to  carry  my  finger  as  far  as  the  interior  of  the  peritoneum,  and  then 
discovered  that  the  reduction  was  incomplete.  The  intestines  were  brought 
out  again ;  and  the  left  index  finger  carried  to  the  bottom  of  the  wound,  soon 
afforded  me  the  certainty  of  a  second  strangulation,  which  was  produced  by  the 
inner  ring.  I  removed  the  stricture,  and  the  reduction  presented  no  further 
difficulty. 

It  is  therefore  necessary  to  distinguish  the  return  of  the  intestines  between 
the  peritoneum  and  the  aponeurosis,  from  that  which  takes  place  between  the 
aponeurosis  and  the  muscles,  or  the  different  muscular  layers  of  the  abdomen, 
and  not  to  confound  the  obstacle  depending  on  the  neck  of  the  sac  with  that 
which  arises  from  a  stricture  in  the  posterior  ring.  When  such  an  acci- 
dent happens,  the  first  thing  to  do  is  to  reproduce  the  hernia.  This  is  accom- 
plished by  directing  the  patient  to  cough,  to  bear  down,  and  even  to  get  up. — 
Frequently  however  the  viscera  come  out  again  spontaneously.  When  they 
can  be  reached  with  the  finger  it  is  still  better  to  take  hold  of  them  and  draw 
them  outwards,  using  all  proper  precautions.  If  the  difficulty  arises  from 
the  neck  of  the  sac, 'tractions  upon  the  portion  of  this  covering  which  remains 
in  the  wound  will  frequently  prove  an  excellent  means  of  attaining  the  end 
proposed,  as  has  been  proved  long  since  by  M.  Dupuytren.  However,  neither 
of  these  resources  will  constantly  insure  success.  Chopart,  Lobstein,  and 
other  experienced  practitioners  have  seen  their  patient  sink  for  want  of  this 
reproducing  of  the  hernia.  There  is  another  circumstance  which  sometimes 
opposes  to  the  immediate  return  of  the  organs  into  the  abdomen;  it  is  the 
case  in  an  old  and  voluminous  hernia.  Having  accomplished  the  reduction 
of  a  tumor  of  this  kind  with  much  difficulty  and  fatigue,  J.  L.  Petit  found  the 
symptoms  to  continue,  and  only  cease  when  the  viscera  were  permitted  to 
descend.  He  explains  the  fact,  by  saying  that  the  abdominal  cavity  was 
accustomed  to  the  absence  of  the  organs ;  and  so  contracted  as  no  longer  to 
allow  them  admission,  so  that  thev  had  lost  as  it  were  the  right  of  domicile. 


574  NEW    ELEMENTS    OF 

When  the  extensibility  of  the  parietes  of  the  abdomen  is  considered,  when  in 
the  same  day  they  permit  the  stomach  and  other  entrails  to  acquire  double  or 
triple  the  dimensions  they  previously  had,  it  is  difficult  to  believe  that  their 
resistance  alone  is  of  a  nature  to  render  the  reduction  of  any  hernia  impossible 
or  dangerous.  Is  it  not  more  probable  that  in  the  environs  of  the  neck  of  an 
old  and  voluminous  hernia,  adhesions  are  established  between  the  organs  so 
as  to  render  their  displacement  difficult,  or  rather  that  the  viscera  being  a 
long  time  displaced  cause  unpleasant  symptoms  to  occur,  because  after  the 
reduction  they  remain  compressed,  agglomerated,  united  into  a  mass,  and  do 
not  freely  spread  behind  the  ring  ?  This  reflection,  which  long  since  occurred 
to  me,  which  has  also  been  -wiade  by  M.  Curveilhier,  and  which  Petit  the 
younger  does  not  forget,  deserves  in  my  opinion  some  notice.  For  the  rest 
we  should  not  go  so  far  as  to  deny  absolutely  the  explanation  of  J.  L.  Petit, 
which  really  applies  to  young  and  vigorous  subjects  whose  abdominal  parietes 
are  endowed  with  great  elasticity,  and  are  of  considerable  thickness,  to  those 
of  a  certain  embonpoint,  and  in  whom  the  epiploon  is  loaded  with  fat.  On  the 
■whole,  it  would  be  better  to  leave  the  intestines  within  the  sac  after  freely 
incising  the  stricture,  than  to  bruise  and  injure  them  by  attempting  their 
reduction.  Experience  has  shown,  that  being  thus  kept  without  they  in  the 
end  insensibly  return,  if  not  entirely  at  least  for  the  greatest  part.  The  hori- 
zontal posture,  the  debilitating  regimen  to  which  the  patient  is  confined,  creates 
by  degrees  in  the  abdomen  a  kind  of  void,  which  singularly  promotes  the 
effect  intended.  Before  declining  the  reduction  we  should  give  it  a  second 
examination.  There  are  a  number  of  alterations  for  which  the  return  of  the 
parts  into  the  abdomen  would  indisputably  be  the  best  remedy.  Thus  con- 
centric ulceration  should  not  prevent  it,  if  confined  to  the  external  membrane 
or  even  to  the  muscular  coat ;  if  in  a  word,  it  does  not  completely  perforate 
the  intestine.  A  coarctation  of  the  displaced  organ  is  not  always  a  counter- 
indication.  If  it  be  recent  and  moderate,  leaving  to  the  alimentary  canal 
at  least  half  of  its  natural  dimensions,  it  maybe  expected  finally  to  disappear, 
and  the  cure  will  probably  be  advanced  by  replacing  in  the  abdomen. 
Gangrene  is  a  condition  which  most  decidedly  opposes  every  attempt  at  reduc- 
tion. But  for  the  same  reason  we  must  not  be  deceived  by  appearances.  If 
the  strangulation  is  acute,  and  there  has  been  inflammation,  and  the  symptoms 
have  lasted  sometime,  the  intestine  contained  in  the  hernia  is  more  or  less 
red.  Frequently  it  is  found  of  a  dark  or  greyish  brown,  with  the  peritoneal 
coat  separable  in  small  flakes,  having  lost  its  smooth  and  moist  appearance 
and  become  wrinkled,  and  all  this  without  the  existence  of  gangrene.  The 
fetid  odor  or  presence  of  fecal  matter  which  some  persons  have  given  as 
characteristic  signs,  may  also  occasion  mistakes.  The  same  remark  applies  to 
the  slate-like,  or  grey  cinereous  tint.  If  its  tunics  are  not  sunken,  flaccid, 
and  folded  as  it  were  upon  themselves,  if  it  resists  the  tractions  made  upon  it, 
if  it  remains  dense  and  shining,  if  the  thickness  of  its  parietes  seems  to  be 
increased  instead  of  diminished,  if  it  preserves  some  warmth,  and  this  warmth 
remains  equal  on  every  point  after  being  exposed  sometime  to  the  air,  if  it  is 
not  the  seat  of  any  perforation,  there  is  no  gangrene.  When  intimate  adhe- 
sions, which  cannot  be  destroyed,  are  encountered,  it  is  not  the  less  neces- 
sary to  make  the  debridement  as  in  ordinary  cases,  only  it  is  proper  to  make 
it  a  little  larger  in  order  afterwards  to  return  the  free  portion  of  the  viscera. 


OPERATIVE    SURGERY.  575 

The  rest  is  left  in  the  sac,  which  is  covered  with  compresses  soaked  in  some 
bland  fluid,  as  in  the  case  of  large  irreducible  hernia.  When  freed  from  the 
constiiction  ot  these  parts,  the  organs,  being  drawn  upon  by  those  of  which  they 
are  a  continuation,  often  in  the  end  return  of  themselves,  or  at  least  form 
within  the  ring  but  a  small  tumor,  which  a  concave  pad  will  easily  support 
after  the  cure. 

B.  Epiplocele. — We  have  as  yet  scarcely  noticed  any  but  intestinal  hernia. 
Epiplocele  existing  by  itself  is  rarely  so  strangulated  as  to  require  a  removal 
of  the  stricture,  but  it  is  very  common  to  find  in  the  same  sac  a.  loop  of  in- 
testine and  some  considerable  portion  of  epiploon.  In  this  case  it  is  proper, 
before  cutting  the  stricture,  to  see  if  the  opening  has  not  contracted  a  union 
with  the  neck  of  the  sac  or  around  the  intestine.  It  is  also  proper  to  make 
the  incision  on  a  point  not  occupied  by  the  epiploon,  so  as  not  to  expose  to 
division  any  of  the  vessels,  sometimes  very  large,  which  run  through  this  ex- 
pansion! Although  it  usually  presents  first  on  opening  the  sac,  yet  the  reduc- 
tion must  begin  with  the  intestine  after  the  removal  of  the  strangulation. 
That  of  the  epiploon  is  always  more  difficult.  It  has  almost  always  under- 
gone some  alteration.  If  it  should  be  fixed  in  the  sac  only  by  bands  and 
filaments  it  would  be  very  easy  to  destroy  them.  When  its  adhesions  are  inti- 
mate and  lamellated  it  becomes  almost  indispensable  to  remove  the  part.  If 
it  have  remained  long  displaced  it  has  become  loaded  with  fat,  or  transformed 
into  an  adipose  mass,  or  reflected  upon  itself,  giving  rise  to  knots,  cylinders, 
and  hard  shining  tumors  which  have  been  compared  to  scirrhus.  But  a 
great  variety  of  forms  are  met  with,  and  it  would  be  almost  as  impossible  as 
useless  to  describe  them  all.  If  these  masses  were  reduced  with  the  vis- 
cera, when  they  are  susceptible  of  this  reduction  we  might  expect  that  some  of 
them  would  be  resolved,  but  this  would  rarely  occur ;  and  should  they  be  of  any 
size  their  presence  in  the  abdomen  would  be  attended  with  too  much  danger  to 
allow  of  the  attempt.  Excision  is  without  danger  when  they  are  peduncu- 
lous,  as  often  happens,  and  when  we  are  not  obliged  to  cut  ii^o  the  sound 
portion  of  the  epiploon.  In  the  month  of  April  last,  M.  Payer  and  myself 
cut  down  to  an  entero-epiplocele  in  which  several  of  these  productions  were 
developed.  One,  four  inches  long  and  from  fifteen  to  twenty-eight  lines 
thick,  adhered  to  the  fundus  of  the  sac  by  an  epiploic  band,  still  distinguish- 
able, and  was  continuous  towards  the  abdomen  with  the  same  membrane,  by  a 
narrow  lamella  of  so  little  vascularity  that  it  was  divided  without  the  least 
flow  of  blood.  Another  not  so  long  but  more  enlarged  about  its  middle, 
which  had  also  a  broad  root,  was  removed  in  the  same  manner  with  no  more 
inconvenience.  Besides,  if  their  root  appears  to  contain  vessels  of  a  certain 
calibre,  nothing  prevents  their  being  encircled  by  a  double  ligature  before 
removal.  Should  the  epiploon  preserve  its  natural  state  it  is  to  be  reduced, 
if  its  return  into  the  abdomen  is  not  attended  with  too  much  difficulty.  With 
this  intention  it  is  pushed  back  by  degrees,  commencing,  as  far  as  the  intestine, 
with  the  part  last  come  out,  after  it  has  been  freed  from  all  adhesion  and 
every  kind  of  duplicature.  When  it  is  irreducible  some  contend  that  it 
should  be  left  in  the  wound,  that  it  will  return  little  by  little,  and  that  a  con- 
cave pad  will  support  very  well  the  part  that  may  remain  without.  Excision, 
which  is  at  first  view  quicker  and  more  satisfactory,  has  not  as  yet  been 
adopted  but  by  a  small  number  of  practitioners.     There  are  three  modes  of 


576  NEW    ELEMENTS    OF 

:W      .     . 

performing  it ;  first,  to  cut  between  the  dead  and  living  parts  in  case  of  gan- 
grene ;  second,  to  cut  in  the  living  part  whether  there  be  gangrene  or  not, 
to  use  no  ligature,  and  reduce  it ;  third,  to  cut  in  the  living  portion  and  tie  sepa- 
rately the  vessels  as  they  spring.  The  first  method  is  bad;  because  if  any 
mortified  tissues  remain,  their  return  into  the  abdomen  could  not  fail  to  be 
dangerous,  and  if  the  bistoury  touch  upon  the  yet  living  tissues  a  hemorrhage 
might  be  the  consequence.  The  second  has  been  defended  by  Caque  of 
Rheims,  who  gives  nine  successful  cases  in  its  favor.  With  this  author  I  am 
convinced  that  ligature  of  the  epiploic  vessels  is  not  always  indispensable,  and 
that  often  they  will  cease  to  bleed  after  a  certain  time.  Nevertheless  I 
would  not  dare  to  propose  his  practice  as  an  example  to  be  followed.  I  con- 
formed to  it  once  with  a  patient  of  M.  Florence.  Until  then  the  operation 
presented  nothing  peculiar.  It  was  necessary  to  remove  a  part  of  the  epi- 
ploon. The  vessels  at  first  scarcely  bled  at  all.  I  made  the  reduction,  and 
in  the  night  a  quantity  of  blood  flowed  from  the  wound.  Syncope,  and 
llpothymia  accompanied  with  cold  sweats  supervened,  and  although  the  vomit- 
ing had  ceased  and  the  matters  resumed  their  natural  course,  the  woman 
died  ten  hours  after  the  operation.  This  was  sufficient  to  make  me  resolve 
not  to  run  the  same  risk  in  future.  The  third  is  the  mode  followed  by  M. 
Boyer.  To  perform  it,  the  surgeon  begins  by  displaying  and  unfolding  the 
epiploon,  so  as  to  have  but  one  membrane  to  divide ;  he  then  cuts  off  with  the 
scissors  or  bistoury  all  he  intends  to  remove,  seizing  each  vessel  as  it  springs 
with  the  forceps,  and  tying  it  immediately.  This  done  nothing  remains  but  to 
push  the  preserved  parts  behind  the  ring,  and  bring  all  the  ends  of  the 
ligature  together  to  one  of  the  sides  of  the  wound.  The  disadvantages  of  this 
operation  are,  the  time  required,  the  minute  search  for  the  vascular  canals,  and 
the  probability  of  omitting  some  of  them,  which  in  the  end  may  give  rise  to 
danger.  This  is  however  the  most  worthy  of  confidence,  and  indeed  the 
only  one  that  ought  to  be  adopted  when  it  has  been  decided  that  nothing  is  to 
be  left  in  the  wound,  and  the  parts  are  to  be  entirely  reduced.  In  this  case 
however  it  would  be  proper  to  introduce  an  important  modification.  The  liga- 
tures, in  fact,  will  not  permit  the  epiploon  to  be  left  behind  the  heniary 
opening,  but  will  oblige  it  to  be  left  in  the  wound.  Torsion  of  the  arteries, 
which  is  easily  performed  in  this  case,  would  supply  their  place  advantage- 
ously, and  ought  to  be  substituted.  I  have  twice  employed  it,  and  I  think  that 
without  it  my  operation  would  have  been  less  simple. 

The  ligature,  for  a  long  time  in  use,  mentioned  even  by  Galen,  has  during 
the  last  century  been  the  object  of  numerous  attacks.  J.  L.  Petit  among 
others  accuses  it  of  causing  dreadful  dangers.  A  patient  thus  treated  was 
immediately  seized  with  colic,  violent  pains  in  the  abdomen,  and  nervous 
symptoms;  and  it  was  not  known  to  what  to  refer  them.  The  surgeon 
renioved  the  dressing  to  see  if  the  intestine  had  not  redescended.  Finding 
nothing  of  this  sort  he  took  away  the  ligature,  and  all  the  symptoms  vanished 
as  by  enchantment.  From  this  and  other  facts  it  was  concluded  that  stricture 
of  the  epiploon  was  almost  as  formidable  as  that  of  the  intestine.  Theory, 
always  ready  to  come  to  the  support  of  suppositions  arising  from  practice, 
seemed  to  account  for  the  phenomenon,  by  snowing  that  the  great  sympathetic 
nerve  distributes  a  certain  number  of  filaments  over  the  whole  pxtent  of  the 
epiploic  expansion      Pipelet  says,  that  the  danger  arose  only  from  the  con- 


OPERA^TIVE    SURGERY.  577 

sjtriction  rolling  into  a  cord  a  membrane  that  should  remain  expanded,  and 
the  opinion  of  J.  L.  Petit  has  thus  passed  into  an  axiom.  However,  as  the 
ligature  is  much  more  convenient,  and  more  easy  of  application,  and  protects 
from  hemorrhage  quite  as  certainly  as  any  other  mode,  some  practitioners 
have  not  been  willing  to  renounce  it  entirely.  Hey,  for  example,  and  Scarpa 
maintain  that  they  removed  its  inconveniences,  without  destroying  its  ad- 
vantages by  means. of  a  very  simple  modification ;  the  first  applied  the  ligature 
after  the  manner  of  the  ancients,  but  tightened  it  only  by  degrees  so  as  to 
strangulate  and  produce  mortification  of  the  organ  only  after  several  days, 
instead  of  suddenly  intercepting  the  circulation;  the  second  leaves  the 
epiploic  tampon  in  place  until  it  is  covered  with  cellular  granulations,  and 
then  strangulates  it  after  the  manner  of  Hey.  The  cases  reported  by  these 
authors  in  favor  of  their  practice  prove  its  harmlessness,  and  leave  no  doubt 
that,  it  ought  to  be  preferred  if  the  ligature  en  masse  is  to  be  dreaded  as  much 
as  Petit  imagines.  Happily  it  is  not  so,  and  on  this  point  we  may  appeal  to 
the  judgment  of  the  academy  of  Surgery.  I  have  already  had  occasion  to  tie 
the  epiploon  four  times,  and  the  four  patients  got  well  without  any  serious 
symptoms.  When  the  tumor  to  be  removed  does  not  exceed  the  size  of  the 
finger,  it  may  in  my  opinion  be  included  without  fear  in  a  strong  ligature,  and 
completely  strangulated  at  some  distance  from  the  ring.  On  the  contrary, 
when  it  is  larger  the  root  may  be  divided  into  as  many  portions  as  desired,  so 
^s  to  admit  a  ligature  about  each  separately.  Two  were  sufficient  in  the  case 
of  a  woman  on  whom  I  operated  in  1829  at  Saint  Antoine.  It  was  the  same 
in  the  case  of  a  man  operated  upon  this  year  (1832)  by  M .  Pay  en.  Quite 
recently,  the  8th  August  1831,  seven  were  necessary  in  the  case  of  a  woman 
upon  whom  I  operated  in  conjunction  with  M.  Gresely.  All  without  the 
ligatures  is  then  cut  oflf,  and  the  ends  of  the  ligatures  are  brought  together  on 
one  or  more  points  of  the  circumference  of  the  ring,  and  the  operation  closes. 
To  sum  up  these  remarks,  if  the  epiploon  is  gangrenous,  and  it  is  desired  to 
return  the  sound  part  into  the  abdomen,  it  is  best  to  cut  in  the  living  portion 
and  twist  the  arteries.  If  the  surgeon  thinks  proper,  on  the  ccmtrary,  not  to 
return  it  beyond  the  herniary  circle,  he  may  confine  himself  to  the  separation 
of  tlie  completely  mortified  parts  without  using  either  the  ligature  or  torsion. 
When  it  is  simply  irreducible  and  still  possessed  of  vitality,  and  we  are 
obliged  to  excise  it  and  then  keep  the  rest  within  the  ring,  one  ligature  in- 
cluding the  whole,  or  several  embracing  each  a  distinct  portion,  present  the 
process  at  once  the  most  simple  and  the  most  prudent  that  can  be  followed. 

On  this  subject  a  question  arises.  Is  it  better,  everything  else  being  equal, 
to  retain  in  the  ring  the  epiploon  from  which  the  excision  has  just  been  made, 
or  to  leave  it  in  the  abdomen  ?  Fixed  in  the  passage  of  the  viscera,  it  would 
contract  adhesions,  vegetate,  become  covered  with  cellular  granulations, 
harden  by  degrees,  and  finally  blend  itself  with  the  cicatrix,  so  as  to  render 
a  return  of  the  hernia  almost  impossible.  If  returned  into  the  abdomen,  it' 
leaves  the  opening  through  which  it  passed  entirely  free,  and  in  no  respect 
increases  the  chances  of  a  radical  cure.  Two  motives  have  prevented  the 
exclusive  adoption  of  the  first  line  of  conduct,  1.  It  has  been  argue'd,  that  tlie 
epiploon  being  once  reduced  should  remain  perfectly  free,  and  oppose  no  ob- 
stacle to  the  various  motions  of  the  digestive  organs ;  2d.  an  apprehension 
has  been  felt  that  the  epiploic  expansion  might  drag  painfully  and  even 


57^  NEW    ELEMENTS   OF 

dangerously  on  some  of  the  viscera,  and  that  thus  stretched  by  its  two 
extremities,  it  might  constitute  a  band  or  budge,  which  could  become  the  cause 
of  internal  strangulation.  A  single  remark  destroys  the  whole  force  of  these 
reasons.  When  it  has  been  returned  into  the  cavity  of  the  abdomen,  the 
bleeding  portion  of  the  epiploon  neither  remains  free  nor  floating:  on  the 
contrary  it  invariably  unites  with  some  point  of  the  surface  of  the  peritoneum, 
so  as  to  induce  the  same  danger  as  if  it  had  its  j^oifit  d^appui  in  the  ring.  I 
think,  therefore,  that  after  excision  it  would  always  be  proper  to  retain  its 
extremity  in  the  wound.  It  has  at  least  this  advantage,  that  it  is  one  of  the 
most  certain  means  of  obtaining  the  radical  cure  of  hernia.  A  number  of 
surgeons  go  so  far  as  to  act  in  this  manner  whenever  the  epiploon,  reducible 
or  not,  is  found  in  the  sac.  In  reducing  it  they  preserve  a  pad  or  kind  of 
stopper  which  closes  the  summit  of  the  wound.  I  have  it  from  Dr.  Stevens, 
the  able  professor  of  New  York,  that  he  long  since  adopted  this  method,  and 
by  it  has  obtained  much  success.  In  my  opinion,  however,  prudence  does 
not  authorize  the  practice  where  the  reduction  is  easy  and  all  the  parts  are 
sound.  The  formation  of  a  band  or  abnormal  septum  in  the  interior  of  the- 
abdomen  is  never  justifiable  when  it  may  be  dispensed  with,  and  the  fear  of 
bringing  on  internal  strangulation  should  evidently  prevail  over  the  desire  of 
obviating  the  necessity  of  a  bandage. 

Some  practitioners  have  thought  that  after  the  return  of  the  whole  of  the 
viscera,  the  sac  remaining  in  the  wound  should  in  its  turn  occupy  the  attention. 
Those  who  with  Garengeot  direct  it  to  be  set  free  without  opening  it,  thought 
to  insulate  it  entirely,  and  agglomerate  it  in  the  interior  of  the  ring,  where  it 
should  be  fixed  by  a  pad  of  lint  or  charpie.     Others  have  advised  to  pass  a 
ligature  over  its  neck  to  strangulate  and  then  excise  it.    Even  in  cases  where 
it  has  been  opened  in  the  whole  of  its  length,  it  was  thought  possible  to  reduce 
it  and  use  it  for  closing  the  passage  of    the  hernia.     Louis  was  strongly 
opposed  to  all  these  attempts,  maintaining  that  the  reduction  of  the  sac  was 
impossible,  and  that  the  adhesions  of  its  external  face  did  not  permit  the 
sliding  necessary  for  its  accomplishment.     On  this  point  Louis  was  assuredly 
mistaken,  at  present  there  is  no  doubt  on  the  subject.     On  the  other  hand  it 
is  extremely  probable  that  being  thus  pushed  back,  opened  or  otherwise,  the  sac 
would  close  the  ring  firmly  enough  to  present  an  obstacle  to  the  return  of  the 
disease.    Excision  or  ligature  would  not  have  the  same  advantages  though 
exposing  to  the  same  inconveniences.  If  it  is  necessary  in  effect,  for  obtaining 
its  separation,  to  have  recourse  to  the  cutting  instrument,  there  is  evidently  a 
risk  in  some  cases  at  least  of  wounding  bloodvessels  or  other  organs  important 
to  be  respected.    I  would  advise,  therefore,  the  reduction  of  the  sac  whenever 
it  is  found  almost  free,  or  when  its  adhesions  are  weak  enough  to  be  broken 
down  without  the  aid  of  the  knife.     It  has  been  thought  beside,  that  after  it 
has  been  once  opened,  if  we  would  not  or  cannot  reduce  it,  it  would  be  useful 
to  cut  away  its  flaps.    To  this  I  see  no  objection,  except  that  it  is  not  ap- 
plicable to  hernias  surrounded  with  large  arteries  or  organs  of  any  import- 
ance.    Nevertheless  if  the  borders  of  the  sac  are  so  perfectly  insulated  as  to 
render  it  certain  that  they  may  be  excised  without  wounding  any  essential 
part,  I  sec  nothing  but  advantage  in  doing  so.     In  this  way  the  wound  is 
neater,  the  suppuration  less  abundant,  and  the  remainder  of  the  operation  be- 
comes necessarily  a  little  more  simple. 


OPERATIVE   SURGERY.  579 

C.  Dressings.— The  dressing  after  the  operation  is  reduced  to  a  small  mat- 
ter.   A  linen  rag  perforated  with  holes  and  spread  with  cerate  is  placed  over 
the  whole  of  the  new  surface.    Rolls  of  simple  charpie  intended  to  push  this 
linen  to  the  very  bottom  of  the  wound  are  immediately  applied  over  it.    Some 
dossils  of  lint  then  follow  with  oblong  or  square  compresses,  and  lastly  a 
bandage  adapted  to  the  species  of  the  hernia.     Instead  of  the  perforated  rag 
some  use  a  fine  linen,  without  any  other  preparation     Being  larger  than  the 
wound  it  serves  as  a  kind  of  chemise  to  the  charpie,  and  fullfils  moreover  the 
some  intention  as  if  it  were  perforated,  but  as  it  does  not  allow  an  issue  to  the 
fluids,  I  see  no  reason  for  preferring  it.     Others  merely  fill  the  whole  open- 
ing with  msall  balls  of  charpie  without  interposing  the  linen,  and  cover  it  with 
dossils  of  lint,  compresses,  and  the  retaining  bandage  as  before.  The  principal 
inconvenience  in  this  practice  is  that  it  renders  the  removal  of  the  deeper  por- 
tions of  the  apparatus  more  difficult  after  the  first  dressing.  Being  in  immediate 
contact  with  the  tissues  the  charpie  contracts  adhesions,  which  suppuration 
does  not  destroy  until  after  some  time,  while  if  a  perforated  linen  separate  them 
we  may  change  and  renew  all  the  dressing  as  well  on  the  second  and  third  day 
as  on  the  first  without  giving  the  least  pain.     For  the  rest,  nothing  is  said  at 
the  present  day  of  keeping  a  tent  in  the  ring,  nor  of  keeping  in  its  place  a  pad 
of  linen  or  charpie  as  directed  by  J.  L..  Petit.     There  is  now  no  dissent  on 
this  subject,  and  operators  are  no  longer  divided  except  on  the  question  of  im- 
mediate union.     Franco,  who  appears  to  be  the  first  to  have  attempted  to  es- 
tablish as  a  rule  the  necessity  of  exposing  the  hernia  and  cutting  the  stricture 
in  case  of  strangulation,  advises  that  the  edges  of  the  wound  be  approximated 
and  the  suture  used  to  keep  them  in  contact.     The  greater  number  of  sur- 
geons of  that  time  seemed  to  have  conformed  to  the  advice  of  Franco.     There 
were  none,  even  to  Rousset,  Pare,  Pigray,  and  Thevenin,  who  had  not  adopted 
it.     It  had  fallen  into  neglect  however,  when  about  the  middle  of  the  last 
century  Mertrud  attempted  its  introduction  a  secone  time,  maintaining  that 
the  wound  in  this  operation  is  in  the  same  condition  as  a  simple  wound.  Not- 
withstanding the  I'easoning  of  Hoin  and  Leblanc,  who  adduced  a  number  of 
facts  in  its  support,  it  at  length  fell  again  into  disuetude,  as  in  the  age  in 
which  it  arose.     Immediate  union  however  appears  to  have  been  attempted  by 
some  modern  practitioners.    The  work  of  Doctor  Serre  proves  beyond  dispute 
that  it  is  in  effect  possible,  by  means  of  the  suture,  to  heal  in  a  few  days  the 
wound  resulting  from  the  operation  for  strangulated  hernia,  and  that  his  able 
preceptor  frequently  employed  it  with  success.    Professor  Berard  informed 
me  that  he  tried  it  at  the  hospital  St.  Antoine,  and  that  his  patient  got  well  in 
six  days.     On  this  subject  all  that  is  required  in  my  opinion  is  merely  the 
correct  understanding  of  it     If  question  is  only  of  the  possibility  of  the  thing 
no  doubt  that  the  practitioner  of  Montpellier  is  entirely  right,  but  it  is  the 
utility  of  this  proceeding  which  is  to  be  examined.     When  the  hernia  is  not 
large,  is  recent,  and  its  coverings  preserve  a  certain  thickness  and  nearly  all 
their  natural  attributes,  when  the  sac  does  not  roll  nor  leave  fringes  nor 
shreds  to  mortify  at  the  bottom  of  the  wound,  immediate  union  may  certainly 
take  place  in  a  large  proportion  of  cases.     When  the  tumor  has  been  of 
larger  size,  and  its  covering,  more  or  less  attenuated,  have  become  the  seat 
of  various  alterations,  when  the  sac  is  quite  large  and  tends  to  roll  upon  itself 
the  reduction  of  viscera,  tiie  chance  of  success  is  not  so  great.     In  this  case 


580  NEW    ELEMENTS   OF 

it  is  to  be  feared  that  suppuration  may  be  established  in  the  depths  of  the 
parts  and  separate  them,  to  spread  in  various  directions,  and  cause  sinuses, 
and  consequently  a  state  of  things  that  may  become  very  serious.  This 
occurred  in  the  only  case  in  which  it  appeared  to  me  prudent  to  attempt  im- 
mediate union.  The  hernia  was  not  very  large,  and  the  lips  of  the  wound 
exactly  adapted  were  supported  towards  their  root  by  an  exact  and  methodical 
compression.  It  appeared  oiji  the  fifth  day  that  agglutination  had  taken 
place.  But  on  the  next  we  were  undeceived.  Swelling,  redness,  pain,  and 
heat  were  manifested  beneath  one  of  the  sides  of  the  division ;  the  inflamma- 
tion increased,  and  was  accompanied  with  fever  and  other  general  symptoms, 
which  only  abated  after  the  opening  of  a  large  abscess  which  was  obscurely 
developed  about  the  inferior  angle  of  the  sac.  Besides,  this  immediate  union 
seems  to  me  to  conflict  with  one  of  the  intentions  of  the  surgeon ;  which  should 
be,  to  favor  as  much  as  possible  the  radical  cure  of  the  disease.  If  it  is  in- 
contestable, that  the  solidity  of  the  cicatrix  is  greater  the  longer  the  wound 
lias  suppurated,  it  is  evident  that  after  the  operation  for  hernia,  patients  have 
more  chances  of  being  radically  cured  when  union  of  the  wound  is  obtained 
by  second  intention  than  in  the  contrary  case.  We  may  add,  that  without 
bringing  the  divided  tissues  into  perfect  contact,  it  is  easy  to  approximate 
them  a  little,  and  diminish  more  or  less  the  extent  of  the  raw  surfaces,  and 
by  keeping  up  the  suppuration  obtain  a  cure  in  twenty  or  thirty  days.  A 
patient  upon  whom  I  operated  with  M.  Amussat,  was  treated  in  this  manner 
and  his  wound  was  completely  closed  on  the  twenty -fourth  day.  A  woman 
to  whom  I  was  called  by  M.  Forget  was  also  entirely  restored  at  the  expir 
ration  of  a  month.  But  I*am  not  sure  that  after  this  operation  a  more  rapid 
cure  would  be  of  as  great  importance  as  some  persons  seem  to  imagine.  In 
conclusion  therefore,  with  some  exceptions,  mediate  union  offers  the  most  ad- 
vantages, and  in  this  place  deserves  the  preference. 

The  patient,  once  dressed,  is  directed  to  make  no  effort  or  motion  which 
may  react  on  the  abdominal  organs,  or  if  he  is  obliged  to  cough,  or  contract 
his  muscles  for  any  purpose,  to  apply  his  hand  in  front  of  tlie  apparatus  to 
support  it.  Without  these  precautions  the  intestine  may  escape  again  and 
renew  the  symptoms.  Lassus  relates  the  case  of  a  man  who  in  this  condition 
had  the  imprudence  to  leap  from  his  bed  and  walk  several  steps.  The  intes- 
tines came  out  in  great  quantity,  and  then  reduction  was  attended  with  great 
difficulty.  We  must  not  permit  ourselves  however  to  be  too  much  alarmed 
by  the  fear  of  this  accident.  After  being  returned  into  the  abdomen  the  intes- 
tine does  not  protrude  again  as  easily  as  may  be  supposed.  A  slight  fit  of 
coughing,  and  the  moderate  efforts  which  the  patient  makes  in  turning  himself 
in  bed  are  not  sufficient  to  reproduce  the  hernia.  If  in  consequence  of  the 
debridement  the  orifice  of  the  abdominal  wall  is  a  little  larger  than  usual,  the 
sensibility  already  existing  in  the  parts,  or  that  which  the  inflammation  soon 
produces,  forms  a  kind  of  barrier  which  the  viscera  rarely  pass  over.  It 
seems  as  if  an  instinct  prevents  them  from  pressing  on  this  side,  and  even 
when  he  has  no  tliought  of  it  the  patient  is  forced  as  it  were  if  he  makes  any 
movement  to  prevent  it  being  propagated  towards  the  wound.  These  remarks 
appear  to  me  useful,  inasmuch  as  though  from  prudence  we  should  prescribe 
rest  and  immobility  to  the  individual  upon  whom  the  operation  has  been  perr 
formed,  yet  there  would  be  this  inconvenience,  that  in  not  daring  to  move  in  one 


i 


OPERATIVE    SURGERY.  581 

way- nor  another,  he  miglit  consider  the  slightest  movement  dangerous.  I 
should  also  have  said  that  there  is  no  necessity  for  making  the  bandage  com- 
press the  front  of  the  wound,  and  that  a  retaining  apparatus  methodically 
applied  perfectly  fulfills  the  end  proposed. 

D.  Results  and  7Ve«/?7ie/if.— Except  in  case  of  particular  accidents  the 
wound  should  not  be  dressed  until  the  third  or  fourth  day.  It  is  only  about 
this  time  that  suppuration  begins  to  be  established.  The  dressing  is  then 
renewed  every  day  and  has  no  peculiarity.  If  shreds  of  the  sac,  of  the  epi- 
ploon, or  any  other  lamellae,  mortify,  they  are  to  be  excised  immediately. 
Emollient  lotions  or  chloruretted  solutions,  and  perhaps  the  decoction  of  cin- 
cona  when  the  suppuration  becomes  fetid  and  greyish  or  the  flesh  remains 
dull,  and  the  use  of  the  nitrate  of  silver  if  the  cellular  granulations  are 
developed  too  actively,  may  become  necessary;  but  these  various  applications 
are  called  for  by  the  same  indications  as  require  them  in  any  other  species  of 
wound.  When  all  goes  on  well,  the  symptoms  of  strangulation  ceaee  almost 
immediately.  Alvine  evacuations  are  abundant  after  several  hours,  and  greatly 
relieve  the  patient.  The  pulse  resumes  strength,  and  sometimes  acquires  so 
inuch  frequency  as  to  indicate  a  febrile  condition,  and  only  after  four  or  five 
days  will  this  slight  reaction  permit  us  to  relax  the  severity  of  regimen.  Most 
frequently  the  functions  are  not  re-established  so  promptly  or  completely. 
Inflammation  of  the  peritoneum  may  extend  instead  of  abating,  or  the  course 
of  fecal  matters  may  not  be  easily  re-established.  The  superior  portion  of 
the  intestine  may  have  been  filled  with  substances  more  or  less  solid,  which 
keep  it  distended  in  comparison  with  that  which  has  been  constricted.  The 
peristaltic  motion  having  besides  been  disturbed,  sometimes  resumes  with 
difficulty  its  habitual  rhythm,  and  the  fecal  matters  are  therefore  not  pushed 
downwards  with  sufficient  force  to  arrive  without  obstacle  at  the  inferior 
extremity  of  the  alimentary  canal.  This  sluggishness  of  the  intestine  may 
depend  on  the  moderate  inflammation  of  its  several  tunics  which  may  have 
occurred  in  the  vicinity  of  the  hernia.  If  therefore  the  stools  are  not 
spontaneously  re-established  in  two  or  three  hours,  a  mild  injection  is  to 
be  given.  If  this  be  not  sufficient,  another  of  more  stimulating  eiFects  is 
to  be  administered.  If  after  twelve  hours  evacuations  have  not  been  pro- 
duced, purgative  enemata  with  the  decoction  of  senna  must  be  resorted  to. 
Many  practitioners  are  in  the  habit  of  employing  at  the  same  time  a  slight 
purgative  administered  by  the  mouth.  Dionis,  who  insists  much  on  the  advan- 
tage of  this  mode,  says  he  received  it  from  Moreau  physician  to  the  Daupliiness. 
Some  surgeons,  at  the  head  of  whom  must  be  placed  Dupuytren  and  Mr. 
Green,  nevertheless  condemn  its  use,  by  saying  that  it  can  only  increase  or 
aggravate  an  inflammation  already  giving  too  much  cause  for  apprehension  in 
individuals  affected  with  strangulated  hernia.  At  first  view  this  reasoning 
may  deceive,  although  in  fact  it  is  easy  of  refutation.  The  truth  is,  that  the 
matters  accumulated  in  the  intestine  are  a, powerful  cause  of  inflammation^ 
and  the  best  mode  of  overcoming  or  preventing  this  inflammation  is  to  oblige 
them  to  escape  by  the  rectum.  In  this  light,  purgative  enemata  and  potions 
of  the  same  nature  have  an  efficacy  which  cannot  be  doubted.  At  the  hospital 
of  Tours,  I  have  seen  M.  Gouraud  operate  for  a  great  number  of  hernias ;  to 
all  his  patients  a  purgative  clyster  was  administered  almost  immediately  after, 
and  no  vvhere  to  my  knowledge  has  a  greater  proportion  of  success  been 


582  NEW  ELEMENTS  OF 

obtained.  M.  Bojer,  who  seems  to  follow  the  same  practice,  has  the  reputation 
of  being  very  fortunate  in  this  kind  of  operation.  As  to  the  nature  of  the 
purgative  it  may  be  varied.  Some  give  one  or  two  ounces  of  castor  oil  in 
spoonful  doscii ;  others  the  epsom  salts.  The  dose  that  I  prefer,  because  I 
have  seen  it  employed  with  great  benefit,  is  composed  of  an  ounce  or  two  of 
manna  dissolved  in  a  glassful  of  mint  infusion.  Some  prefer  this  last  article 
in  four  ounces  of  red  wine.  Common  opinion  is  against  the  use  of  this  vehicle, 
and  for  myself  I  have  nothing  to  say  in  its  favor.  It  is  unnecessary  to  add 
that  the  administration  of  a  purgative  is  not  called  for,  and  is  at  least  useless 
when  the  stools  occur  spontaneously  and  no  sign  of  intestinal  embarrassment 
is  manifest. 

When  instead  of  simple  obstruction  symptoms  of  true  inflammation  are 
remarked,  or  when  peritonitis  is  threatened,  notwithstanding  the  course  of  the 
feces  is  re-established,  the  patient  should  without  hesitation  be  subjected  to 
the  most  energetic  antiphlogistic  treatment.  One  or  more  bleedings  from  the 
arm,  one  or  more  applications  of  leeches  to  the  number  of  twenty,  thirty,  forty, 
and  even  sixty,  if  the  strength  of  the  patient  permit,  in  the  course  of  twenty^ 
four  hours,  should  be  prescribed,  if  instead  of  decreasing  the  phlegmasia  tends 
on  the  contrary  to  extend  and  become  general.  I  see  no  reason  why  the 
mercurial  treatment,  mercurialization,  should  not  have  its  turn ;  why  we  should 
not  make  every  two  or  three  hours  friction  on  the  abdomen  with  two  or  three 
drams  of  Neapolitan  ointment,  giving  at  the  same  time  two  grains  of  calomel 
eveiy  two  hours.  The  cases  of  puerperal,  simple,  and  traumatic  peritonitis, 
which  have  evidently  yielded  to  this  treatment,  sufficiently  authorize  its  use 
wlienever  sanguineous  evacuations  give  no  further  chance  of  success.  Unfor- 
tunately these  are  not  the  only  obstacles  which  may  oppose  the  re-establish- 
ment of  the  functions  after  celotomy.  Besides  the  return  en  masse  of  the 
intestine  which  continues  to  be  strangulated  by  the  neck  of  the  sac,  or  which 
lodges  in  the  substance  of  the  abdominal  parietes,  it  is  also  to  be  feared,  lest 
the  loop  which  was  without,  pass  in  its  return  above  or  below  an  abnormal 
band  which  is  so  often  met  with  behind  or  around  the  herniary  openings ;  and  of 
which  almost  every  author  reports  examples.  It  is  also  possible,  tliat  the 
portion  just  reduced  may  make  a  bend  or  angle  so  acute  as  not  to  allow  tlie 
matters  to  pass  through  it,  of  which  a  case  of  Lassus  gives  instance.  The 
same  difficulty  may  depend  on  the  intestine  being  twisted  so  as  entirely  to 
close  its  cavity.  It  may,  moreover,  have  passed  through  a  rent  in  the  epiploon, 
in  some  old  false  membrane  or  in  the  mesentery.  In  fine,  if  the  vomiting,  pain, 
and  distress  continue  with  the  constipation  after  the  reduction  of  the  viscera, 
without  these  symptoms  being  referable  to  violent  inflammation  of  the  perito- 
neum or  some  viscus,  when  there  is  no  reason  to  suspect  an  effusion  of  intes- 
tinal matter  we  are  authorized  to  conclude  that  the  strangulation  still  exists, 
and  from  external  has  become  internal.  In  this  case  the  patient  runs  the 
greatest  risk,  for  ,with  the  exception  of  very  few  cases  surgery  has  but  feeble 
aid  to  offer.  However,  we  should  try  those  that  reason  recommends.  The  first 
indication  is  to  bring  out  the  hernia,  as  when  the  viscera  have  been  returned, 
pushing  before  them  the  neck  of  the  sac.  The  patient  is  for  this  purpose  made 
to  cou^i  and  move  about;  if  unsuccessful,  the  finger  should  be  carried  through 
the  ring  into  tlie  abdomen  to  discover  as  much  as  possible  the  state  of  things. 
If  the  wxrgeon  clearly  distinguishes  the  intestinal  loop,  and  finds  it  tense,  fixed. 


OPERATIVE    SURGERY.  583 

immovable,  he  will  attempt  to  seize  it  with  dressing  forceps  and  bring  it 
without.  If  a  band,  a  circle  or  any  lamella  seem  to  cause  the  stricture,  he 
should  immediately  divide  it  with  scissors  or  the  bistoury,  directed  by  the  finger. 
If  the  finger  cannot  reach  the  parts,  or  only  afibrds  confused  notions  of  their 
disposition,  the  environs  of  the  wound  are  to  be  examined  with  care,  to  see  if 
the  organs  contained  in  the  abdomen  form  there  no  prominence  or  tumor 
visible  through  the  skin.  There  is  no  question  that  then  in  a  desperate  case 
he  should  freely  enlarge  the  incision  of  the  ring,  and  penetrate  as  far  as  the 
point  occupied  by  the  strangulated  organs  ;  so  as  to  bring  them  completely  in 
view,  and  be  enabled  to  give  them  full  liberty  to  spread  within  the  abdomen* 

§  5.  Gasirotomy. 

The  symptoms  which  characterize  internal  strangulation  being  due  to  the 
inability  of  the  intestinal  matters  to  pass  through  their  natural  course,  should 
be  altogether  similar  to  those  of  incarcerated  hernia.  It  seems  then  at  first 
view  that  this  is  easily  recognized.  We  have  on  the  one  hand  all  the  signs  of 
herniary  strangulation,,  and  on  the  other  a  complete  absence  of  swelling  on  the 
surface  of  the  body ;  yet  it  some  times  happens  that  the  diagnosis  remains 
uncertain.  Notwithstanding  the  presence  of  an  external  hernia,  it  is  not 
impossible  to  mistake  for  external  strangulation  a  disease  entirely  indepen- 
dent of  it.  A  partial  peritonitis,  an  acute  inflammatory  tumor  of  the  bottom 
of  the  abdomen,  and  abscesses  which  are  frequently  developed  in  either  iliac 
fossa,  have  often  been  the  cause  of  repeated  vomitings,  obstinate  constipation, 
and  acute  pain,  upon  a  fixed  and  circumscribed  point  of  the  peritoneal  cavity. 
In  fine,  an  almost  insurmountable  difficulty  consists  in  distinguishing  the  obsta- 
cle in  question  from  organic  lesion  of  the  intestine,  from  volvulus,  and  from 
strangulation  proper.  However,  if  the  affection  attacks  suddenly  upon  a  strain 
or  any  violence  whatever,  if  the  patient  has  thought  he  perceived  a  tearing  ac- 
companied with  crepitation  and  pain,  propagated  from  a  given  point  to  the  rest 
of  the  abdomen,  if  from  this  moment  vomiting  first  of  alimentary  and  mucous 
substances,  and  then  of  stercoraceous  matters  continues,  while  alvine  evacua- 
tions have  become  impossible,  and  the  usual  signs  of  violent  peritonitis  are 
absent,  it  would  be  very  difficult  not  to  admit  the  existence  of  internal  stran- 
gulation. Three  different  methods  have  been  proposed  to  remedy  accidents  of 
this  description.  The  old  surgeons  who  were  famous  for  suspecting  invagi- 
nations and  twisting  of  the  alimentary  tube,  had  great  confidence  in  quick- 
silver, leaden  bullets,  purgatives,  &c.  They  hoped  by  means  of  such  heavy  or 
active  substances  to  act  mechanically  upon  the  entrails,  or  force  them  to  be- 
come disengaged  by  means  of  precipitate  movements.  MM.  Balluci,  Bellini, 
and  Ribell  have  in  our  days  brought  out  examples  in  favor  of  fluid  mercury. 
In  recent  and  simple  volvulus  such  resources  may  be  followed  sometimes  with 
success ;  but  there  is  no  one  who  would  not.  be  deterred  from  their  use  in 
cases  of  internal  strangulation.  For  my  part  I  would  not  hazard  the  attempt. 
Local  and  general  bleeding,  cataplasms,  opiates,  calculated  to  moderate 
inflammation  and  ease  pains,  have  no  kind  of  influence  over  the  state  of  stric- 
ture in  which  tlie  intestine  is  found.  Their  sole  advantage  lies  in  favoring  the 
efforts  of  the  system  and  the  action,  by  means  of  which  it  has  been  in  certain 
cases  so  fortunate  as  to  re-establish  the  continuity  of  the  intestine  withoyt 
effacing  its  calibre.     The  ivaginated  intestinal  portion,  may  in  fact  after  a 


584  NEW   ELEMENTS   OF 

shorter  or  longer  period  and  alarming  symptoms,  separate  by  the  rupture  o€ 
its  neck,  or  of  its  root,  whether  from  gangrene  or  the  progress  of  simple,  elimi- 
native  ulceration.  Then  the  mortified  mass  becoming  free  passes  through  all 
the  inferior  portion  of  the  alimentary  tube,  and  is  in  the  end  expelled.  In 
this  manner  have  come  away  the  caecum,  a  great  portion  of  the  sigmoid  flexure 
of  the  colon,  and  a  considerable  portion  of  small  intestine,  of  which  the  me- 
moir of  Hevin  contains  numerous  examples.  MM.  Rigal  and  Bourial.have 
seen  as  much  as  thirty  inches  of  the  small  intestine  expelled  by  this  mechanism. 
Similar  observations  have  been  reported  by  MM.  Mallet  of  Rouen,  Bailie, 
Lobstein,  Lacoste,  Boucher  of  Lille,  Gualthier  of  Claubry,  &c.  Other  facts  no 
less  remarkable  have  been  since  collected  and  published  in  the  Bulletins  of 
the  Philomathic  Society,  and  the  society  of  the  Faculty  of  Medicine,  in  many 
theses,  and  most  of  the  scientific  journals. 

It  is  easy  to  see  that  such  a  termination  is  not  possible  except  in  cases  of 
invagination,  and  that  to  destroy  a  real  strangulation  we  cannot  depend  upon 
the  efforts  of  the  system.  Gastrotomy  presents  as  the  last  resort.  Up  to  the 
present  time  but  few  persons  have  dared  to  perform  it,  and  experience  has  in 
some  degree  remained  silent  as  to  its  value.  We  cannot,  indeed,  take  any 
count  of  the  history  of  the  Baroness  of  Lanti,  mentioned  by  Bonnet,  who 
according  to  an  ecclesiastic  had  been  cured  of  an  iliac  passion  by  incision  of 
the  lower  belly.  Although  the  case  in  which  Nuck  advised  the  abdomen  to 
be  opened,  in  order  to  reach  the  intestines  and  set  them  free,  is  a  little  more 
authentic,  and  although  M.  Fusch  has  shown  latterally  a  case  of  gastrotomy 
for  invagination  completely  successful,  we  can  yet  rely  only  with  extreme 
reserve  on  this  paucity  of  observations.  However,  if  it  happen  that  we  have 
a  certainty  almost  complete  of  the  existence  either  of  a  recent  invagination  or 
of  a  strangulation,  and  that  the  location  of  the  disease  is  well  determined,  we 
ought,  I  think,  to  hazard  the  operation  of  gastrotomy,  which  was  employed  in 
the  time  of  Praxagoras  who  performed  it,  uniting  the  wound  of  the  abdomen 
immediately  by  the  suture.  M.  Dupuytren,  who  tried  it  once,  would  probably 
have  succeeded  if  he  could  have  cut  as  he  wished  on  the  side  where  the  pain 
was  felt,  instead  of  the  linea  alba  according  to  the  advice  of  the  consulting 
surgeons.  One  case  at  the  hospital  St.  Antoine,  proves  also  tl\at  it  is  some- 
times possible  to  tell  exactly  enough  during  life  the  precise  seat  of  the 
strangulation,  and  that  Laennec  was  probably  right  in  advising  the  epigastrium 
to  be  opened  in  diaphragmatic  hernias  in  order  to  remove  the  viscera  from  the 
chest  with  the  fingers.  The  patient  should  be  placed  as  for  the  operatio'n  of 
ordinary  hernia.  The  incision,  better  crescentic  than  straight,  should  be  made 
very  near  the  strangulation.  If  we  are  not  sure  of  the  seat  of  this  last,  it  is  to 
be  made  outside  of  the  rectus  muscle,  and  with  the  fingers  we  are  then  to  seek 
for  the  diseased  portion.  In  a  case  of  invagination  the  two  ends  of  the  intes- 
tine are  to  be  drawn  in  an  opposite  direction,  and  the  whole  immediately 
replaced  in  the  peritoneal  cavity.  If  there  is  strangulation  the  finger  will 
doubtless  detect  it  and  insulate  it,  so  that  a  curved  bistoury  wrapped  with 
linen  to  witliin  several  lines  of  its  extremity,  may  divide  without  danger  the 
band  or  constricting  circle.  Another  species  of  internal  strangulation  deserves 
to  be  noticed  ;  it  is  that  which  occurs  after  the  forced  reduction  of  a  hernia./ 
When  it  is  caused  by  tiie  neck  of  the  sac,  if  the  taxis  is  em^jloyed  with  any 
viplence  the  tumor  may  return  dragging  with  it  its  intimate  covering.  Then 
it  places  itself  between  the  parietal  peritoneum  and  the  deep  aponeurosis  of 


OPERATIVE  SURGERY.  585 

the  abdomen,  precisely  as  it  is  observed  in  some  cases  of  the  operation  for 
strangulated  hernia,  properly  so  called.  M.  Delmas  cites  a  case  in  which  the 
organs  were  thus  arrested  in  the  very  substance  of  the  muscles.  They  may 
also  pass  beneath  a  band,  or  through  a  fissure  in  the  same  manner  as  in  re- 
ducing them  after  opening  the  sac,  as  I  have  already  mentioned.  It  is 
unfortunately  too  common  a  tiling  to  see  these  reductions  en  masse  under  the 
influence  of  the  taxis,  offer  no  impediment  to  the  progress  of  the  symptonis. 
There  are  few  authors  who  have  not  collected  examples,  and  they  are  still 
daily  met  with  in  practice.  If  the  symptoms  only  announce  the  continuation 
of  the  strangulation,  without  indicating  the  existence  of  fecal  effusion ;  in 
other  words,  if  the  intestine  seem  neither  gangrenous  nor  broken,  we  should 
not  despair  of  the  life  of  the  patient,  but  attempt  to  give  him  assistance.  The 
first  care  is  to  bring  out  the  hernia  again.  If  nothing  present  at  the  ring,  the 
surgeon  would  be  blameable  to  temporize  too  long,  and  refrain  from  performing 
the  operation  immediately.  He  knows  that  a  herniary  tumor  exists,  that  after 
giving  rise  to  symptoms  or  remaining  for  some  time  without,  it  has  disappeared 
suddenly  under  the  influence  of  external  efforts ;  the  opening  which  gave  it 
passage  is  free  and  easily  admits  the  extremity  of  the  finger,  quite  frequently 
even  presents  a  kind  of  depression  or  cul-de-sac,  seems  to  be  drawn  inwards 
by  some  band  or  adherent  membrane ;  sometimes  also  the  finger  introduced 
into  this  depression  feels  at  its  bottom  the  intestinal  tumor  incompletely 
reduced.  In  this  Supposition  the  soft  parts  are  to  be  incised  as  in  ordinary 
strangulated  hernia,  and  by  degrees  we  arrive  at  its  interior.  If  the  sac  can 
be  reached,  it  is  rare  that  the  operator  does  not  reach  the  seat  of  the  disorder. 
M.  Dupuytren,  who  has  been  frequently  called  upon  in  this  species  of  stran- 
gulation, and,  at  the  Hotel  Dieu,  has  seen  a  great  number  of  cases,  remarks, 
that  after  having  vainly  endeavored  to  bring  out  the  viscera  again,  there 
remains  the  resource  of  freely  incising  the  ring  in  the  direction  in  which  there 
are  no  vessels,  and  of  arriving  thus  within  the  abdomen. 

§  6.  Hernia  loith  Gangrene. 

Gangrene, — When  gangrene  is  evident  the  division  of  the  tissues  does  not 
require  the  same  precautions  as  in  the  ordinary  operation.  The  incisions  in 
fact  may  without  danger  penetrate  at  one  stroke  as  far  as  the  intestine.  If 
it  affect  all  the  tumor,  and  the  hernia  is  voluminous,  after  several  deep 
incisions  the  whole  of  the  mortified  parts  should  be  removed ;  we  may  however 
confine  the  incision  to  the  intestinal  loop  and  wait  for  the  exfoliation  of  the 
remaining  tissues.  Numerous  cases  attest  that  the  system  may  then  quite 
easily  effect  a  complete  case.  Traveling  in  Germany,  J.  L.  Petit  alighted  one 
day  at  a  tavern,  and  was  immediately  struck  with  the  odor  of  gangrene.  He 
was  shown  in  the  adjoining  room  a  man  laboring  under  the  symptoms  of  hernia 
with  mortification.  Thinking  this  man  lost,  he  merely  made  some  incisions 
in  the  tumor,  which  immediately  discharged  an  abundant  quantity  of  matters. 
On  his  return,  twenty-eight  days  afterwards,  lie  learned,  not  without  surprise, 
that  his  patient  was  completely  cured,  and  that  without  stercoral  fistula. 
Going,  on  another  occasion,  to  La  Ferte-sous-Jouarre,  and  losing  his  way  in 
the  night,  he  stopped  at  a  house  in  which  he  saw  a  light  to  inquire  the  road. 
The  woman  of  the  house  told  him  that  her  husband  was  at  the  tjoint  of  death 
49 


586  NEW  ELEMENTS   OF 

and  entreated  him  to  enter.  This  was  also  a  case  of  strangulated  hernia, 
which  J.  L.  Petit  contended  himself  with  opening  and  cleansing,  recommen- 
ding them  to  use  no  other  treatment,  thinking  that  the  patient  could  not 
recover.  A  cure  took  place  however,  and  the  individual  himself  went  sometime 
after  to  inform  the  surgeon  of  it.  But  it  cannot  be  denied,  that  it  is  better  to 
free  the  tumor  with  the  scissors  or  bistoury  of  all  its  contents  whidi  are  ■ 
evidently  mortified.  For  the  rest,  there  is  no  reason  to  act  otherwise  than  if 
the  intestine  alone  were  mortified,  and  the  gangrene  only  known  after  opening 
the  sac.  In  this  last  case  the  gangrene  may  occupy  only  the  most  projecting 
part  of  the  strangulated  loop,  as  it  may  have  its  seat  even  within  the  ring,  and 
on  the  points  which  immediately  suffer  the  constriction.  Several  methods 
have  been  advised  in  this  case.  One  of  the  most  ancient  consists  in  opening 
the  intestine  freely  to  give  issue  to  the  contained  matters,  and  trusting  for  the 
rest  to  the  resources  of  nature.  By  acting  in  this  way  two  things  are  to  be 
apprehended;  first,  that  the  stricture  may  be  such  as  to  render  difficult  the 
passage  of  the  substances  which  should  pass  through  the  alimentary  canal ; 
and  secondly,  the  almost  necessary  estalDlishment  of  a  preternatural  anus. 
To  these  apprehensions  some  reply  that  the  ring  is  always  large  enough  to 
permit  the  end  of  the  intestine  in  its  natural  state  to  preserve  within  it  its 
permeability ;  that  the  inferior  portion  of  this  canal,  receiving  no  more  matters, 
becomes  obliterated ;  that  the  portion  corresponding  with  the  stomach  alone 
continuing  to  receive  the  alimentary  mass,  must  be  suflGiciently  free  in  the 
herniary  orifice,  to  fullfil  without  danger  the  functions  of  an  abnormal  anus. 
On  the  other  hand,  experience  shows  that  this  practice  has  often  been  followed 
by  a  radical  and  ready  cure.  The  two  cases  just  quoted  are  a  proof  of  this, 
and  J.  L.  Petit  relates  others  no  less  remarkable.  Thus,  being  in  Flanders, 
this  surgeon  was  called,  on  his  way  to  Douay,  to  give  his  advice  respecting 
a  tumor,  which  was  strangulated  and  could  not  be  reduced  A  charlatan, 
whose  advice  the  patient  and  his  friends  adopted,  maintained  that  this  tumor 
was  an  abscess  and  ought  to  be  opened.  J.  L.  Petit  declared  that  serious 
accident  might  be  the  result,  and  that  at  least  a  stercoral  fistula  would  follow. 
On  his  return  they  assured  him  that  the  patient  was  perfectly  cured.  He 
learned  moreover  that  this  man  thus  opened  all  strangulated  hernias,  and  in 
the  environs  of  Douay  and  Cambray  he  had  in  this  manner  operated  on  a 
great  number  of  persons,  which  practice  had  given  him  a  brilliant  reputation 
in  the  country.  I  saw  last  year  a  student  of  medicine  who  assured  ine  that 
his  father,  a  pi-ovincial  surgeon,  had  been  induced  from  experience  to  pursue 
a  similar  method,  and  that  ten  or  twelve  times  already  he  had  used  it  with 
success,  whether  the  strangulated  hernia  was  or  was  not  attended  with 
gangrene.  When  it  is  remembered  that  preternatural  ani  of  long  standing 
have  in  the  end  spontaneously  disappeared,  although  the  two  ends  of  the 
intestine  had  become  fixed  and  stopped  in  the  ring,  and  a  considerable  portion 
had  been  removed,  these  results  soon  lose  their  marvellous  aspect.  In  fact, 
the  intestine  being  opened  and  ceasing  to  be  distended  in  hernia  is  a  reason 
also  for  the  speedy  disappearance  of  the  strangulation.  The  elasticity  of  the 
mesentery  and  the  naturid  movements  of  the  cn-gans  ccmtained  in  the  abdomen, 
must  tend  without  interruption  to  draw  towards  their  roots  that  which  had 
escaped  in  hernia.  By  degrees  the  two  ends  of  intestine  gain  the  posterior 
face  of  the  ring,  and  approach  each  other;  their  orifice?  finally  correspond  ; 


OPERATIVE    SURGERY.  5ST 

substances  pass  trom  the  superior  to  the  inferior  portion,  instead  of  escaping 
bj  the  wound,  which  also,  by  its  retraction  opposes  a  greater  or  less  resistance. 
All  authors  however  do  not  view  this  in  the  same  light.  Scarpa  directs,  after 
opening  the  intestine  that  the  ring  be  incised  more  or  less.  Without  this 
precaution,  says  he,  matters  accumulated  behind  would  have  too  much  diffi- 
culty in  escaping,  and  might  create  a  dangerous  inflammation,  supposing  even 
that  they  do  not  keep  up  the  symptoms  of  strangulation.  What  danger  after 
all  would  there  be  in  this  practice  ?  The  adhesions  which  he  admits  on  the 
limits  of  the  gangrene  would  be  full  assurance  of  safety.  Even  when  the 
intestine  would  have  to  be  incised  from  within  outwards  at  the  same  time 
as  tiie  sac  or  the  fibrous  ring  that  surrounds  it,  according  to  his  views  there 
would  be  no  reason  to  fear  eiFusion  into  the  peritoneum.  Of  late,  M.  Dupuy- 
ti-eu,  who  strenuously  opposes  this  doctrine,  maintains  that  when  there  is 
gangrene  extending  to  the  ring  the  edges  of  the  herniary  orifice  are  usually 
Aortified,  and  that  the  intestine  being  opened  the  strangulation  must  soon 
disappear  of  itself,  and  consequently  render  no  kind  of  incision  necessary. 
He  thinks  besides  that  the  adhesions  pointed  out  by  Scarpa  are  far  from 
being  constant  on  the  whole  circumference  of  the  intestine,  and  that  they 
would  not  oppose  a  sufficient  barrier  to  the  effusion  of  matters  if  the  inci- 
sion of  the  dio;estive  tube  was  carried  behind  the  rin*. 

It  is  certainly  incorrect  to  say  that  gangrene  is  never  developed  without 
being  preceded  by  adhesions  between  the  neighboring  serous  surfaces.  Several 
times  already  has  the  opening  of  bodies  who  died  from  strangulated  hernia, 
convinced  me   that   Scarpa  has   singularly  exaggerated   the  importance  of 
this  morbid  condition,  and  that  he  was  led  into  error  as  to  the  frequencv 
and  rapidity  of  its  development ;  that  in  fine  these  adhesions  are  sometimes 
confined  within  such  narrow  limits  that  it  would  be  difficult  not  to  go  beyond 
tliem  in  giving  freedom  to  the  herniary  circle  through  the  intestine.     On  the 
other  hand  it  seems  to  me  that  mortification  of  the  neck  of  the  sac,  and  of  the 
edges  of  the   ring,  is   much   less  common  than  M.  Corbin  and    Caillard, 
make  M.  Dupuytren  to  affirm,  and  that  if  we  were  to  rely  on  it  to  terminate 
the  sti'angulation  we  would  frequently  have  to  repent  our  confidence.     It  does 
not  take  place,  for  instance,  when  the  mortification  is  in  the  free  part  of  the 
intestine.     As  the  intestine  is  endowed  with  a  vitality  much  more  active,  and 
contains  vessels  in  much  greater  number  than  the  opening  which  compresses 
it,  it  were  to  be  presumed,  if  experience  did  not  prove  it,  that  in  becoming 
gangrenous  in  the  ring  it  would  not  necessarily  induce  mortification  of  tHia 
latter.     I  will  add,  that  if  we  do  not  incise  it,  the  intestine   more  or  less 
inflamed  behind  the  destroyed  part  becomes  generally  the  seat  of  considerable 
swelling  which  invades  its  three  tunics  and  principally  its  mucous  coat,  and 
that  this  swelling  arrested  behind  by  the  constricting  circle  is  developed 
almost  entirely  on  the  internal  side,  so  as  sometimes  to  produce  a  more  or  less 
complete  obliteration  of  the  intestinal  opening.     I  saw  this  in  a  woman  treated 
for  hernia  with  gangrene  at  the  hospital  of  Improvement,  in   1824,  and  who 
died  the  next  day.     It  has  also  happened  several  times  in  other  hospitals  at 
Paris  within  several  years,  if  I  may  believe  the  report  of  several  residents 
sufficiently  instructed  to  form  a  correct  judgment  on  such  questions.    In  short, 
if  after  having  opened  the  intestine  the  matters  it  contains,  whether  in  tlie 
liernia-or  within  the  abdomen,  freely  escape  by  the  opening,  if  the  stricture 


588  NEW    ELEMENTS    OF 

of  the  ring  is  slight,  incision  is  to  be  dispensed  with.  If  on  the  contrary  the 
finger  carried  into  the  strangulated  portion  have  difficulty  in  penetrating  and 
passing,prudence  dictates  in  my  opinion  that  this  opening  should  be  enlarged. 
If  the  instrument  can  be  easily  passed  between  the  viscus  and  the  sac,  without 
exposing  to  destruction  the  adhesions  which  may  exist  behind,  the  incisions 
may  be  performed  as  in  the  ordinary  operation.  If  it  be  otherwise,  the 
bistoury  is  to  be  carried  into  the  interior  of  the  intestine,  to  cut  from  the 
centre  to  the  circumference  in  one  or  several  directions  the  orifice  through 
which  the  matters  are  to  pass.  By  reflecting  on  the  natural  disposition  of  the 
parts,  it  will  be  seen  moreover  that  these  incisions  expose  less  than  is  thought 
to  an  effusion  into  the  peritoneum.  This  effusion  cannot  in  fact  be  feared, 
unless  the  incision  is  carried  beyond  the  posterior  orifice  of  the  ring,  and 
consequently  much  beyond  the  place  occupied  by  the  strangulation;  the 
stricture  in  these  cases  being  almost  constantly  a  little  nearer  the  external 
aponeurosis  than  i\\Q  fascia  propria  or  the  interior  peritoneum.  This  perhaps 
may  reconcile  the  ideas  of  M.  Dupuytren  with  the  practice  of  Scarpa.  Yet 
I  cannot  omit  saying,  that  the  danger  of  not  incising  in  case  of  gangrene  does 
not  at  first  appear  very  great.  If  after  some  hours  the  colic  continues,  tlie 
symptoms  of  strangulation  have  not  ceased,  and  in  removing  the  dressing  we 
see  that  the  matters  escape  with  difficulty,  we  are  then  able  to  introduce 
into  the  superior  part  of  the  intestine  either  a  female  catheter,  a  silver 
canula,  or  still  better  a  large  tube  of  gumelastic,  and  thus  remedy  this  diffi- 
culty at  once.  If  notwithstanding  this  attention  the  engorgement  of  the 
tissues  and  the  narrowness  of  the  ring  oppose  the  re-establishment  o^  the 
functions,  it  will  be  still  time  on  the  next  day  or  the  day  following  to  dilate 
by  incision,  as  would  have  been  done  on  the  day  of  the  operation,  and  perhaps 
with  less  apprehension,  since  it  is  then  almost  impossible  that  solid  adhesions 
should  not  have  been  effected  around  the  herniary  opening. 

§  7.  Enteroraphy. 

We  have  as  yet  supposed  the  parts  left  in  place,  but  a  great  number  of 
practitioners  think  it  necessary,  in  order  to  be  assured  of  the  limits  of  the 
gangrene,  to  draw  through  the  ring  a  portion  of  the  intestine  which  has  not  been 
contained  in  it;  to  excise  by  cutting  upon  the  living  portion  all  that  is 
mortified;  to  reduce  the  sound  parts  so  as  to  leave  in  the  wound  only  the 
opening  or  openings  that  have  just  been  made,  or  to  attempt  on  the  spot  their 
immediate  union  by  stretching  together  the  two  ends  of  intestine;  hence  have 
arisen  several  important  operations. 

l^t.  Littre  for  example  tied  the  inferior  end  so  as  to  produce  its  oblitera- 
tion, and  kept  the  superior  end  in  the  ring,  establishing  an  artificial  anus  which 
the  patient  was  to  carry  during  the  remainder  of  his  life.  Louis,  who  was 
not  opposed  to  the  practice  of  Littre,  found  however  one  difficulty,  that  of 
distinguishing  immediately  the  superior  from  the  inferior  portion  of  the  ali- 
mentary tube.  To  obviate  this,  he  advised  to  give  the  patient  a  little  syrup 
of  cichory,  which  being  evacuated  after  some  hours  would  indicate  by  its  green 
color  in  which  direction  was  the  stomach  and  in  which  the  rectum.  This 
would  be  an  ingenious  mode  without  doubt,  but  it  is  rare  that  we  are  obliged 
to  have  recourse  to  it.     After  tiie  division  of  the  intestine,  its  inferior  end 


OPERATIVE  SURGERY.  589 

rarely  fails  of  collapsing  and  dwindling  to  the  size  of  a  large  cord,  while  the 
otlier  preserves  nearly  its  primitive  dimensions,  and  besides  does  not  cease  to 
give  issue  to  fecal  matters.  The  process  of  Littre,  having  for  its  end  the 
establishment  of  a  disgusting  infirmity  ought  to  be  rejected,  and  deserves  not 
the  least  attention  at  the  present  day. 

2d.  Lapeyronie  has  proposed  another,  at  the  same  time  more  simple  and 
much  more  rational.  The  surgeon  passes  behind  the  division  a  double  thread 
through  a  fold  of  the  mesentery,  and  after  pushing  the  two  ends  of  the  in- 
testine within  the  abnormal  limits,  uses  this  thread  to  prevent  its  being  lost 
completely  by  fastening  them  externally  to  any  part  of  the  dressings.  An  arti- 
ficial anus  is  thus  obtained  it  is  true,  but  one  that  can  be  cured  spontaneously 
or  by  the  assistance  of  art.  Scarpa,  who  condemns  this  process  of  Lapeyronie, 
directs  after  destroying  the  gangrenous  parts  to  leave  the  two  ends  of  the 
organ  in  the  wound.  The  adhesions  which  they  have  contracted,  says  he, 
while  the  mortification  was  in  progress,  always  suffice  to  prevent  their  too 
rapid  return  and  all  danger  of  effusion  into  the  peritoneum.  According  to 
him  the  mesenteric  thread  would  be  injurious  in  more  than  one  respect ;  first, 
in  being  an  obstacle  to  the  gradual  retraction  of  the  parts,  and  to  the  formation 
of  what  the  celebrated  surgeon  of  Pavia  calls  the  membranous  funnel  of  the 
artificial  anus ;  secondly  because  the  thread,  which  will  shortly  cut  through 
the  mesentery,  may  at  the  same  time  divide  vessels  from  which  hemorrhage 
might  be  serious ;  and  in  the  last  place,  because,  resting  against  the  deeper 
face  of  the  intestines  it  is  capable  of  causing  ulceration  and  perforation,  in  the 
same  manner  as  a  ligature  cuts  through  an  artery  around  which  it  has  been 
placed.  But  as  the  fears  of  Scarpa  are  not  entertained  by  all  surgeons,  some 
have  put  in  practice  the  process  of  Lapeyronie  even  of  late,  and  say  they  have 
no  reason  to  regi*et  it.  M.  Hervez  of  Chegoin,  among  others,  reported  a  case 
to  tlie  academy  of  medicine,  in  1829.  It  would  be  easy,  besides,  to  leave  this 
thread  in  place  for  only  one  or  two  days  if  its  presence  proved  really  obnoxious. 
Instead  of  forming  a  noose  of  it  the  two  portions  of  which  should  be  united  or 
twisted  on  each  other,  they  may  be  kept  apart  by  fastening  them  separately 
without,  and  after  a  given  time  it  would  be  very  easy  to  withdraw  this  thread 
by  pulling  one  of  its  extremities  before  it  could  divide  the  mesentery  or  de- 
stroy the  continuity  of  the  intestine.  No  doubt  we  may  in  strictness  dispense 
with  the  precaution  of  Lapeyronie  when  the  excision  has  not  been  made  in  the 
living  part,  or  when  it  is  very  near  the  ring,  and  if  during  tlie  operation  we 
have  not  thought  proper  to  displace  tlie  strangulated  intestinal  circle ;  but  in 
other  cases  it  would  be  imprudent  I  think  to  leave  hanging  in  the  wound,  as 
Richter  directs,  a  long  portion  of  the  divided  organ,  or  to  push  it  back  into 
tlie  strangulating  circle,  as  proposed  by  Desault,  without  taking  the  precaution 
of  fastening  it  by  some  means  to  the  exterior. 

Sd.  Suture. — By  following  the  course  just  marked  out,  the  immediate  result 
will  be  a  stercoral  fistula,  or  a  preternatural  anus.  The  suture  has  been  pro- 
posed for  the  purpose  of  preventing  this  infirmity  by  immediately  re-establish- 
ing the  continuity  of  the  divided  tube.  This  indication  many  authors  have 
endeavored  to  fulfill  by  various  means,  which  having  often  sunk  into  neglect 
has  of  late  been  again  attracting  some  attention. 

Upon  a  Foreign  Body.— -To  four  gentlemen  who  united  for  the  purpose  of 
relieving  in  common  the  poor  patients  of  Paris,  is  attributed  the  first  idea 


590  NEW    ELEMENTS    OF 

of  bringing  together  the  two  ends  of  the  intestine  and  sewing  them.  These 
surgeons  commenced,  it  is  said,  by  procuring  the  trachea  of  an  animal,  and 
introduced  one  of  its  extremities  into  the  superior,  and  the  other  into  the 
inferior  division  of  the  interrupted  canal,  the  two  raw  circles  of  which  were 
then  approximated,  and  fastened  and  kept  in  contact  by  several  stitches  which 
also  passed  through  the  trachea,  and  after  some  time  were  with  it  carried  off 
in  the  stools.  G.  de  Salicet,  who  lived  before  Guy  de  Chauliac,  does  not 
mention  the  trachea  of  the  animal,  but  lie  was  acquainted  with  the  process  of 
the  four  surgeons  and  formally  condemns  it.  ''Do  not  listen,"  says  he, "  to  those 
who  say  that  before  sewing  the  gut,  an  '  elder  pipe  or  some  such  thing  should 
be  put  in,  and  that  upon  this  canula  the  wounded  gut  is  to  be  sewed,  for,'  &c. 

and  further  *  it  would  be  better a  portion  of  the  gut  of  some  beast 

but  neither  this  nor  any  thing  else- .'  "     For  the  rest,  it  is  very  certain 

that  the  old  surgeons  had  on  this  subject  the  idea  which  is  at  present  enter- 
tained. Guillaume  only  mentions  it  in  incomplete  divisions  of  the  intestinal 
circle,  and  expressly  informs  us  that  all  others  are  necessarily  fatal.  Nothijig 
shows  that  Guy  entertained  a  different  opinion,  *'  And  if  there  is  necessity 
for  sewing  (the  parts  cantained  in  the  abdomen),  and  that  it  be  of  benefit  as  at 
the  bottom  of  the  stomach  and  large  guts,  let  them  be  sewed  with  t!ie  glover's 
stitch.  Some,  as  Garnier,  Rogier,  and  Theodore,  put  into  the  gut  a  canula  of 
elder  to  prevent  the  feces  from  rotting  the  stitches.  Others,  as  Guillaume 
has  related,  place  in  it  the  portion  of  the  gut  of  some  beast,  or  a  portion  of  the 
trachea  arteria  as  the  four  masters  direct."     Watson  has  since  proposed  a 

,  canula  of  isinglass.  Some,  with  Scarpa,  mention  a  cylinder  of  tallow.  Saba- 
tier,  Ritch,  Desault,  and  Chopart,  direct  a  piece  of  a  playing  card  smeared 
with  essence  of  turpentine  or  the  oil  of  hypericum,  or  varnished  in  any  other 
manner.  The  process  of  the  ancients  had  so  little  attracted  attention, 
that  Duverger  a  surgeon  of  Maubeuge,  who  reproduced  it  at  the  beginning  of 
the  last  century,  was  thought  to  be  its  inventor.  It  does  not  appear  after  all 
that  it  has  been  often  tried,  or  that  up  to  the  present  time  there  have  been 
more  than  two  or  three  successful  cases.     If  it  is  to  be  attempted,  it  would  be 

'in  my  opinion  a  matter  of  indifference  whether  to  employ  a  very  pliant  animal 
trachea,  a  cylinder  of  fish-glue,  of  card  or  paper,  or  a  canula  of  gumelastic. 
Having  coated  with  varnish  this  species  of  tunnel  or  tube,  which  must  ol' 
necessity  be  somewhat  smaller  than  the  intestine,  three  or  four  loops  of  thread  or 
Ri'k  are  to  be  passed  through  the  middle  several  lines  distant  from  each  other, 
each  carrying  a  needle  at  its  extremity  to  make  so  many  stitches.  Its  intro- 
duction into  the  superior  division  of  the  alimentary  tube  will  be  attended  but 
with  very  trifling  difficulty ;  but  for  its  admission  into  the  lower  portion,  that 
part  should  be  held  by  two  pairs  of  forceps,  keeping  its  sides  apart  and  thus 
enlarging  the  opening.  This  being  done,  the  ends  of  each  thread  ought  to  be 
passed  successively  from  within  outwards,  at  two  or  three  lines  from  the  edge, 
through  the  corresponding  end  of  intestine.  After  they  have  been  tied  and  cut 
very  near  the  knot,  the  whole  is  replaced  in  the  abdomen ;  a  gentle  purgative  is 
then  given,  and  the  patient  treated  as  after  the  ordinary  operation  for  strangu- 
lated hernia.  While  the  union  is  taking  place,  the  threads  are  cutting  through  the 
tissues,  and  when  this  is  accomplished  the  foreign  body  being  set  free  descends 
with  the  intestinal  matters  and  is  expelled.  Instead  of  four  threads,  Durverger 
recpmaiends  but  two,  one  in  front,  the  other  behind.   Those  of  Ritch,  depend- 


OPERATIVE    SURGERY.  591 

ing  on  the  same  cord,  had  the  inconvenience  of  forming  a  kind  of  transverse 
bridge  in  the  interior  of  the  card.  Desault  had  no  other  motive  than  to  remove 
this  peculiarity,  in  proposing  the  modification  attributed  to  him,  which  is  not 
of  sufficient  importance  to  be  given  here  in  detail.  This  suture  is  in  the  first 
place  difficult  to  perform;  and  besides,  it  is  to  be  feared  that  in  the  space 
between  the  stitches  union  may  not  take  place,  and  that  becoming  free  the 
threads  may  leave  ulcerations,  and  allow  fluids  to  be  effused.  In  fine,  its 
dangers  are  so  formidable,  that  in  the  absence  of  conclusive  experiments  and 
numerous  facts  which  science  does  not  yet  possess,  despair  of  every  other 
means  should  alone  induce  us  to  determine  upon  its  employment. 

4th.  Suture  with  Invagination. — Randhor,  a  surgeon  of  the  duke  of  Bruns- 
wick, having  to  treat  a  soldier  in  whom  the  continuity  of  the  intestinal  tube 
had  just  been  destroyed,  concluded  to  introduce  the  superior  into  the  inferior 
portion,  and  fix  it  in  this  position  by  two  stitches,  reduce  it,  and  leave  it  then 
in  the  abdomen.  His  patient  was  completely  cured.  He  died  several  years 
after  of  another  affection,  and  Randhor  was  enabled  to  examine  the  state  of 
the  parts.  He  removed  the  portion  formerly  divided  and  sent  it  to  Moebius, 
who  had  occasion  to  show  it  to  Heister,  who  immediately  began  to  try  the 
same  operation  on  dogs  but  without  success.  Extolled  by  some,  rejected  as 
impossible  or  dangerous  by  others,  admitted  by  Louis  to  be  very  ingenious, 
and  tried  a  number  of  times  since  it  became  known,  the  method  of  Randhor 
seems  to  have  succeeded  but  in  a  very  small  number  of  cases.  M.  Boyer 
performed  it  once  ;  his  patient  died.  In  another  case  he  could  not  finish  it. 
I  have  seen  it  tried  by  M.Richerand  at  the  hospital  St.  Louis  on  a  patient 
who  also  died  the  next  day.-  M.  Lavielle  of  Membaste,  MM.  Chemery  Have, 
Schmidt,  and  some  others,  have  however  each  reported  a  case  of  success  in 
support  of  the  Ranhorian  operation. 

The  first  difficulty  is  to  overcome  the  contraction  of  the  inferior  division  of 
the  intestine.  One  of  the  best  means  for  this  purpose,  is  to  seize  by  their  four 
extremities  at  once  the  two  principal  diameters  with  as  many  forceps  or 
hooks.  To  prevent  the  superior  division  from  filling  or  swelling  an  assistant 
has  to  take  hold  of  four  or  five  inches  of  it  and  keep  it  sufficiently  compressed, 
while  the  surgeon  endeavors  to  fix  it  in  the  orifice  of  the  rectal  portion. 
But  there  is  another  obstacle,  which  M.  Richerand  I  believe  was  the  first 
clearly  and  positively  to  point  out.  The  researches  of  Bicbat  on  the  different 
tissues,  prove  in  fact  that  mucous  membranes  will  contract  no  mutual  adhe- 
sions ;  and  that  adhesive  inflammation  in  general  only  takes  place  between 
cellular  surfaces.  But  in  the  invagination  after  the  manner  of  Randhor,  it  is 
the  peritoneal  coat  of  the  superior  intestinal  portion  which  is  in  contact  with 
the  mucous  membrane  of  the  other.  If  the  law  established  by  Bichat  is 
correct,  and  if  the  remark  of  M.  Richerand  is  well  founded,  adhesion  of  the 
two  ends  of  the  intestine  must  be  impossible  by  the  method.  Thus  was  it 
nearly  renounced,  when  M.Raybard  advocated  it  anew,  and  endeavored  to 
show  that  it  ought  to  be  preferred  to  that  which  has  recently  been  brought 
forward  to  supply  its  place. 

Process  of  M.  Raybard. — In  support  of  his  assertions  this  surgeon  publishes 
a  certiiin  number  of  experiments  upon  living  animals,  and  observations  in 
pathological  anatomy  gathered  from  man.  Like  Randhor,  M.  Raybard  directs 
the  mesentery  first  to  be  incised  parallel  with  the  concavity  of. -the  intestine. 


592  '  NEW    ELEMENTS   OF  ' 

to  the  extent  of  several  lines.  He  then  passes  a  thread  a  little  above  the. 
wound,  so  that  one  of  its  ends  remains  within  the  canal  while  the  other 
hangs  without.  According  to  him,  it  is  sufficient  to  have  two  loops  thus 
placed,  one  upon  each  extremity  of  the  antero -posterior  diameter  of  the  altered 
canal.  With  a  needle,  the  internal  extremity  of  each  is  passed  from  within 
outwards  through  Uie  inferior  division  of  the  organ,  to  invaginate  methodically 
the  two  parts,  and  terminate  by  tying  each  stitch  into  a  knot.  M.Raybard 
contends  that  his  process  is  at  once  the  most  certain  and  easy,  and  much  less 
dangerous  than  that  proposed  by  M.  Jobert;  I  have  not  learned  that  he  has 
made  any  application  of  it  to  the  human  subject. 

Suture  with  Contact  of  Serous  Surfaces. — Experiments,  already  of  ancient 
date,  may  be  brought  to  the  support  of  M.  Richerand's  ideas.  Messrs.  Schmidt, 
Thompson,  and  Travers  have  noticed  this  singular  phenomenon,  viz.  that  if  a 
thread  is  tied  round  a  small  perforation  of  the  intestine,  this  thread  soon 
buries  itself  as  in  a  depression,  so  as  to  approach  gradually  the  interior  of  the 
canal  and  there  become  entirely  free,  at  the  same  time  that  the  membrane^ 
or  the  serous  surface  approximates  behind,  and  blends  with  a  plastic  layer,  so  as. 
to  prevent  the  opening  which  would  otherwise  be  the  consequence.  Besides, 
Mr.  Travers  has  seen  that  if  the  whole  calibre  of  the  alimentary  canal  is . 
strangulated,  the  peritoneum  of  the  superior  portion  adheres  so  rapidly  to 
tliat  of  the  inferior  part,  that  the  septum  formed  by  this  strangulation  soon 
becomes  gangrenous,  is  detached,  and  carried  in  the  direction  of  the  rectum,  so 
that  at  length  the  tube  is  completely  re-established.  In  France  the  labors  of 
M.  Dupuytren  on  preternatural  anus  give  the  same  fact,  and  show  with  what 
facility  and  promptitude  two  points  of  the  externalface  of  the  intestine  unite, 
when  kept  in  contact. 

Process  of  M.  Jobert. — From  these  various  elements,  M.  Jobert  has  derived 
a  method  which  seems  at  first  to  promise  real  advantage.  This  surgeon 
begins  by  turning  inwards  the  orifice  of  the  inferior  intestinal  division,  he 
then  performs  the  suture  like  Randhor,  and  in  this  manner  conti'ives  that  the 
two  ends  of  the  organ  shall  be  in  contact  by  their  serous  surfaces.  Two 
threads  are  sufficient,  he  does  not  tic  them,  but  keeps  them  without  so  as  to 
remove  them  after  several  days  by  drawing  on  their  extremities.  Experiments 
made  upon  cats  and  dogs  have,  it  is  said,  perfectly  succeeded  in  his  hands^ 
He  has  shown  several  to  the  committee  of  the  academy  of  medicine,  who  have 
seen  the  digestive  tube  fully  cicatrized,  presenting  a  solid  ring,  projecting 
internally,  and  very  complete  at  the  place  which  had  been  occupied  by  the 
wound.  But  this  kind  of  invagination  does  not  seem  to  present  less  serious 
difficulties  than  that  of  Randhor,  and  at  first  view  oiFers  only  the  advantage 
of  plating  in  contact  two  portions  of  peritoneum,  instead  of  applying  tlie 
peritoneum  against  a  mucous  membrane  as  in  the  ancient  process.  There 
are  wanting  examples  of  this  mode  of  proceeding  on  the  human  subject. 

Process  of  M.  Denans. — A  surgeon  of  Marseilles,  M.  Denans,  proposed 
about  the  same  period  with  M.  Jobert  another  sort  of  invagination.  Three 
small  hollow  cylinders  of  metal  are  necessary  for  it.  He  places  one  in  each 
end  of  the  intestine,  the  wound  of  which  he  inverts  or  invaginates  on  the  in- 
ternal face  of  this  species  of  rings  ;  the  third,  a  little  smaller  than  the  other 
two,  is  to  be  passed  within  the  upper  one  and  then  within  the  inferior,  so  as  to 
form  a  kind  of  staff  or  axis  for  the  support  of  both.     A  thread  embraces  an4 


OPERATIVE    SURGERY  593 

fixes  all  three  upon  two  different  joints  of  the  intestinal  circle.  The  ends  of 
the  suture  are  cut  very  near  the  peritoneum,  and  tlie  whole  is  replaced  and 
left  in  the  abdomen.  Union  of  the  parts  soon  takes  place.  All  tliat  is 
pressed  between  the  three  cylinders  soon  becomes  gangrenous,  is  detached, 
and  these  foreign  bodies  descend  and  are  discharged  by  stool.  At  the  last 
meeting  for  admission  M.  Guersent,  Jr.  justified  all  the  assertions  of  M.  De- 
nans  by  showing  to  tlie  jury  a  portion  of  intestine  perfectly  cicatrized,  the 
two  ends  ot  which  had  been  coaptated  by  the  process  of  the  cylinders. 

Process  of  M.  Lembert. — M.  Lembert,  a  former  student  in  the  hospitals  of 
Paris,  proposed,   in   1825,  another  method  of  bringing  the  serous  surfaces 
together.     With  an  ordinary  needle  he  passed  as  many  threads  as  he  wished 
to  make  stitches  through  the  parietes  of  the  superior  portion  first,  and  then 
through  those  of  the  inferior  end  of  the  intestine.     The  point  of  his  needle  is 
carried  two  or  three  lines  from  the  wound  on  the  external  surface  of  the 
organ ;  he  makes  it  penetrate  as  far  as  the  mucous  membrane,  passing  be- 
tween the  tissues,  brings  it  out  at  about  two  lines  from  its  insertion,  and  thus 
fixes  his  thread ;  with  the  same  precautions  he  directs  the  needle  on  the 
external  face  and  in  the  substance  of  the  rectal  end  of  the  intestine,  applying 
successively  and  in  the  same  manner  all  the  threads  he  deems  proper,  and  has 
then  only  to  tie  them  to  complete  the  suture.     By  drawing  upon  these  threads 
the  lips  of  the  wound  are  forced  to  be  inverted  on  their  internal  surface,  for- 
ming a  valve  or  border  projecting  into  the  interior  of  the  canal,  producing  at 
the  same  time  the  immediate  contact  of  the  external  surface  of  the  ends  of  in- 
testine whose  continuity  is  to  be  re-established.    These  three  processes  tend 
to  the  same  end,  the  union  of  two  serous  surfaces.    That  of  M.  Denans  seems 
to  offer  more  certainty  and  less  danger  than  the  two  others,  inasmuch  as 
nothing  can  derange  it.    However,  who  would  be  so  bold  as  thus  to  leave  the 
intestine  in  the  abdomen  ?    Who  can  insure  that  these  inflexible  cylinders 
will  not  perforate  the  organ  if  tliey  should  take  a  wrong  position  in  the  inte- 
rior of  the  abdomen  ?    In  operating  like  M.  Jobert  there  is  danger  of  the 
threads  relaxing,  and  some  points  of  the  intestinal  periphery  may  remain 
disunited  and  permit  effusion.     The  modification  ofM.  Lembert  is  apparently 
much  more  simple  and  easy,  it  requires  no  previous  inversion  nor  invagina- 
tion, but  it  seems  to  be  more  likely  than  the  preceding  to  leave  some  vacancy 
between  the  stitches,  through  which  substances  of  some  fluidity  may  escape. 
If  I  intended  to  employ  it  I  would  prefer  using  the  overcast  stitch ;  that  is,  I 
would  pass  the  needle  obliquely  from  above  downwards,  from  the  superior 
end  over  the  external  face  of  the  inferior,  so  as  to  reascend  to  the  first  a  line 
or  two  from  the  point  of  departure,  returning  upon  the  second,  and  then  again 
to  the  first,  and  so  on  until  I  had  gone  over  the  whole  circumference  of  the  in- 
testine.    To  finish  I  should  only  have  to  draw  in  different  directions  the  two 
ends  of  the  thread,  of  which  one  would  be  the  beginning  and  the  other  the  ter- 
mination.of  the  suture.  If  simple  pulling  will  not  force  the  lips  of  the  wound  to 
become  inverted,  and  the  peritoneal  coats  to  come  into  mutual  contact,  the 
beak  of  a  sound  will  complete  the  suture  with  great  facility.     A  double  knot 
will  then  finish  the  operation.     The  extremities  of  the  thread  or  one  of  them 
will  be  sufficient  to  retain  the  organ  behind  the  ring,  if  we  do  not  wish  to 
leave  it  at  large  in  the  abdomen,  in  which  case  a  knot  is  not  indispensable. 
But  after  aJl,  does  pi-udence  permit  us  to  have  recourse  to  such  means,  means 
75 


594  NEW  ELEMENTS  Ot 

which  will  necessarily  produce  death  if  they  should  fail  of  their  intended  effect  B* 
Is  it  right  thus  to  risk  human  life,  when  by  establishing  an  artificial  anu»-- 
we  are  almost  sure  of  an  eventual  cure  ?  I  have  practised  upon  dogs  the  pro- 
cess of  M.  Jobert  and  that  of  M.  Lembert  modified  as  I  have  just  shown. 
Whether  it  was  that  I  did  not  take  all  proper  precautions,  or  that  I  had  not> 
the  skill  necessary  for  tlie  attempt,  I  must  confess,  that  in  two  cases  out  oP 
six  fecal  matters  were  effused  into  the  abdomen,  and  the  death  of  the  animals 
was  the  consequence.  I  will  add,  that  of  the  other  four  only  two  were  per- 
fectly cured,  while  the  third  and  fourth  retained  a  small  orifice  tlirough  which 
escaped  mucosities,  and  which  were  not  surrounded  with  adhesions  or  false 
membranes  and  gave  no  favorable  assurances  for  the  future.  I  also  wished 
to  renew  the  experiments  of  Mr.  Travers,  and  the  truth  is,  that  in  the  two 
dogs,  all  that  I  tried,  the  strangulated  intestine  broke,  and  I  found  it  wholly, 
divided  after  the  death  of  the  animals,  which  took  place  on  the  following  dayi^ 
B.  Ulceration. — What  I  have  as  yet  said  is  only  applicable  to  wounds 
which  include  the  whole  of  the  intestinal  circumference,  either  with  or  without 
loss  of  substance,  whetlier  dependant  on  gangrene  or  a  wound  on  some  point 
of  the  abdominal  cavity.  If  the  mortification  is  confined  to  the  peritoneal 
coat,  or  does  not  extend  to  tlie  mucous  membrane,  we  may,  as  Desault 
recommends,  restore  their  parts  to  the  place,  and  trust  entirely  to  the  resources 
of  nature.  Adhesive  inflammation  will  be  developed  around  the  altered  layer, 
and  soon  produce  exfoliation  of  the  dead  lamellae,  and  will  not  permit  the* 
intestine  to  be  perforated.  But  one  of  two  things  is  true :  either  tlie  gangrene 
is  evident,  and  in  this  case  not  having  any  certainty  whether  it  extends  or 
does  not  extend  through  the  substance  of  the  organic  parietes,  the  surgeon 
cannot  think  of  reduction;  or,  its  existence  may  be  doubtful,  and  then 
prudence  directs  that  the  intestine  be  returned  into  the  abdomen.  If  it 
occupies  but  a  small  space,  the  part  may  be  cut  out,  including  some  of  the 
living  portion,  and  so  as  to  form  an  elliptical  wound,  longitudinally  or 
transversely  as  it  may  be  easiest  to  make  it  in  one  or  the  other  of  these 
directions.  On  the  contrary,  if  it  occupies  a  great  part  of  the  circumfe- 
rence of  the  intestine,  and  that  for  more  than  half  an  inch,  it  would  be 
better  to  remove  a  complete  segment  of  this  cylinder,  and  to  try  one  of  the 
methods  pointed  out  above.  The  gangrenous  portions  being  removed,  the 
solution  of  continuity  is  reduced  to  the  slate  of  a  simple  wound,  and  is  to  be 
treated  as  such.  Modern  experience  has  proved  that  the  perforation  of  an 
intestine  by  a  penetrating  or  cutting  instrument  may  be  left  without  danger 
in  the  abdomen  when  it  is  less  than  two  or  three  lines  in  diameter.  The 
muscular  fibres  soon  contract  its  circumference,  so  as  to  force  the  mucous 
membrane  to  become  engaged  in  and  close  it.  A  larger  incision,  one  of  three 
or  four  lines  for  instance,  does  not  more  constantly  cause  extravasation  ;  its 
edges  adhere  sometimes  to  the  corresponding  surface  of  another  intestinal 
circumvolution,  or  it  comes  in  contact  with  a  fold  of  epiploon,  which  often 
engages  in  it  and  closes  it  like  a  stopper.  It  would  be  imprudent,  however, 
when  8uch  lesions  are  visible  to  leave  them  to  the  care  of  nature.  If  it  is 
true  that  the  greater  number  of  them  are  healed  without  giving  rise  to  unplea- 
sant s}Tiiptom8,  it  is  also  very  probable  that  some  would  be  followed  by  fatal 
effusion.  In  hernids  these  wounds  present  under  two  distinct  forms,  first,  in 
the  state  of  a  simple  division  when  they  are  produced  by  the  cutting  instru- 


OPj^RATIVE    SURGERY.  395 

ment  used  by  the  operator ;  secondly,  under  the  aspect  of  ulcer  or  solution, 
with  loss  of  substance  if  stricture  in  the  ring  has  been  the  cause.  In  this 
last  case  there  is  scarcely  any  hope  of  seeing  them  closed  without  assistance, 
and  if  they  are  to  be  treated  by  tlie  suture  it  is  proper  first  to  smooth  their 
edges.  We  have  here  to  choose  among  the  glover's  suture,  the  suture  of  Le 
Dran,  and  the  suture  a  points  passes.  The  glover's  suture  has  the  advantage 
of  being  quickly  and  easily  performed,  and  of  exactly  closing  the  wound, 
but  it  is  very  difficult  to  witlidraw  the  thread  when  we  think  union  is  effected. 
Besides  being  less  quickly  performed,  the  suture  a  anse,  or  of  Le  Dran,  has 
the  inconvenience  of  puckering  and  contracting  the  intestine  in  consequence 
of  the  size  of  the  wound ;  but  the  threads  being  passed  but  once  through  the 
tissues  are.  easily  drawn  and  removed  through  the  opening  in  the  abdominal 
parietes.  The  suture  a  points  passes  offers  nearly  the  same  advantages  as  the 
glover's  suture,  and  if  modified  as  directed  by  Bichat  its  removal  is  less  liable 
to  produce  rupture  of  the  adhesions  and  growing  cicatrix  than  the  simple 
overcast  stitch.  The  spiroid  suture,  combined  with  the  principles  of  M. 
Lembert,  seems  no  less  entitled  to  respect.  Whether  the  wound  be  longitu- 
dinal or  transverse  the  operation  is  always  to  be  performed  after  tlie  same 
rules. 

When  tlie  coaptation  is  effected,  we  may  act  in  two  different  ways ;  first  we 
may  tie  the  suture  and  cut  it  close  to  the  intestine,  then  reduce  this,  and  leave 
it  free  in  the  abdominal  cavity ;  or  secondly,  we  may  keep  the  tliread  and 
fasten  it  externally  in  the  dressing,  to  prevent  the  wounded  organ  from 
escaping  to  any  distance,  and  to  force  it  to  contract  adhesions  behind  the  ring. 
If  it  were  true,  as  it  is  asserted,  that  ligatures  fixed  in  the  substance  of  the 
coats  of  the  intestine  always  fall  into  the  interior  of  the  canal,  the  first  method 
should  evidently  be  preferred,  since  the  other  would  not  fail  to  obstruct  in 
some  degree  the  passage  of  intestinal  matters ;  but  most  surgeons  of  the 
present  day  have  not  as  yet  adopted  this  plan.  The  two  cases  of  M.Cloguet 
and  M.  Liegard,  who  followed  the  process  of  M.  Lembert,  are  in  fact  the 
only  ones  as  yet  to  be  brought  in  its  support ;  and  quite  recently  too,  M. 
Hervez  of  Chegoin  preferred  passing  a  thread  into  the  mesentery  to  retain 
the  wounded  organ  to  attempting  the  suture,  although  the  wound  was  not  more 
than. two  lines  in  diameter.  M.  Raybard  maintains  that  the  principal  end  of 
enteroraphy  is  to  fix  the  two  lips  of  the  solution  separately  behind  the  open- 
ing in  the  abdominal  parietes,  so  that  after  they  have  been  united  with  the 
peritoneum  the  threads  may  be  drawn,  and  the  division  of  the  abdomen  and 
that  of  the  intestine  healed  at  the  same  time.  If  it  be  a  long  wound  this 
practitioner  conducts  the  operation  in  the  following  manner.  A  flat  piece  of 
white  wood,  small,  thin,  and  oiled,  from  twelve  to  fifteen  lines  long,  and  from 
four  to  six  broad,  is  carried  into  the  intestine.  A  loop  of  thread  attached  to 
the  middle  of  this  slip  of  wood,  armed  at  each  end  with  a  needle,  is  then 
passed  from  one  side  to  the  other,  from  the  interior  to  the  exterior,  through 
the  whole  substance  of  the  abdominal  parietes,  so  that  the  small  foreign  lamella 
presses  at  once  the  two  lips  of  the  intestine  against  the  two  sides  of  the 
abdominal  wound,  which  at  the  same  time  it  keeps  hermetically  closed. 

When  the  adhesion  of  these  various  parts  seems  sufficiently  solid,  M. 
Raybard  withdraws  his  thread,  the  slip  of  wood  comes  away  with  the  stools, 
when  the  cicatrization  of  the  wound  in  the  abdomen  only  remains  to  be  at- 


59o  NEW    ELEMENTS   OF 

tended  to  if  not  already  healed.  If  this  process  is  blamed  for  intetitidnally 
producing  adhesions  which  will  necessarily  prevent  the  intestine  from'resum- 
ing  its  primitive  mobility,  it  is  but  just  to  acknowledge  that  in  other  sutures 
the  same  thing  almost  as  certainly  takes  place,  if  not  as  completely,  whenever 
the  extremities  of  the  thread  are  kept  without.  It  is  even  true  that  it  is  not 
more  thoroughly  avoided  by  cutting  the  threads  close  to  the  intestine  and 
leaving  the  organ  behind  the  wound.  Adhesive  inflammation,  which  is  indis- 
pensable to  cieatrization,  seldom  fails  of  uniting  the  circumference  of  the  vis- 
ceral wound  to  the  tissues  which  are  in  more  or  less  immediate  contact  with 
it.  Another  objection  better  founded  is  the  use  of  the  slip  of  wood,  which 
seems  hardly  applicable  to  any  other  than  longitudinal  divisions  the  conse- 
quences of  penetrating  wounds  of  the  abdomen,  and  not  to  cases  where  the 
parts  have  escaped  through  a  herniary  opening.  For  the  rest  we  niay  have 
to  fear  lest  the  extremities  or  edges  of  this  foreign  body  perforate  the  parietes 
of  the  wounded  intestine  by  ulceration  or  gangrene.  It  must  be  admitted, 
however,  that  in  wounds  of  the  convexity  of  an  intestinal  loop,  this  process 
seems  worthy  of  trial;  the  better,  as  it  permits  at  once  the  immediate  union 
of  the  abdominal  wound  by  the  twisted  or  quilled  suture,  or  the  siiture  a  points 
passes  ;  if  not  by  the  same  thread  which  passes  through  the  intestine  as  di- 
rected by  M.  Raybard.  To  resume ;  therefore,  whether  the  intestine  be  held 
or  left  at  large  it  does  not  cicatrize  without  uniting  in  some  measure  with  the 
surrounding  parts,  so  that  on  this  point  eveiy  one  may  be  free  to  act  according 
to  his  own  ideas.  Therefore  I  cannot  seriously  blame  M,  Guillaume  for  having 
sewed  the  external  wound  with  the  glover's  suture,  for  a  patient  whom  he 
treated  for  a  division  of  the  intestine.  To  conclude,  if  the  parietes  of  the 
organic  cylinder  were  only  divided  or  perforated  to  the  extent  of  one  or  two 
l;nes,  it  would  be  better  to  take  hold  of  the  two  lips  at  once  with  a  forceps  and 
close  it  by  passing  round  it  a  thread,  as  in  tying  the  extremity  of  an  artery. 
Sir  A,  Cooper  and  another  surgeon  I  think  have  each  had  a  successful  case 
by  this  method  in  the  London  hospitals. 

§  8.  Preternatural  Anus. 

The  operations  by  which  art  sometimes  remedies  the  preternatural  anus 
are  rather  few  in  number.  For  a  long  time  none  was  eveYi  attempted, 
and  it  is  only  since  the  middle  of  the  last  century  that  operative  surgery  has 
positively  undertaken  the  relief  of  this  disgusting  affection. 

A.  Suture, — One  of  the  first  processes  that  presented  itself  to  the  mind, 
waft  the  suture.  It  seemed  that  by  approximating  the  lips  of  the  wound  or  the 
integuments  previously  pared,  and  keeping  them  in  contact,  we  might  succeed 
in  forcing  the  matters  to  resume  their  natural  course  and  enter  the  inferior 
portion  of  the  intestine.  Lecat  is  the  first  who  expressed  a  desire  to  put  this 
method  into  execution.  He  had  admitted  into  his  hospital  a  woman  affected 
for  several  months  with  preternatural  anus  in  1739,  and  for  the  purpose  just 
pointed  out;  but  various  circumstances  independent  of  his  will  caused  his 
project  to  fail.  Lebrun  was  more  fortunate;  he  put  in  practice  the  idea  of 
liccat.  A  crucial  suture  appeared  to  him  sufficient  in  the  patient  he  had  to 
treat.  He  uged  only  caustic  for  making  rare  the  lips  of  the  wound.  For  two 
days  every  thing  presaged  success.     There  were  no  bad  symptoms,  and  cica- 


OFERATIVE  SURGERY.  597 

tiization  was  alreaiSy  far  advanced,  when  on  the  third  day  it  became  neces- 
sary to  remove  the  threads  and  give  issue  to  the  intestinal  matters.  Lebrun 
intended  to  recommence  the  operation  afterwards,  but  the  patient  would  not 
on  any  account  consent.  This  attempt  has  been  generally  blamed,  so  that 
few  surgeons  have  been  bold  enough  to  renew  it.  It  was  however  renewed 
some  years  since  by  M.  Judey  for  an  accidental  inguinal  anus  of  four  months' 
standing,  the  consequence  of  gangrene.  The  success  was  complete  accord- 
ing to  M.  Richerand  who  communicated  the  fact  to  the  academy  of  medicine. 
M.  Blandin  seems  to  have  been  less  fortunate.  He  once  attempted  to  close  a 
preternatural  anus  by  the  suture,  but  the  symptoms  that  soon  manifested 
themselves,  obliged  him  to  re-oj}en  the  wound.  A  modification  of  this  process 
could  not  fail  of  being,  and  in  fact  was  proposed  about  twelve  years  since. 
The  integuments  in  general  are  so  hardened  and  blended  with  the  subjacent 
layers  around  the  w^ound  that  it  would  be  extremely  difficult  to  approximate 
its  lips  or  bring  them  in  contact.  M.  Collier  thought  that  a  portion  of  skin 
detached  from  the  neighboring  part,  turned  over  and  fixed  by  stitches  or  pins 
in  the  anus  according  to  the  principles  of  rhinoplasm  would  obviate  this  in- 
convenience. A  patient  thus  treated  by  him  was  completely  cured,  and  this 
mode  of  operating  has  received  the  approbation  of  M.  Dupuytren,  in  cases  at 
least  where  there  remains  only  a  stercoral  fistula  after  the  re-establishment  of 
the  alvine  evacuation  by  the  natural  anus.  Perhaps  there  would  be  an  advan 
tage  also  in  modifying  tliis  last  idea  by  dissecting  the  skin  which  surrounds 
the  abnormal  anus  to  the  extent  of  an  inch  or  two,  preserving  on  its  internal 
face  as  much  cellular  tissue  as  possible,  and  then  making  raw  the  ulcerated 
edges  to  give  them  a  form  more  elongated  and  regular,  and  then  fixing  them 
with  one  or  more  points  of  twisted  suture.  The  approximation  will  then  take 
place  without  the  least  difficulty  or  dragging  of  the  parts.  A  moderate  com- 
pression would  be  then  indispensable  as  in  the  preceding  process,  in  order  to 
keep  the  deeper  surface  of  the  dissected  flaps  in  contact  with  the  parts  from 
which  they  have  been  separated,  and  prevent  tlie  intestinal  matters  from  ^ 
being  effused  betM^een  them.  On  the  whole,  suture  of  the  abnormal  anus  is 
bad  and  should  be  proscribed.  It  is  proper  only  in  certain  cases  to  complete 
tlie  cure  which  sometimes  remains  imperfect  after  other  treatment,  or  when  by 
any  means  the  course  of  the  stools  is  re-established,  and  when  for  several 
months  the  stercoral  orifice  has  given  issue  only  to  mucosities,  biliary  matters, 
or  other  intestinal  fluids,  and  when  in  spite  of  every  care  and  the  best  devised 
dressings,  this  orifice  still  remains.  The  suture  by  tJie  process  of  M.  Collier, 
or  by  dissection  of  the  circumference  of  the  wound  may,  I  think,  find  in  this 
case  its  proper  application,  and  conduce  to  success. 

B.  Compression. — Compression  is  a  means  which  has  more  than  once  been 
employed  with  advantage,  and  is  still  frequently  used.  It  is  besides,  often 
indispensable  as  a  preparatory  step  or  a  supplementary  one,  to  remove  certain 
complications  which  render  other  processes  altogether  impracticable.  Thus 
the  intestine  may'  be  invaginated  through  the  preternatural  anus,  protrude 
externally,  and  in  the  end  form  a  tumor  which  has  in  some  subjects  been  seen 
to  acquire  a  size  of  six  inches,  a  foot,  and  even  more  in  length,  taking  a 
cylindrical  form,  from  the  extremity  of  which  fecal  matters  are  discharged. 
It  is  evident  that  such  an  invagination  constitutes  a  serious  malady ;  and  as 
many  surgeons  have  remarked,  its  root  is  subject  to  strangulation  like  every 


59S  NEW   ELEMENTS   OF 

other  species  of  hernia.  Patients  have  died  in  consequence  of  it,  and  I  need 
not  say  that  when  this  strangulation  exists,  we  ought  if  reduction  is  impossible 
to  lay  open  the  ring  and  incise  it  from  within  outwards ;  in  a  word,  remove 
the  stricture  as  in  ordinary  hernia.  Even  in  the  absence  of  all  stricture  the 
intestinal  cylinder  witli  its  mucous  membrane  turned  outwards  does  not 
remain  long  in  this  position  without  undergoing  alterations.  Thus  it  is  to  be 
apprehended  that  tJie  peritoneum  of  the  invaginated  portion  will  soon  contract 
intimate  adhesions  with  that  of  the  ensheathing  portion,  and  the  other  tunics 
thicken  and  become  hard,  so  as  to  render  the  reduction  difficult  if  not  alto- 
gether impossible.  To  remedy  accidents  of  this  description  when  not  beyond 
the  resources  of  art,  compression  has  been  advised.  Desault,  Sabatier,  and 
Noel  of  Rheims,  have  vouched  for  its  efficacy.  Since  then  it  has  become  in 
some  sort  a  vulgar  remedy.  If  the  tumor  is  long,  it  is  enveloped  with  thin 
compresses,  after  being  cleansed ;  then  a  bandage  is  applied  rather  narrow 
than  too  wide,  and  is  arranged  in  the  same  manner  as  a  roller  upon  a  limb. 
At  first  the  diminution  of  this  mass  being  very  rapid,  the  bandage  ought  to  be 
frequently  reapplied ;  afterwards  it  is  to  be  renewed  at  longer  intervals.  If 
the  serous  surfaces  of  the  organ  do  not  oppose  an  invincible  obstacle,  its 
reduction  will  soon  become  practicable.  For  the  rest,  it  is  evident  that  after 
this  reduction  the  preternatural  anus  will  nevertheless  continue  to  exist,  and 
other  means  must  be  used  to  make  it  disappear.  As  the  projection,  the  kind 
of  buttress  or  prominent  margin  which  separates  the  superior  intestinal  portion 
from  the  inferior,  is  the  principal  obstacle  to  the  passage  of  substances  from 
the  former  into  the  latter,  it  was  natural  to  expect  that  by  pushing  back  this 
projection  the  disease  might  be  cured.  Compression  was  therefore  proposed. 
It  was  in  the  school  of  Desault  that  it  found  most  partizans  and  received 
useful  improvements.  By  means  of-  tents,  introduced  first  into  the  inferior 
end  and  then  into  the  superior  and  fastened  without  by  a  thread  passed  around 
the  middle,  Desault  was  confident  of  freeing  a  passage  to  the  matters,  which 
would  not  be  long  in  following.  His  tent  being  placed,  he  applied  a  pyramidal 
tampon  to  support  its  convexity  and  push  it  as  much  as  possible  into  the 
abdomen.  When  these  tents  could  be  introduced  of  considerable  size,  and 
the  stools  had  returned  almost  to  their  natural  freedom,  he  only  compressed 
the  external  opening  to  prevent  all  oozing  by  it.  It  cannot  be  denied  that  a 
treatment  so  well  contrived  has  more  than. once  been  attended  with  success. 
However,  tiie  presence  of  a  tent  filling  both  portions  of  the  intestine,  and  of  a 
pyi-amld  of  charpie,or  compresses  hermetically  closing  the  wound,  is  not  borne 
without  inconvenience  by  every  patient.  Some  suffer  from  colics,  and  pains 
so  acute  as  to  oblige  them  to  abandon  it.  Another  means  of  obtaining  the 
same  result  has  sometimes  been  employed  at  the  Hotel  Dieu.  It  is  a  kind 
of  crescent  of  ebony  or  ivory  from  six  to  eight  lines  long,  with  a  handle  from 
five  to  six  inches  in  length,  and  furnished  with  a  sponge  or  compress.  Carried 
to  the  bottom  of  the  accidental  anus,  it  embraces  in  its  concavity  the  intestinal 
promi-ience,  which  is  pushed  back  by  pressing  upon  the  handle  wrapped  with 
linen,  and  which  it  is  easy  to  fix  by  means  of  a  truss  or  other  appropriate 
bandage. 

C.  Enierotomy  or  M,  Dupuytren^s  method, — Notwithstanding  compression, 
the  most  methodical  and  best  applied,  the  preternatural  anus  sometimes  resists 
the  eftbrts  of  the  surgeon,  and  continues  to  the  despair  of  the  patient.    The 


OPERATIVE    SURGEBY.  599 

eflferts  of  Scarpa,  in  throwing  light  upon  the  mechanism  of  this  affection,  have 
shown  that  what  this  author  calls  the  promontory,  results  from  the  conjunction 
of  the  two  ends  of  the  intestine  which  present  behind  the  ring,  in  tlie  manner 
of  a  double  barreled  gun.  This  being  the  case,  it  was  natural  to  endeavor 
not  only  to  push  back  this  projection  but  even  to  destroy  it.  Schraakhalden 
seems  to  have  had  the  first  notion  of  this,  and  published  it  in  1798,  in  his 
inaugural  dissertation.  He  directs  a  curved  needle  to  be  passed  through  the 
base  of  this  prominence,  and  a  strong  ligature  to  be  introduced  in  order  to  cut 
by  degrees  in  the  direction  of  its  length  upon  tightening  the  thread,  or  acting 
as  in  fistula  ad  amim  by  apolinosis.  According  to  J.  S.  Dorsey,  his  father  in 
law.  Dr.  Physick,  tried  a  similar  operation  in  January  1809,  and  completely 
succeeded. 

The  proposition  of  the  Grerman  surgeon  had  made  no  impression  in  his 
country,  and  that  of  the  American  author  would  probably  have  passed  un- 
noticed, if  about  the  same  time,  in  1813,  M.  Dupuytren  had  not  undertaken 
on  his  part  to  introduce  it  in  France,  and  especially  if  he  had  not  arrived  at  a 
method  much  more  certain  and  more  efficacious.  Like  Dr.  Physick,  the  sur- 
geon of  the  Hotel  Dieu  confined  himself  in  his  first  operations  to  the  carrying 
of  a  thread  through  the  projection,  so  well  described  by  Scarpa,  in  order  to 
cut  it  from  behind  forwards.  The  adhesions  contracted  by  the  peritoneal 
Surfaces  around  the  union  were  sufficient  to  prevent  all  effusion  into  the 
abdomen.  The  matters  being  no  longer  gathered  about  the  ring,  and  finding  a 
passage  through  the  inferior  portion,  necessarily  took  the  course  towards  the 
rettum.  Although  several  attempts  confirmed  these  anticipations,  M.  Dupuy- 
tren soon  discovered  that  the  needle  might  be  carried  beyond  the  protecting 
adhesions,  and  perforate  a  point  of  the  alimentary  tube  which  communicated 
with  the  cavity  of  the  peritoneum.  Alarmed  at  this  danger  he  thought  of 
enterotomy,  and  for  fifteen  years  followed  it  with  almost  constant  success. 
His  pinciers,  the  internal  face  of  the  beak  of  which  is  undulated  so  as  to  em- 
brace the  parts  more  exactly  and  prevent  their  sliding  upon  each  other,  is 
jointed  like  a  forceps,  and  closed  by  a  screw  througli  their  handles.  One  of 
the  branches  of  this  instrument  is  to  be  carried  into  each  portion  of  intestine, 
so  as  deeply  to  embrace  the  projection  for  the  extent  of  an  inch  or  an  inch 
and  a  half.  Pressure  must  then  be  sufficient  to  determine  mortification  of 
the  parts  and  so  stop  the  circulation  immediately.  The  mechanism  of  this 
process  is  easily  conceived.  The  peritoneum  is  necessarily  brought  in  con- 
tact with  itself  on  the  circumference  of  the  enterotome.  Eliminatory  inflam- 
rnation  is  gradually  developed  and  transmitted  to  some  lines  beyond.  Solid 
adhesions  are  the  inevitable  result,  and  no  perforation  on  the  side  of  the  peri- 
toneum is  then  to  be  dreaded.  In  proportion  as  the  eschar  is  detached  the 
instrument  becomes  more  and  more  movable,  and  comes  away  when  it  is 
entirely  insulated.  If  the  compression  was  not  sufficiently  powerful  at  first, 
the  blood  might  still  be  introduced  between  tJie  blades  of  the  forceps,  in 
■which  case  gangrene  would  not  take  place.  The  external  peritoneum  might 
hot  have  inflamed  to  the  point  necessary  to  produce  proper  adhesions.  A 
perforation  towards  the  cavity  of  the  abdomen  would  be  to  be  apprehended, 
and  the  detachment  of  the  morbid  septum  not  effected.  The  pain  besides 
"would  be  morQ  violent,  and  the  cure  slower  even  if  it  ever  took  place.  This 
method,  employed   more  tlian  twenty    times  by  M.  Dupuytren,  since  by 


600  NEW   ELEMENTS   OF 

M.  Hej  of  BonneTal,  Lallemand,  Delpech,  and  other  practitionei's,  has 
not  as  jet  occasioned  any  serious  symptoms  except  on  4;hree  or  four  patients. 
When  the  perforation  has  been  eftected  the  matters  are  drawn  to  the  inferior 
intestine,  and  the  stools  become  regular.  Every  day  less  is  passed  by  the 
wound,  which  rapidly  contracts  and  is  soon  reduced  to  a  simple  fistula,  if  not 
wholly  cicatrized.  Fever  rarely  supervenes;  colics  or  symptoms  of  slight 
inflammation  of  the  intestine  or  peritoneum  are  the  only  unpleasant  symptoms 
that  have  been  observed,  and  most  frequently  the  patient  scarcely  suflTers 
from  the  operation. 

*  Some  persons  have  nevertheless  attempted  further  improvement  by  modi- 
fying the  enterotome  forceps.  Thus  M.  Liotard  in  his  thesis  proposed  an 
instrument,  a  kind  of  punch -plyers,  which  is  to  cut  out  a  circular  portion  of 
the  morbid  septum,  without  touching  its  free  edge,  and  so  that  there  will 
result  an  opening  in  some  measure  similar  to  that  of  a  natural  intestine.  This 
process^  which  is  unapplied  as  yet,  would  have  the  disadvant^e  of  not  suiting 
every  case,  of  exposing  to  be  cut  some  sound  portions  of  a  free  loop  of  intes- 
tine, whicn  may  have  placed  itself  behind  or  between  the  two  branches  of  that 
of  which  the  septum  is  to  be  perforated,  and  finally  of  beinjj;  too  difficult  of 
execution,  for  the.plates  of  M.  Scolard  are  too  large  to  be  easily  introduced 
through  a  preternatural  anus,  and  through  the  ends  of  intestine  themselves, 
which  in  this  case  are  usually  very  much  contracted.  M.  Delpech  has  made 
use  of  an  instrument  which  acts  pretty  nearly  by  the  same  mechanism  as  that 
of  M.  Liotard.  It  is  a  long  forceps  terminating  in  two  knobs,  a  little  elon- 
gated, similar  to  the  shells  of  a  walnut,  the  circumference  slightly  concave  in 
the  direction  of  their  length.  These  are  separately  introduced.  As  they  at 
first  compress  only  at  their  beak,  they  divide  the  septum  but  by  degrees  and 
from  behind  forwards,  while  with  the  enterotome  of  M.  Dupuytren,  com- 
pression being  generally  stronger  the  nearer  the  heel  of  the  instrument,  it  is 
from  before  backwards  that  gangrene  is  produced.  M.  Delpech  has  well  per- 
ceived that  his  forceps,  useful  perhaps  in  particular  cases,  is  incapable  of  gen- 
erally supplying  the  place  of  that  of  M.  Dupuytren.  It  may  offer  some 
advantages  I  suppose  when  the  partition  is  extremely  long  and  deeply  seated, 
or  when  to  reach  it  we  are  obliged  to  pass  through  an  irregular  passage 
more  or  less  sinuous ;  but  these  are  circumstances  which  always  escape  from 
tile  rules  of  a  general  description,  and  must  be  left  to  the  skill  of  those  who 
meet  with  them. 

In  this  method,  as  in  every  other,  two  things  are  to  be  separately  considereid, 
the  end  and  the  means.  It  appears  to  me  that  there  can  be  no  variety  of 
sentiment  at  present  except  upon  the  last,  and  there  is  no  reason  why  attempts 
should  not  be  made  to  modify  them  further.  »Since,  by  depressing  the  pro- 
jection in  the  preternatural  anus  a  passage  is  opened,  why  not  make  this 
depression  by  a  canula,  which  will  at  the  same  time  allow  of  cicatrization  of 
the  exterior  division?  This  advice  was  given  by  M.  Colombe  in  1827; 
and  M.  Forget  informs  me  that  since  1824  he  has  advanced  a  similar  sugges- 
tion. M.  Colombe  directs  a  large  canula  of  gumelastic  two  or  three  inches 
long  to  be  placed  in  the  two  ends  of  tKe  intestine,  a  canula  slightly  curved 
which  will  rest  by  its  concavity  on  the  free  edge  of  the  septum,  and  will  carry 
on  the  middle  of  its  convex  side  a  thread  intended  to  hold  it  until  the  wound 
b  almost  entirely  closed,  or  the  course  of  matters  so  completely  re-established 
as  to  leave  no  longer  any  fear  of  their  escape  externally. 


OPERATIVE    SURGERY.  6©1 

At  tjie  first  glance,  this  method  appears  to  deserve  consideration,  and  seems 
specially  suitable  for  cases  in  which  the  re-entering  angle  formed  by  the  me- 
senteric wall  of  the  intestinal  loop  is  very  open,  or  the  projection  is  not  very 
great,  particularly  for  those  in  which  the  intestine  has  not  been  destroyed  in 
the  whole  of  its  circumference ;  but  it  is  to  be  feared  that  in  others  it  will  be 
insufficient,  and  must  be  counted  inferior  at  least  to  that  oi  M.  Dupuytren.  I 
will  add,  that  to  have  great  chance  of  success  it  is  necessary  to  use  a  very  large 
canula,  the  introduction  of  which  will  at  first  be  attended  with  considerable 
-  difficulty.  I  practised  it  in  August  1831,  at  La  Pitie,  and  the  patient  died 
three  days  after  of  intense  peritonitis.  The  intestine  was  perforated  behind 
and  the  canula  engaged  in  the  orifice.  Whether  this  be  referred  to  cause  and 
eft'ect  or  to  simple  coincidence,  such  a  result  does  not  argue  much  in  favor  of 
the  method. 

Operative  Process. — When  the  surgeon  has  decided  upon  attempting  the 
cure  of  artificial  anus,  he  must  first  think  of  surmounting  the  obstacles  which 
in  some  cases  oppose  the  introduction  of  tlie  enterotome.     If  the  integuments 
have  not  been  widely  opened,  or  if  from  any  cause  sinuous  passages,  or  ster- 
coral fistulas  are  observed  in  its  vicinity ;  if  a  tumor,  sinuses,  or  erysipelatous 
inflammation  exist  in  front  of  the  canal  which  it  is  proposed  to  pass  through, 
doubtless  the  first  step  should  be  to  remove  these  various  obstacles,  either  by 
incisions  and  even  proper  excisions,  or  by  general  or  local  bleedings,  emollient 
Or  laxative  topical  applications,  baths,  lotions,  &c.     In  a  patient,  in  whom  the 
strangulated  hernia  had  never  been  operated  upon,  I  saw  five  or  six  openings 
and  a  tumor  as  large  as  the  fist  form  in  front  of  the  ring,  caused  by  thickening 
and  chronic  phlegmasia  of  the  skin,  the  cellular  or  adipose  tissue,  and  the 
different  lamellse  contained  in  the  inguinal  canal.     I  was  therefore  obliged  to 
circumscribe  this  mass  by  two  crescentic  incisions,  and  in  removing  it,  to 
penetrate  as  far  as  the  root  of  the  spermatic  cord  in  order  to  display  the  intes- 
tinal orifice.     In  such  a  case,  it  should  be  recollected  that  the  operation  ought 
to  be  performed  at  two  difi*erent  periods;  that  is,  before  proceeding  to  use  the 
enterotome  we  should  wait  till  the  preparatory  wound  has  healed.     At  other 
times  we  are  obliged  to  dilate  for  a  week  or  two  the  preternatural  anus  itself. 
In  some  cases  the  cutaneous  orifice  is  so  far  from  the  intestine  that  there  is 
great  difficulty  in  penetrating  the  latter.     The  perforated  portion  may  besides 
have  remained  crooked,  and  be  bent  either  in  the  interior  of  the  canal  itself  or 
behind  the  ring,  forming  folds  which  may  have  contracted  adhesions  among 
themselves,  and  may  thus  give  rise  to  difficulties  which  it  is  necessary  to  over- 
come before  proceeding  further.     The  inferior  end,  which  is  always  strongly 
contracted,  may  again  be  placed  above  the  upper,  around  which  it  may  be 
twined,  of  which  an  interesting  case  may  be  seen  in  the  memoir  of  Mr.  Del- 
pech.     Although  very  rare,  the  obliteration  of  this  part  of  the  alimentary  tube, 
however  old  the  disease  may  be,  is  yet  possible;  a  fact  observed  at  the  Val- 
de-Grace,  on  an  old  man,  aftected  for  forty  years  with  accidental  inguinal  anus, 
demonstrates  it  beyond  dispute  ;  so  that  it  is  well  to  remember  it  before  car- 
rying the  forceps  upon  the  wall  of  partition  which  it  is  intended  to  destroy. 
If  then  the  wound  is  situated  at  any  considerable  depth,  and  there  is  any  doubt 
-of  the  nature  of  the  relations  existing  between  orifices  of  the  abnormal  anus, 
we  should  endeavor  gradually  to  dilate  the  passage  which  leads  into  the  su- 
perior intestine,  and  do  the  same  with  the  inferior  by  the  introduction  of  long 
76 


602  NEW    ELEMENTS   OF 

tents,  bougies,  sounds,  gumelastic  canulas  or  pieces  of  prepared  sponge,  and 
never  have  recourse  to  tlie  enterotome,  before  being  able  with  the  finger  to 
ascertain  the  position  of  the  parts  and  the  relation  of  the  septum  with  each  end 
of  the  intestinal  tube. 

When  we  have  arrived  at  this  point  the  operation  itself  may  be  performed. 
The  patient  is  placed  as  for  celotomy.  The  fore  finger  of  the  left  hand  serves 
as  a  guide  to  one  of  the  branches  of  the  forceps,  which  it  conducts  under  the 
inferior  face  of  the  projection  which  is  to  be  destroyed.  An  assistant  is  to 
keep  this  in  place  while  the  operator  in  the  same  manner  introduces  the  other 
into  the  upper  end  of  the  affected  tube.  He  then  takes  hold  of  both,  turns 
them  on  their  axis  so  as  to  be  able  to  close  them,  carries  his  finger  again  nearly 
to  their  extremity  to  ascertain  how  far  they  embrace  the  promontory,  and  to 
push  them  without  fear  as  far  as  he  wishes  the  consequent  mortification  to  ex- 
tend. The  screw,  or  any  other  means  intended  to  bring  them  together,  is  then 
applied  upon  the  extremity  of  their  handle,  and  compression  cairied  to  a 
degree,  as  has  been  already  said,  proper  to  suspend  circulation  and  vitality  in 
the  septum  which  they  grasp.  It  only  remains  to  surround  them  with  charpie 
and  compresses  and  fix  the  whole  with  a  bandage,  and  the  operation  is  finished. 
The  charpie  and  other  dressings  are  to  be  renewed  as  often  as  the  flow  of  mat- 
ters is  necessary,  taking  every  precaution  however  not  to  derange  the  position 
of  the  forceps.  Any  symptoms  that  may  be  developed  are  to  be  met  by  the 
requisite  treatment.  As  soon  as  any  gurgling  is  heard,  and  tlie  least  tenesmus 
manifested,  injections  more  or  less  stimulating  are  positively  indicated, 
especially  when  the  instrument  begins  to  get  loose,  and  if  the  separation  of  the 
eschar  seems  already  to  have  taken  place.  The  remaining  treatment  has  nothing 
peculiar.  The  patient  should  preserve  the  horizontal  position,  from  time  to 
time  take  a  laxative,  have  frequent  recourse  to  clysters,  and  take  all  kinds  of 
nourishment.  By  this  means  the  external  wound  is  often  entirely  closed, 
although  in  general  some  weeks,  and  even  in  some  cases  it  appears  months  are 
necessary  to  accomplish  it.  There  are  persons  also  in  whom  this  opening 
reduced  to  a  simple  fistula  resists  every  treatment,  and  obliges  the  surgeon  to 
employ  only  palliatives.  To  this  obstinate  continuance,  which  there,  is  nothing 
apparently  to  keep  up,  we  have  opposed,  says  M.  Dupuytren,  without  any 
great  result,  powdered  colophony  introduced  into  the  fistula,  cauterization  of 
iti-edges  with  nitrate  of  silver,  their  approximation  by  adhesive  strips,  excision 
of  their  edges  formed  of  the  skin  and  mucous  membrane,  in  fine  their  union 
by  the  twisted  suture  ;  we  have  even  conceived  the  idea,  in  order  to  keep  them 
in  contact,  of  approximating  them  by  means  of  two  oblong  pads  fixed  to  a 
girdle,  and  connected  together  by  two  screws.  This  apparatus  had  no  better 
success  than  the  others.  It  is  therefore,  an  infirmity  which  requires  new- 
researches,  new  modes  of  treatment,  and  against  which  we  are  obliged  to  con- 
fine ourselves  to  the  use  of  means  to  preserve  cleanliness.  As  it  only  occasions 
a  slight  oozing,  it  is  enough  to  keep  a  little  soft  charpie  upon  the  sore,  and  to 
renew  it  several  times  a  day,  in  order  that  the  mucosites  and  other  intestinal 
fluids  which  it  imbibes,  may  not  have  time  to  become  decomposed  or  fetid  by 
their  accumulation.  In  this  case  it  is  proper  in  my  opinion  to  try  tlie  pro- 
cesses borrowed  from  rhinoplasmus,  after  the  manner  of  Dr.  Jameson  or  M. 
Collier,  unless  we  choose  first  to  make  trial  of  dissection  and  elongation  of; 
the  edges-of  the  abnormal  anus.     Tn  case  of  a  preternatural  anue,  the  cure  of  ! 


/  OPERATIVE    SURGERY.  603 

which  cannot  or  should  not  be  attempted,  the  best  means  to  be  employed  is 
the  box  invented  by  Juville.  Any  other  vessel  constructed  on  the  same  prin- 
ciples will  serve  the  same  turn ;  and  may  be  found  in  plenty  with  truss-makers 
or  manufacturers  of  gumelastic  surgical  instruments. 

B.       PARTICULAR  HERNIAS. 
ARTICLE    I. 

Inguinal  Hernia. 

§  1.  Anatomical  remarks. 

The  points  of  the  abdominal  wall  that  give  passage  to  the  viscera  in  cases 
of  inguinal  hernia,  are  bounded  below  by  the  ligament  of  Fallopius  and  the 
OS  pubis,  above  by  the  inferior  edge  of  the  transverse  muscle,  and  internally 
by  the  tendon  of  the  rectus.  Poupart's  ligament  extending  from  the  anterior 
superior  spine  of  the  ileum  to  the  spine  of  the  pubis,  represents  a  cord  to 
which  we  may  give  three  edges ;  first,  inferior,  which  is  continuous  with  the 
aponeurosis  of  the  thigh,  and  which  we  shall  have  occasion  to  study  hereafter ; 
the  second,  superior  and  subtegumentary,  which  receives  the  aponeurotic 
fibres  of  the  external  oblique  muscle ;  the  third,  posterior  or  peritoneal,  from 
which  arises  the  fascia  trayisversalis.  The  cutaneous  margin,  which  is  so 
completely  continuous  with  the  external  aponeurosis  of  the  abdomen  that 
many  authors  have  regarded  it  as  its  termination,  requires  to  be  distinguished 
from  it.  This  aponeurosis,  in  fact,  is  constituted  of  solid  fibres  united  in  lit- 
tle bands,  which  sticking  upon  Poupart's  ligament  form  with  it  an  angle  the 
more  acute  the  nearer  they  approach  the  symphisis.  The  separation  of  its 
fibres  into  two  divisions  in  arriving  at  the  body  of  the  pubis,  forms  the  exter- 
nal opening  of  the  passage  througli  which  the  spermatic  cord  passes,  and 
this  opening  is  not  owing  to  the  division  of  the  internal  extremity  of  the  liga- 
ment of  Fallopius.  These  fibres  are  besides  supported  by  a  kind  of  web  of 
condensed  cellular  tissue  which  is  found  in  the  composition  of  all  aponeurosis, 
and  crossed  at  right  angles  by  other  fibres  much  more  sparse  (and  sometimes 
even  entirely  wanting,  especially  in  early  life) ;  which  when  quite  numerous 
give  it  the  appearance  of  a  distinct  tissue.  The  posterior  edge  of  the  liga- 
ment of  Fallopius  is  continuous  with  a  lamina  upon  which  there  has  been 
much  discussion  of  late  years,  and  which  received  only  cursory  notice  until 
it  was  described  by  Sir  A.  Cooper.  From  it  the  fascia  transversalis,  ascen- 
dens,  reflexa,  &c.,  ascend  behind  the  posterior  face  of  the  internal  oblique 
muscle,  arrive  on  the  corresponding  face  of  the  transversalis,  and  extend 
transversely  from  the  spine  of  the  ileum  to  the  rectus  abdominis.  Its  fibres 
are  parallel  to  each  other,  and  are  directed  a  little  towards  the  median  line  in 
its  external  half.  It  is  very  thin,  and  most  frequently  reduced  to  the  form  of 
a  cellular  lamella  in  the  latter  direction,  but  is  more  solid  and  incontestibly 
fibrous  in  its  internal  moiety.  Its  aspect  varies  singularly  according  to  the 
subject,  age,  and  sex.  In  infancy  and  in  the  female  it  can  scarcely  be  distin- 
guished from  the  cellular  tissue  which  usually  covers  its  two  faces,  while  in 
the  adult  man,  and  especially  in  a  lean  subject,  it  forms  an  aponeurosis,  the 
existence  of  which  cannot  possibly  be  called  in  question.    Its  presence  in 


604  NEW   ELEMENTS    OF 

this  place  is  but  the  repetition  of  the  aponeurosis  of  the  external  oblique  mus- 
cle reduced  to  its  elementary  condition.  Holding  in  some  sort  a  middle 
place  between  the  cellular  tissue  and  fibrous  layers  proper,  the  descriptive 
details  of  it  which  have  been  given  are  the  less  justified,  as  every  large  mus- 
cle is  covered  with  a  lamella  nearly  similar,  either  externally  or  internally, 
when  they  have  not  a  true  albugineous  covering.  It  is  further  necessary  not 
to  confound  it  with  the  peritoneal  cellular  tissue,  from  which  it  is  as  distinct 
as  the  aponeurosis  of  the  external  oblique  is  from  the  fascia  superjicialis,  with 
which  the  fascia  transversalis  has  been  incorrectly  compared.  The  opening 
which  it  presents  a  little  without  the  middle  of  its  width,  gives  passage  to  the 
spermatic  cord,  rests  on  Poupart's  ligament,  and  sometimes  extends  so  high 
up  as  to  form  an  actual  division  between  its  two  halves.  In  some  subjects 
the  internal  moiety  of  this  fascia  is  really  all  that  can  keep  the  name  of  apo- 
neurosis, the  other  portion  is  so  thin  and  analogous  to  cellular  tissue. 

Between  these  two  fibrous  layers  are  found  the  inferior  fibres  of  the  trans- 
versalis muscle,  and  particularly  those  of  the  internal  oblique,  some  bundles 
of  which  arise  from  the  gutter  between  the  two  edges  of  the  ligament  of 
Fallopius  and  form  the  creraaster  muscle.  Of  late  years  surgeons  have 
agreed  that  the  opening  which  gives  passage  to  a  bubonocele  is  not  a  simple 
ring  as  formerly  described,  but  an  actual  canal,  having  an  anterior  and  a  pos- 
terior orifice  and  an  intermediary  space.  This  disposition,  of  which  Riolan 
the  younger  had  an  imperfect  ideay.ashad  also  Gimbernat,  who  pointed  it  out 
positively  in  1787,  and  afterwards  in  1793,  seems  nevertheless  not  to  have 
been  known  toRichter,  nor  the  surgeons  who  wrote  before  Scarpa,  A.  Cooper, 
Hesselbach,  &c.  At  present,  as  the  fact  may  be  confirmed  by  every  one  on 
the  dead  subject,  its  existence  is  not  thought  of  being  called  in  question, 
though  there  are  some  practitioners  who  are  not  willing  to  give  it  the  name  of 
canal. 

Supposing  the  spermatic  cord  removed,  we  may  accord  to  the  inguinal 
canal,  first,  an  anterior  or  external  wall  formed  by  tlie  aponeurosis  of  the 
external  oblique,  some  fibres  of  the  internal  oblique  and  loose  lamella  of  cel- 
lular tissue;  secondly,  a  posterior  wall  formed  by  the  internal  portion  of  the 
fascia  transversalis,  thirdly,  a  superior  side  belonging  to  the  edge  of  the 
transversalis  muscle  or  to  the  union  of  the  two  aponeurosis  just  mentioned ; 
fourthly,  an  inferior  wall,  which  is  only  the  internal  third  of  the  groove  formed 
by  the  separation  of  the  external  aponeurosis  and  the  fascia  transversalis. 
Its  direction  is  oblique  from  behind  forwards,  from  without  inwards,  and  a 
little  from  above  downwards.  One  of  its  two  openings  corresponds  to  the 
cavity  of  the  abdomen,  the  other  to  the  integuments.  The  first  ordinarily 
presents  the  form  of  an  ovel,  its  base  resting  upon  the  ligament  of  Fallopius, 
while  its  apex  is  prolonged  towards  the  transversalis  muscle;  its  internal 
margin,  the  firmest  and  most  prominent,  has  received  from  some  authors  the 
name  of  falciform  edge ;  the  external,  a  little  more  depressed  and  less  appar- 
ent, seems  in  the  greater  number  of  cases  to  be  blended  with  the  correspond- 
ing wall  of  the  canal,  in  which  it  is  insensibly  lost.  The  second,  or  the  ring 
of  the  external  oblique,  is  triangular  and  formed  below  by  the  edge  of  the 
pubis,  within  and  above  by  one  of  the  strips  of  abdominal  aponeurosis,  and 
without  by  the  termination  of  Poupart's  ligament  as  well  as  another  bundle 
of  the  aponeurosis  of  the  external  oblique.     Surgeons  usually  give  the  name 


OPERATIVE  SURGERY.  605r 

of  pillars  to  its  two  principal  edges,  and  make  them  rise  from  the  bifurcation 
of  Poupart's  ligament,  which  as  we  have  seen  is  a  material  error.  The 
internal  pillar  goes  to  be  blended  or  crossed  with  its  fellow  before  the  sym- 
phisis, and  belongs  entirely  to  the  aponeurosis,  while  the  external  is  alone 
formed  by  tlie  ilio-pubic  ligament;  besides  it  is  completed  superiorly  by  the 
termination  of  another  band  of  the  external  fascia.  The  superior  angle  of 
the  ring  extends  sometimes  very  high  and  very  far  outwards,  while  on  other 
cases  it  is  much  depressed  and  as  it  were  destroyed  by  the  transverse  fibres, 
which  convert  into  a  distinct  tissue  the  external  fibrous  layer  of  the  abdomen. 
Hence  a  great  variety  in  its  dime'nsions,  and  a  greater  or  less  disposition  to 
strangulation  in  hernias  formed  by  this  passage. 

In  a  well  formed  adult,  the  passage  of  the  spermatic  cord  is  an  inch  and 
a  half  to  two  inches  in  length,  measured  from  one  of  its  openings  to  the  other, 
and  three  inches  including  the  openings  themselves.  In  some  subjects  I  have 
found  it  half  an  inch  to  an  inch  longer,  while  in  others  it  has  been  so  short 
that  the  external  border  of  its  scrotal  orifice  was  placed,  as  it  were,  opposite 
the  internal  border  of  its  abdominal  orifice.  In  childhood  it  scarcely  exists, 
so  that  to  escape  without,  the  organs  have  only  a  ring  to  pass  through  instead 
of  a  canal,  as  its  two  openings  correspond  and  no  distinct  wall  can  be  recog- 
nized in  it.  This  disposition  is  very  easy  to  be  conceived.  While  the  angle 
formed  by  the  edge  of  the  coxal  bones  is  widening  and  enlarging,  the  spine  of 
tlie  ileum  is  necessarily  being  removed  from  the  pubis.  'The  organs  contained 
in  the  cavity  of  the  greater  pelvis  are  drawn  outwards  to  a  distance  greater 
as  the  pelvis  becomes  larger ;  whence  it  results  that  the  opening  in  the  fascia 
iransversalis,  which  must  follow  this  eccentric  movement,  leaves  by  degrees 
the  level  of  the  ring  in  the  external  oblique  which  remains  fixed  on  the  pubis, 
and  these  two  orifices  separate  from  eacli  other,  as  two  plates  which  are  made 
to  slide  over  each  other  in  opposite  directions.  This  kind  of  movement,  this 
crossing  of  the  two  principal  openings  of  the  inguinal  canal  must  be  there- 
fore much  more  marked  in  the  female  in  whom  t!ie  cristse  of  the  ilia  are 
usually  very  far  apart,  than  in  the  male  in  whom  the  fibres  retains  through  life 
some  of  the  characters  which  it  possessed  in  infancy.  It  is  easy  to  see  there- 
fore how  the  organs  have  at  their  first  deviation  more  difficulty  in  traversing 
the  inguinal  tract,  after  it  acquires  the  form  of  a  canal  than  while  it  remained 
in  the  state  of  a  simple  ring,  and  that  this  difficulty  is  greater  as  these  openings 
become  more  distant  from  each  other.  One  consequence  to  be  drawn  from 
this  fact  is,  that  bubonocele  should  be  more  common  in  children  than  in 
adults,  in  man  than  in  women,  and  that  every  inguinal  hernia  developed  in 
youtli,  which  is  kept  reduced  for  some  years,  finding  a  canal  or  two  walls 
kept  in  contact  by  pressure,  substituted  for  an  annular  opening,  may  be  thus 
radically  cured  ;  while  after  the  growth  of  the  subject  the  reduction  of  the 
hernia  would  not  give  the  same  chance  of  success.  When  it  exists  for  a  long 
time,  the  presence  of  the  viscera  in  tlie  groin  frequently  brings  back  this  track 
to  its  primitive  form,  by  enlarging  the  ring  in  the  external  oblique  at  the 
expense  of  its  external  semi-circumference,  while  on  the  other  hand  it  dilates 
the  orifice  in  the  fascia  trcmsversalis  by  pressing  back  its  internal  edge.  It  is 
a  kind  of  Z,  which  is  to  be  made  straight  by  drawing  upon  its  two  extremities, 
so  that  tlie  canal  disappears  in  agreat  measure,  and  often  becomes  a  real  circle 
again»  as  in  tire  child.    The  inguinal  tract  and  its  pubic  opening  are  cover- 


606  NEW  ELEMENTS  OF 

ed  in  front  by  cellular  tissue  and  the  skin.  In  the  first,  run  some  branches  of 
the  cutaneous  and  of  the  superior  external  pudic  arteries.  Behind,  it  is  also 
covered  with  two  layers ;  the  cellular  tissue  and  the  peritoneum  are  intro- 
duced with  the  cord  through  the  opening  of  the  transverse  fascia  into  the  ingui- 
nal canal  and  thus  arrive  in  the  scrotum,  so  that  even  without  hernia  there 
is  found  in  it,  first,  a  prolongation  of  peritoneum  lined  externally  Avith  its 
fascia  propria;  secondly,  the  vas  deferens,  the  spermatic  vessels,  and  what 
is  called  the  sheath  of  the  cord  ;  thirdly,  the  tunnel -formed  prolongation  of 
the  fascia  transversalis,  which  their  parts  bring  with  them  supposing  that  any 
power  whatever  has  drawn  them  out  from  the  interior  of  the  abdomen. 

Between  the  peritoneum  and  the  posterior  face  of  the  canal,  or  in  the 
substance  of  the  fascia  propria,  there  are  organs  which  itis  important  to  notice; 
the  epigastric  artery  for  example,  which  after  rising  from  the  external  iliac  at 
the  point  where  this  vessel  enters  the  crural  canal,  is  directed  inwards  and 
downwards,  then  upwards  around  the  inferior  and  internal  part  of  the  cord, 
or  the  inferior  and  internal  semi -circumference  of  the  abdominal  orifice  of  the 
canal,  in  order  to  reach  the  posterior  face  of  the  transversalis  muscle,  and 
gain  the  external  edge  of  the  rectus,  penetrating  the  fibres  and  terminating 
above  the  umbilicus  by  anastomosis  with  the  internal  mammary  and  the 
inferior  intercostals.  This  artery,  the  volume  of  which  is  about  that  of  a 
small  quill  before  reaching  the  abdominal  muscles,  gives  off  some  branches 
worthy  of  notice,  although  generally  very  small.  It  detaches  one  near  its 
origin  which  is  soon  divided  into  two  branches,  one  of  which  engages  in  the 
crural  canal  while  the  other  runs  towards  the  obturator  foramen.  A  little  further 
off  another  is  given  off,  which  almost  immediately  enters  the  inguinal  canal, 
follows  its  internal  wall,  and  is  found  in  the  scrotum  in  the  substance  of  the 
cremaster  muscle ;  this  last  branch  ordinarily  furnishes  another,  which  runs 
transversely  behind  the  body  of  the  pubis,  and  anastomoses  with  its  fellow  of  the 
opposite  side.  Lastly,  a  third  arises  a  little  higher  up,  is  also  directed  trans- 
versely inwards,  and  is  of  no  consequence  in  surgery  unless  it  attain  a  large 
size  and  the  hernia  is  formed  inside  of  the  epigastric.  With  respect  to 
inguinal  hernia,  the  sub-pubic  artery  presents  varieties  of  which  the  surgeon 
should  be  aware.  I  do  not  refer  to  its  arising  from  the  iliac  a  little  higher  or 
a  little  lower;  this  will  be  noticed  hereafter ;  but  I  cannot  pass  by  in  silence 
two  or  three  anomalies  recently  observed.  In  one  v/hich  has  been  drawn  by 
M.Hesselbach,  this  artery  comes  from  the  hypogastric,  and  instead  of  running 
obliquely  inwards  rather  tends  to  incline  slightly  outwards  after  going  beyond 
the  line  of  the  inguinal  canal.  In  a  subject  examined  by  M.  Michelet  at  the 
Cochin  hospital,  it  arose  in  the  thigh  from  the  internal  circumflex,  and  ascended 
to  take  its  usual  place  between  the  peritoneum  and  the  abdominal  muscles. 
Quite  recently  M.Lauth  wrote  to  me  that  he  had  found  two  on  the  same  side, 
one  coming  from  the  hypogastric,  the  other  from  the  external  iliac ;  one  without, 
the  other  within  the  line  of  the  spermatic  cord. 

As  it  forms  a  certain  prominence  behind  the  fascia  transversalis,  the  epi- 
gastric artery  gives  rise  at  this  point  to  a  fold  which  divides  the  posterior  wall 
of  the  inguinal  passage  into  two  very  distinct  excavations,  one  of  which  I 
propose  to  call  the  external  iyigidnal  fossetie,  ^nd  which  corresponds  to  the 
entrance  of  the  canal ;  the  other  which  it  is  necessary  to  call  the  middle  fossette 
or  depression,  which  is  traversed  by  the  organs  in  direct  inguinal  hernia,  and 


OPERATIVE   SURGERY.  607 

corresponds  to  the  external  part  of  the  ring  in  the  external  oblique.  Within 
this  excavation,  and  always  in  the  substance  of  the  fascia  propriUy  is  found 
another  prominence,  a  mere  vestige  of  the  umbilical  artery,  which  separates 
the  middle  fossette,  of  which  I  have  just  spoken,  from  a  tliird  depression, 
bounded  inwardly  by  the  fundus  of  the  bladder  or  the  external  edge  of  the 
rectus  muscle,  and  which  I  would  call  the  internal  inguinal  fossette  in  which 
the  viscera  have  also  been  seen  to  engage  and  form  hernia. 

The  concomitant  veins  of  the  umbilical  and   epigastric  arteries  are  in 
general  of  too  small  a  size  to  require  any  particular  notice.     However,  it  may 
happen  that  a  larger  branch  than  usual  may  arise  from  the  hypogastric  or  in- 
ternal iliac,   and  ascend  independant  of  the  epigastric  veins  behind  tlie 
muscles,  to  reach  the  neighborhood  of  the  umbilicus,  and  anastomose  witli  the 
umbilical  vein.    Three  anomalies  of  this  kind  have  been  published  laterally 
by  Manec,  Meniere,  and  Clement.     The  abdominal  serous  membrane  extends 
as  far  as  the  testicle,  under  the  name  of  the  tunica  vaginalis,  and  represents 
a  canal,  which  after  some  time  is  closed  and  transferred  into  an  impervious 
cord,  and  in  the  end  is  blended  with  the  surrounding  cellular  tissue,  and  converts 
the  tunica  vaginalis  into  a  sack  without  an  opening,  leaving  at  the  same  time 
a  tunnel -formed  depression  of  greater  or  less  depth  at  the  posterior  ring  of 
the  inguinal  passage.     However,  instead  of  being  thus  obliterated,  this  prolon- 
gation may  only  contract  and  remain  a  little  canal  more  or  less  dilatable  until 
adult  age.     As  the  spermatic  vessels  and  the  vas  deferens  are  placed  beneath 
the  peritoneum,  and  enter  the  inguinal  canal  supported  by  the  internal  and 
inferior  edge  of  its  abdominal  orifice,  the  prolongation  must  be   naturally 
situated  without  and  a  little  in  front  of  the  spermatic  cord,  so  tliat  the  vas 
deferens  is  found  within  and  behind.     The  spermatic  artery  is  a  little  outwards 
and  in  front.     The  two  corresponding  veins  are  seen  one  within,  the  other 
without  the  artery,  a  little  more  in  the  rear  and  on  the  same  plane  with  the 
vas  deferens.     The  filaments  of  the  trisplanchnic  nerve,  situated  a  little  more 
superficially,  are  united  with  these  several  objects  by  means  of  loose  lamellated 
cellular  tissue.     Still  further  outwards  is  the  peritoneal  prolongation,  then  the 
inguinal  branch  of  the  epigastric  artery  and  the  scrotal  branch  of  the  genito- 
crural  nerve.     Thus  around  the  cord,  taken  in  its  whole,  there  exist,  first,  a 
canaliculate  prolongation  of  the  fascia  transversalis,  enveloping  at  the  same 
time  a  similar  prolongation  of  ik^  fascia  propria,  the  peritoneal  filament  and 
the  various  constituent  parts  of  the  cord  itself;  secondly,  the  envelope  formed 
by  the  fibres  of  the  internal  oblique  or  the  cremaster  muscle ;  thirdly,  issuing 
from  the  canal  another  sheath  continuous  with  the  circumference  of  the  ring, 
and  which  is  but  a  prolongation  of  the  fundamental  cellulo-fibrous  tissue  of 
the  external  aponeurosis  of  the  abdomen ;  in  the  last  place  come  ih'&fasdd 
superficialis  and  the  integuments.     Let  us  remark,  moreover,  that  the  whole 
cord  twists  a  little  upon  itself  in  passing  through  the  inguinal  canal,  and  that 
the  parts  which  at  their  entrance  where  behind  and  within,  are  in  the  end 
found  in  front  and  sometimes  even  on  the  external  side. 

Surgical  Remarks, — The  external  inguinal  fossette  is  evidently  the  point 
which  offers  the  least  obstacle  to  the  viscera.  It  is  through  this  therefore  that 
hernias  pass  most  frequently  and  with  the  greatest  facility,  until  latterly 
these  were  the  only  hernias  which  occupied  the  attention  of  the  faculty,  and 
it  is  only  within  thirty  years  that  it  has  been  deemed  necessary  to  give  them 


608  NEW  ELEMENTS  OF 

a  particular  name  to  distinguish  them  from  those  that  follow  another  route. 
The  term  external  inguinal  hernia,  proposed  bj  Hesselbach,  although  gene- 
rally adopted  in  France,  is  nevertheless  not  without  its  inconvenience.  In 
fact,  hernias  may  be  developed  still  further  without,  and  it  is  well  known 
that  Heister  calls  crural  hernia,  external  inguinal  hernia.  After  passing  the 
posterior  opening  of  the  canal,  if  the  hernia  meets  too  great  a  resistance  at 
the  orifice  in  the  external  oblique,  it  may  be  kept  back,  and  thus  remain 
in  the  interior  of  the  passage.  Lecat  seems  to  have  had  an  idea  of  a  case  of 
this  kind,  and  Mr.  Lawrence  and  some  other  surgeons  have  positively 
observed  it  since.  It  is  this  that  M.  Boyer  names  intra-inguinal  hernia. 
Arrested  by  the  ring  in  the  external  oblique,  and  pushed  by  the  action  of  the 
muscles,  the  organs  may  double  themselves  outwards  or  upwards,  and  ascend 
some  distance  in  the  very  substance  of  the  parietes  of  the  abdomen,  as  Hes- 
selbach  seems  to  have  experienced.  Strangulation  then  will  occur  much 
more  readily,  for  the  angle  formed  by  the  change  of  direction  in  the  intestine 
is  of  itself  sufficient  to  produce  it.  It  is  only  in  cases  in  which  the  viscera 
have  cleared  the  cutaneous  orifice  of  the  canal,  that  hernia  is  really  complete; 
so  that  the  name  of  incomplete  inguinal  hernia  is  more  proper  for  it  than  intra- 
inguinal  hernia.  However,  a  case  reported  by  Mr.  Lawrence,  proves  that 
there  may  be  at  the  same  time  a  hernia  without,  and  a  hernia  within  the 
canal ;  or  rather  the  hernia  in  this  case  was  as  it  were  divided  into  two  parts 
by  the  ring  in  the  external  oblique.  Instead  of  penetrating  through  the 
opening  in  the  fascia  transversalis,  the  organs  have  been  seen  to  emerge 
without  this  orifice,  separating  the  fibres  of  the  external  portion  of  the 
fascia,  and  falling  afterwards  as  usual  into  the  scrotum.  M.  Blandin  asserts 
that  he  saw  an  example  of  it  on  the  examination  of  a  dead  body,  and  that 
in  the  subject  of  which  he  speaks  a  fibrous  band,  two  lines  wide,  separated 
the  neck  of  the  hernia  from  the  abdominal  orifice  of  the  inguinal  passage. 
In  such  a  case  the  viscera  would  no  longer  have  the/rtsa«  transversalis  for  an 
envelope  unless  they  had  carried  it  before  them  instead  of  separating  its 
fibres.  J.  L.  Petit  long  since  noticed  another  variety  of  inguinal  hernia. 
The  organs  escaped  through  a  frayed  portion  of  the  external  pillar  of  the 
ring.  Arnault  saw  the  same  thing  in  a  subject  in  whom  two  hernias  existed 
at  the  same  time,  the  one  crural,  the  other  a  little  more  elevated,  which 
were  only  separated  by  a  little  fibrous  band.  Many  practitioners  have 
disputed  the  existence  of  the  variety  mentioned  by  Petit,  although  Richter 
has  formally  announced  it  since ;  but  a  case  observed  latterly  by  M.  Roux 
at  la  Charite,  leaves  no  further  doubt  on  this  subject.  I  have  met  with  it 
myself  once  in  a  young  student  of  medicine.  This  young  man  had  several 
times  perceived  a  tumor  which  appeared  to  be  in  the  groin,  and  was  soon 
after  returned.  It  was  situated  six  lines  exterior  to  the  ring.  Besides,  when 
it  is  recollected  that  most  of  the  bands  of  the  aponeurosis  of  the  external 
oblique  leave  between  them  a  slight  interval  before  attaching  themselves  to 
the  crural  arch,  it  is  readily  understood  how  the  viscera,  if  arrested  within 
by  ajiy  obstacle,  may  succeed  in  forcing  one  of  these  interspaces,  and  in  some 
measure  create  a  new  abdominal  ring.  Laeunec  cites  a  much  more  remark- 
able arrangement.  He  had  to  dissect  the  body  of  an  individual  who  had  die^l 
of  the  consefjuences  of  a  strangulated  hernia.  The  organs  had  escaped  by 
the  natural  passage,  and  returned  into  the  abdomen  through  an  opening  with- 


OPERATIVE    SURGERY.  .    ,  609 

out  the  aponeurosis  of  the  external  oblique.  In  a  subcutaneous  abscess  Mr, 
CofFart  found  a  long  portion  of  epiploon  above  the  crista  of  the  ileum.  In 
fine,  J.  L.  Petit  says,  that  he  saw  an  inguinal  hernia  which  was  formed 
through  the  internal  pillar  of  the  ring,  leaving  the  ring  itself  entirely  free. 
The  work  of  Juville  on  bandages  contains  a  similar  observation.  However, 
this  may  be ;  and  in  all  these  varieties  the  epigastric  artery  remains  on  the 
internal  side  of  the  neck  of  tlie  hernia.  Contrary  cases  form  another  species, 
first  described  by  Camper  in  1759,  afterwards  by  Cline  in  1777,  by  Rouge- 
mont,  Chopart,  and  Desault,  but  the  characters  of  which  were  not  well 
understood  until  after  the  labors  of  Hesselbach,  A.  Cooper,  Scarpa,  Law- 
rence, and  J.  Cloquet.  Instead  of  following  the  inguinal  passage,  running 
obliquely  inwards,  as  in  external  hernia,  the  intestines  engage  in  the  middle 
fossette  between  the  epigasti'ic  and  umbilical  arteries,  depressing,  elongating, 
drawing,  or  perforating  the  internal  portion  of  the  fascia  transversalis,  that  is, 
the  posterior  wall  of  the  canal,  and  thus  arrive  directly  in  the  ring  in  the 
external  oblique,  and  fall  as  in  the  preceding  case  into  the  middle  of  the 
scrotum.  As  the  epigastric  artery  remains  externally,  Hesselbach  gave  the 
name  of  internal  inguinal  hernia  to  this  species  of  rupture,  which  has  latterly 
been  mentioned  by  several  authors.  Messrs.  Lawrence  and  Hassenden  have 
observed  it  quite  recently  in  a  patient  who  died  in  St.  Bartholomew's  hospital. 
Others  have  proposed  to  call  it  direct  inguinal,  in  contradistinction  to  tlie  pre- 
ceding which  they  designate  by  the  title  of  oblique.  Some  prefer  calling  it 
ventro -inguinal ;  but  as  all  these  denominations  are  more  or  less  faulty,  it  is 
probable  that  the  one  founded  on  the  relations  of  the  epigastric  artery  will 
alone  be  preserved.  It  will  also  be  seen  that  the  spermatic  cord  is  not  in 
the  same  relative  situation  in  the  one  of  these  cases  as  in  the  other ;  that  ex- 
ternal inguinal  hernia  must  push  it  inwards  and  backwards ;  on  the  contrary, 
that  internal  hernia  will  almost  of  necessity  tlirow  it  more  or  less  outwards. 
It  appears  from  an  observation  of  Wilmer  and  another  of  A.  Cooper,  that 
hernia  may  also  pass  out  by  the  internal  inguinal  fossette.  It  would  be  even 
curious  to  know  if  this  is  not  the  place  in  which  inguinal  hernias  of  the  blad- 
der and  uterus  sometimes  take  place  ?  The  fascia  transversalis  in  its  thickest 
portion  is  then  depressed  or  frayed  as  before.  To  clear  the  ring  the  organs 
must  follow  an  oblique  direction  from  within  outwards  and  from  above  down- 
wards.   I  do  not  know  what  name  it  would  be  proper  to  give  such  a  hernia. 

C.  Infantile  Hernia, 

In  the  adult  inguinal  hernia  almost  constantly  pushes  the  tunica  vaginalis 
inwards  and  backwards.  In  very  early  life  things  are  different,  it  is  in  front 
that  the  ser<fll*htunic  of  the  scrotum  is  situated.  Hey,  who  first  described  this 
species  of  hernia,  called  it  by  the  name  of  hernia  infantilis,  and  that  in  which 
the  tunica  vaginalis  remained  behind,  virilis.  He  met  with  it  in  several 
subjects,  particularly  in  a  child  sixteen  months  old.  It  was  strangulated  in  a 
child  twenty -nine  days  old,  whose  case  Mr.  Hunt  has  since  published,  and  in 
another  fourteen  months  old  successfully  operated  upon  by  Mr.  Lawrence. 

Hernia  of  the  vaginal  sac. — If  the  tunica  vaginalis  is  not  closed  above,  the 
organs  will  lodge  there  in  preference ;  and  the  hernia  which  in  this  case  is  in 
immediate  contac^t  with  the  genital  organs,  takes  the  name  of  congenital  her- 
77 


610  NEW    ELEMENTS   OF 

nia.  The  name  is  incorrect.  The  species  of  disease  it  designates  may  be 
manifested  many  years  after  birth.  Hey,  Dupuytren,  Lawrence,  and  Roux 
have  shown  tliat  the  testicle  long  retained  in  the  ring^  may  in  descending  at 
twelve,  fifteen,  twenty  or  twenty-five  years  of  age,  be  followed  by  a  hernia 
also  enveloped  by  the  tunica  vaginalis.  Moreover  the  viscera  may  descend  in 
this  tunic,  although  the  testicle  had  taken  its  place  in  the  scrotum  at  a  very 
remote  period.  Hence,  even  a  rupture ;  the  possibility  of  which  would  doubt- 
less hardly  be  admitted  by  many  surgeons,  but  of  which  I  have  observed  two 
cases  which  appeared  to  me  quite  conclusive.  M.  D.  student  of  medicine, 
twenty  years  old,  was  all  at  once  seized  with  violent  pains  in  the  groin  on 
returning  home  one  evening  from  walking  with  two  of  his  companions;  a 
strangulated  inguinal  hernia  became  manifest.  By  the  operation  which  took 
place  next  day  we  found  the  intestine  in  contact  with  the  testicle ;  the  stran- 
gulation was  produced  by  the  external  ring.  The  young  man  was  completely 
and  promptly  relieved.  No  previous  hernia  had  existed,  both  testicles  had 
long  been  in  their  natural  place.  The  tumor  arose  suddenly  and  immedi- 
ately, became  as  large  as  the  head  of  a  foetus,  and  yet  the  sac  was  formed  by 
the  tunica  vaginalis.  It  would  be  in  vain,  it  seems  to  me,  in  order  to  impair 
the  value  of  this  fact,  to  endeavor  to  maintain  that  a  portion  of  intestine 
might  be  in  the  inguinal  canal  unknown  to  the  patient,  or  that  he  was  deceived 
as  to  the  descent  of  the  corresponding  testicle.  M.  D.  had  rather  a  certain 
degree  of  leanness  than  embonpoint,  and  was  in  the  habit  of  giving  gi'eat  at- 
tention to  every  thing  that  concerned  his  health.  It  is  therefore  certain  that 
vaginal  hernia  may  occur  in  adult  man  long  after  the  descent  of  the  testicle. 
Besides,  here  is  another  case  verified  upon  the  opening  of  a  dead  body.  In 
1829  there  entered  my  ward  at  the  hospital  St.  Antoine  a  young  wine  mer- 
chant, strong  and  of  low  stature,  who  the  evening  before  had  made  a  violent 
effort  in  attempting  to  lift  a  cask.  Being  questioned  in  every  way  he  con- 
stantly answered  that  until  then  he  never  had  a  hernia.  That  for  which  he 
came  to  seek  assistance  was  of  the  size  of  two  fists,  completely  strangulated, 
and  in  the  end  required  an  operation.  The  intestine  was  contained  in  the 
tunica  vaginalis  and  in  contact  with  the  testicle.  The  '  debridement'  was  suc- 
cessively performed  upon  the  two  orifices  of  the  canal  and  the  neck  of  the  sac. 
An  intense  peritonitis  caused  death  on  the  third  day.  On  opening  the  body 
we  found  that  the  entrance  of  the  vaginal  membrane,  frayed  on  tliree  points 
of  its  internal  semi-circumference,  was  torn  behind  at  is  entrance  into  the 
scrotum,  that  the  inguinal  passage  preserved  all  its  length  and  its  obliquity, 
and  in  fine,  that  to  escape,  the  viscera  had  been  obliged  to  distend  and  enlarge 
forcibly  the  serous  prolongation  of  the  peritoneum,  which  was  contracted  but 
not  entirely  obliterated.  Since  this  period  a  third  case  of  the  same  kind  has 
been  published,  obtained  in  the  wards  of  M.  Dupuytren.  The  young  man, 
eighteen  years  old,  affirmed  that  the  testicle  of  this  side  had  descended  at  the 
same  time  as  that  of  the  other.  Another  patient,  twenty-one  years  old,  who 
on  mounting  a  horse  perceived  a  vaginal  hernia  appear,  although  both  his 
testicles  were  free,  presents  a  fourth  example.  M.  Lafond  in  his  thesis  says, 
that  he  saw  a  young  ecclesiastic  about  twenty  years  old,  whose  testicle  had 
not  always  been  in  the  scrotum,  suddenly  seized  with  inguinal  hernia,  which 
became  strangulated  and  required  an  operation,  and  which  also  was  in  the 
tunica  vagiiialis.     At  first  view,  it  seems  difficult  to  conceive  of  a  hernia  of 


OPERATIVE    SURGERY.  611 

this  kind  in  an  adult.  However,  by  remarking,  as  Hunter  and  Callisen  and 
several  anatomists  since  have  observed,  and  as  I  have  observed  myself  on  two 
dead  bodies,  that  the  scrotal  prolongation  of  the  peritoneum  remains  some- 
times pervious  during  life  under  the  form  of  a  little  canal,  that  at  other  times 
also  it  only  closes  at  its  superior  orifice  in  such  a  manner  that  the  tunica 
vaginalis  ascends  into  the  thickness  of  the  abdominal  parietes,  this  fact  will  no 
longer  be  incomprehensible,  and  in  nothing  repugnant  to  reason,  nor  contrary 
to  the  most  simple  anatomical  notions. 

From  what  has  been  said,  hernia  of  the  tunica  vaginalis  presents  three  dif- 
ferent grades ;  first,  that  which  is  formed  in  the  fetus  in  the  first  moment 
of  existence,  and  this  is  properly  congenital  hernia,  or  the  elytroid  hernia  of 
birth ;  secondly,  that  which  arises  from  the  arrest  of  the  testicle  in  the  ring, 
preventing  the  tunica  vaginalis  from  closing  above,  and  allowing  the  viscerate 
be  engaged  or  even  drawing  them  into  it,  when  it  finally  descends,  if  it  has 
contracted  adhesions  with  them,  or  by  merely  preparing  a  sac  for  their 
reception :  it  is  this  variety,  elytroid  hernia  of  adolescents  or  adults  to  which 
M.  Dupuytren  wished  to  call  the  attention  of  surgeons,  and  which  Lawrence, 
M.  Roux,  and  others  have  noticeid;  thirdly,  that  which  I  have  just  mentioned, 
the  predisposing  cause  of  which  is  the  incomplete  obliteration  of  the  cavity  of 
that  portion  of  the  peritoneum  contained  in  the  inguinal  canal.  Inquinal  hernia 
is  much  more  rare  in  woman  than  in  man,  yet  less  so  than  is  said  or  generally 
supposed,  and  is  not  attended  with  exactly  the  same  cliaracters  as  in  the  other 
sex.  The  canal  which  receives  it  being  longer,  much  less  in  width  and  filled  with 
the  round  ligament,  which  does  not  extend  like  the  spermatic  cord  free  beyond 
it,  but  slightly  disposes  the  abdominal  organs  to  issue  by  this  passage,  and 
much  less,  as  the  iliac  fossa  presents  in  its  environs  a  much  more  favorable 
point  for  their  passage.  However,  it  must  not  be  forgot,that  the  inguinal  opening 
in  young  girls  not  being  a  canal  but  merely  a  simple  ring,  hernias  of  this  de- 
scription are  quite  as  common  in  one  sex  as  in  the  other.  The  round  liga- 
ment, in  penetrating  the  groin  and  the  extremity  of  the  labia  pudendi,  is 
sometimes  accompanied  with  a  peritoneal  prolongation,  known  by  the  name  of 
canal  or  ligament  of  Nuck,  which  has  been  considered  as  analagous  to  the  tu- 
nica vao;inalis.  The  fact  is,  that  the  intestines  have  been  seen  engasred  in 
this  appendix  in  young  girls,  giving  rise  to  a  hernia  known  by  the  name  of 
congenital  hernia  of  girls.  It  is  perceived,  that  in  adult  age  the  same  thing 
may  happen  if  the  ligament  of  Nuck  remains  permeable,  but  for  the  most  part 
the  organs  will  pass  in  front  and  outwards,  carrying  witli  them  a  real  sac  as  in 
men. 

§  3.  Composition, 

The  sac  of  inguinal  hernia  seems  to  be  most  easily  torn.  It  was  upon  an 
inguinal  hernia  that  the  groom  mentioned  by  J.  L.  Petit  received  a  kick  from 
a  horse,  and  the  rupture  in  question  was  produced.  The  case  of  rupture  of 
the  sac  observed  by  M.  Boyer,  and  published  by  Mr.  Raymond,  also  related 
to  inguinal  hernia.  It  is  the  same  with  that  mentioned  by  MM.  Diveux 
and  Plaignan(^,  with  a  third  case  inserted  in  the  Montpellier  Collection  of 
Theses  for  1817,  and  a  sixth  met  with  by  M.  Darbefeuille  of  Nantes,  which 
has  this  remarkable  circumstance,  that  ^ej  were  able  to  confirm  the  fact  by 


612  NEW   ELEMENTS    OF 

dissection  of  the  dead  body ;  and  a  seventh  published  in  1826  by  M.  Breiden- 
bach  of  Heidelberg.  Not  only  may  the  sac  of  inguinal  hernias  be  torn  and 
let  the  organs  escape  between  the  other  envelopes  of  the  tumor,  but  they  may 
be  ruptured  also  on  the  side  of  the  tunica  vaginalis,  into  which  it  has  fre- 
quently opened,  whether  previously  filled  with  fluid,  that  is,  being  the  seat 
of  hydrocele,  or  in  its  natural  condition  entirely  free.  M.  Dupuytren  has 
published  several  remarkable  examples  of  this  communication  of  the  hernial 
sac  with  the  tunica  vaginalis,  which  he  has  observed  sometimes  below,  at 
other  times  in  front,  and  in  some  cases  quite  behind.  It  is  evident  that  this 
rupture  is  calculated  to  cause  strangulation  without  preventing  its  being  at 
the  same  time  otherwise  developed,  and  which,  if  not  foreseen  at  the  time  of 
operating,  would  expose  the  viscera  to  be  penetrated  before  recognizing  the 
sac.  It  is  in  inguinal  hernia  also  that  incomplete  sacs  are  most  frequently 
met  with,  which  is  explained  by  the  seat  of  the  organs,  which  in  escaping 
from  the  abdomen,  carry  with  them  the  adhesions  by  which  they  remain  fixed 
in  their  natural  cavity.  Although  most  of  the  causes  of  the  errors  pointed- 
out  in  the  article  on  the  operation  in  general  may  complicate  its  diagnosis,  it 
is  proper  to  say  nevertheless,  that  ganglions,  hydatids,  and  especially  the  adi- 
pose layers  or  tumors  which  have  been  mentioned,  are  more  rarely  found  on 
its  surface  than  on  that  of  some  other  species  of  hernia.  It  should  also  be 
remarked  that  the  sac  of  inguinal  hernia  is  that  which  contains  usually  the 
most  serosity,  and  is  almost  the  only  one  in  which  it  has  been  found  to  the 
amount  of  pounds  or  pints.  All  the  organs  contained  in  the  abdomen  have 
been  seen  in  inguinal  hernia;  the  coecum  frequently  forms  it.  A  number  of 
cases  prove  even  that  it  may  enter  the  scrotum  by  the  inguinal  canal  of  the  left 
side,  and  also  that  the  sigmoid  flexure  of  the  colon  is  found  sometimes  in 
right  inguinal  hernia.  The  bladder  penetrates  it  easily,  as  do  also  the  ovaries 
and  the  uterus.  Moreover  Ruysch  and  J.  L.  Petit  have  observed  in  it  the 
spleen,  Reizelius  the  liver,  M.  Yvan  has  recently  obtained  at  the  Hospital  of 
the  Invalids  a  case  which  proves  that  the  stomach  itself  may  descend  into  the 
scrotum. 

When  the  coecum  engages  itself  gradually  in  the  groin,  and  the  hernia  ac■^ 
quires  a  large  size,  it  is  not  rare  to  see  it  fixed  there,  as  in  the  iliac  fossa,  by 
its  posterior  face,  which  may  then  become  external  and  even  anterior.  This, 
disposition  Scarpa  wished  particularly  to  make  known,  and  M.  Sterlin  (who 
gives  the  name  of  acystic  to  the  kind  of  hernia)  and  M.  Colson  had  it  in  view 
when  they  spoke  of  inguinal  hernias  deprived  of  their  sac.  It  is  evident 
besides,  that  if  in  this  case  the  incision  should  fall  without,  and  be  carried 
upon  an  adherent  part  of  the  organ,  there  would  be  great  risk  of  opening  it, 
and  the  sac  would  escape  the  search  of  the  operator  if  the  precaution  was  not 
taken  to  look  for  it  inwardly  and  in  front.  Although  the  sigmoid  flexure  of 
the  colon  has  most  frequently  a  mesentery  at  its  posterior  edge,  it  happens 
that  in  the  scrotum  it  sometimes  loses  this  fold,  and  finally  becomes  adherent, 
there  in  the  manner  of  the  coecum.  Pelletan,  Lassus,  and  several  other, 
practitioners  have  published  examples  of  this.  A  remark  which  must  not  be 
forgotten  is,  that  in  hernia  formed  by  the  descending  colon  injections  are 
nol;  received  but  in  very  small  quantity,  as  M.  Berard  has  noticed ;  a  pecu- 
liarity which  may  be  explained  by  the  length  of  the  portion  of  intestine 
between  the  anus  and  the  hernia.     The  bladder  is  the  third  organ  which  may 


{ 


iibi: 

.mm 


OPERATIVE    SURGERY.  613 

present  in  the  hernia  with  a  sac  more  or  less  complete,  the  same  as  the 
coecum.  The  ovary  and  the  uterus  offer  nothing  peculiar,  unless  it  is  that 
their  organs  as  well  as  t!ie  bladder  are  unlikely  to  cause  symptoms  of  stran- 
gulation. 

If  the  envelopes  of  inguinal  hernia  present  fewer  morbid  anomalies  than 
those  of  other  hernias,  they  have  on  the  other  hand  a  certain  number  peculiar 
to  themselves.  Thus  the  spermatic  cord  contains  adipose  masses  susceptible 
of  hypertrophy,  capable  of  acquiring  an  enormous  size,  and  of  simulating 
epiploic  hernia.  The  serous  or  purulent  cysts  which  are  quite  frequently 
developed  in  it,  are  calculated  to  cause  several  symptoms  more  or  less  ana- 
logous to  those  of  strangulation.  M..  Marjolin,  M.  Roux,  M.  Ouvrard  of 
Angers  and  others,  have  seen  inflammation  in  the  mass  of  the  cord  produce  ajl 
the  symptoms  of  strangulated  hernia,  and  M.  Briot  of  Besancon  speaks  bf 
an  imposthumated  ganglion  which  was  taken  for  an  intestinal  tumor  until  the 
close  of  the  operation.  M.  Pecot  mentions  a  fact  which  tends  to  prove  tliat 
the  pus  of  a  diffused  abscess,  and  an  abscess  from  congestion,  which  following 
the  inguinal  passage  makes  a  tumor  in  the  groin,  may  deceive  in  the  same 
way.  The  strangulation  in  these  cases  presents  all  the  varieties  heretofore 
noticed.  In  the  most  recent  hernias,  its  seat  is  the  fibrous  ring  in  the  externkl 
oblique.  Sometimes,  however,  it  is  formed  by  the  opening  of  the  fascia 
transversalis^  as  I  found  to  be  the  case  in  an  adult  male.  At  this  point,  and 
more  frequently  still  at  the  neck  of  tlie  sac,  old  hernias  exist.  In  internal 
inguinal  hernia,  the  viscera  having  escaped  through  a  simple  ring  and  not 
through  a  canal,  the  strangulation  belongs  almost  always  to  the  first  or  third 
species,  whether  the  tumors  have  passed  through  the  natural  ring,  or  through 
a  fissure  in  the  internal  pillar.  If  the  hernias  which  pass  through  the  external 
pillar  become  strangulated,  they  may  present  the  three  varieties  of  ordin?iiy 
hernia;  but  if  the  intestine  be  arrested  in  the  inguinal  canal,  or  in  the  sub- 
stance of  tiie  abdominal  parietes,  the  strangulation  will  only  be  susceptible  of 
the  second  or  third  variety.  It  was  in  inguinal  hernia  that  Arnaud  saw  tlie 
epiploon  form  a  kind  of  ferule  which  strangulated  the  intestine  in  the  centre 
of  the  ring;  and  met  with  a  loop  of  this  organ  so  intimately  adherent  to  the 
parietes  of  the  inguinal  circle,  tliat  it  seemed  impossible  for  him  to  insulate 
it.  It  was  in  this  hernia  in  fine,  that  Pelletan,  Lassus,  as  well  as  others  and 
myself  have  met  with  epiploic  masses  under  every  form,  and  those  numerous 
anomalies  which  have  been  noticed  in  treating  of  hernia  in  general. 

§  4.  Operation, 

As  the  integuments  preserve  in  general  a  certain  flexibility  at  this  point,  it 
is  almost  always  possible  to  form  a  fold  for  incising  them.  Whether  one  or 
"le  other  method  be  adopted,  the  incision  should  extend  a  half  inch  or  an 
^h  above  the  ring,  and  descend,  unless  there  is  a  special  contra-indication, 
tlie  bottom  of  the  tumor,  the  great  axis  of  which  it  should  follow.  This 
Incision  requires  some  precaution.  The  spermatic  cord  not  having  an  inva-, 
riable  position,  it  would  be  easy  in  some  cases  to  wound  the  vas  deferens  or 
tlie  spermatic  artery,  as  happened  twice  to  Hey.  In  external  inguinal  hero^ 
it  has  been  found  passing  in  front  of  the  tumor,  so  as  to  be  external  wii^ 
arriving  at  its  inferior  part.    Only  some  days  since,  I  myself  met  with  an 


014  NEW  ELEMENTS  OP 

instance  at  La  Pitie,  in  a  patient  who  had  an  enormous  hernia.  In  internal 
inguinal  hernia,  the  same  thing  may  happen  but  in  an  opposite  direction ;  that 
is,  the  cord  which  is  situated  externally  in  issuing  from  the  canal  may  gradu- 
ally pass  in  front  and  then  inwards  to  be  continuous  with  the  generative  gland 
which  is  below,  and  also  on  the  internal  side.  No  doubt  that  in  cases  of  this 
kind,  the  instrument  will  cut  almost  inevitably  one  of  the  constituent  parts  of 
the  spermatic  cord  as  happened  to  Dr.  Hey,  and  as  it  was  easy  to  do  in  the 
cases  reported  by  Sclimucker,  Camper,  Le  Dran,  Boudou,  M.  Fardeau, 
Scarpa,  A.  Cooper,  Lawrence,  Blizard,  and  some  others.  The  tissues  which 
separate  the  integuments  from  the  sac  are  to  ^be  cut  therefore  with  care,  and 
in  this  respect  at  least  it  would  be  dangerous;^  follow  literally  the  advice  of 
Louis,  who  directs  them  to  be  penetrated  unhesitatingly,  and  in  some  sort  at 
a  single  stroke  either  with  a  sharp  pointed  probe  or  common  bistoury.  The 
division  of  these  intermediatory  layers  is  performed  according  to  the  rules 
laid  down  in  the  beginning.  As  to  the  sac,  if  it  presents  no  wrinkle  it  is 
most  prudent  to  enter  it  below,  in  front,  and  a  little  externally.  After  open- 
ing it  widely  upwards  as  far  as  the  ring,  the  question  is,  whether  it  is  indis- 
pensable to  prolong  the  incision  quite  to  the  bottom.  Some  think  not,  and 
among  others  Dr.  Hey,  as  well  as  Scarpa,  fearing  to  touch  the  tunica  vagi- 
nalis which  is  found  on  this  side,  direct  at  least  a  half  inch  to  be  left  infe- 
riorly.  In  reality,  it  is  altogether  a  matter  of  indifference  which  of  the  two 
methods  be  adopted.  When  the  hernia  is  congenital,  the  organs  having 
widened  and  distended  more  or  less  the  tunica  vaginalis  beneath  the  testicle, 
there  are  two  obstacles  to  contend  with  in  this  point  of  view.  If  the  sac  is 
opened  in  its  whole  extent,  the  testicle  tends  continually  to  escape  from  the 
bottom  of  the  wound,  and  may  thus  cause  accidents.  If  the  serous  pouch  is 
only  incised  in  its  superior  half  the  genital  gland  will  be  much  more  easily 
retained ;  but  the  pus,  if  it  form,  will  accumulate  in  the  cul-de-sac  preserved 
below,  and  may  occasion  other  dangers.  In  this  case  therefore  it  would  be 
best  to  make  a  large  opening,  then  bring  the  edges  of  the  tunica  vaginalis  in 
front  of  the  testicle,  and  keep  them  there  by  one  or  more  stitches. 

On  account  of  the  vessels  which  it  is'  important  not  to  injure,  inguinal 
hernia  is  one  of  those  which  are  best  adapted  to  dilatation,  if  this  method  is  to 
be  employed  in  any  case.  Theory  directs  incision,  the  only  resource 
employed  at  present,  to  be  performed  in  different  directions  according  to  the 
species  of  bubonocele.  For  example,  it.  will  be  proper  to  direct  it  outwards 
on  one  of  the  points  of  the  external  semi-circumference  of  the  ring,  for 
hernias  the  neck  of  v^Kich  is  situated  externally  to  the  epigastric  artery,  that 
is,  all  that  pass  through  the  superior  orifice  of  the  inguinal  canal ;  inwards, 
on  the  contrary,  for  internal  inguinal  hernia,  and  directly  upwards  when  an 
epigastric  artery  exists  in  each  side,  as  might  have  been  the  fact  in  the  case 
reported  by  M.  Lauth.  This  variable  indication  explains  the  so  opposite 
councils  given  on  this  subject  by  the  most  cojnmendable  authors.  Sliarp, 
Lafaye,  Pott,  and  Sabatier  direct  the  incision  to  be  made  upwards  and 
outwards,  because  the  epigastric  artery  is  commonly  found  on  the  inside ; 
Verduc,  Garengetrt,  and  Heister,  on  the  contrary,  direct  it  to  be  made  inwards, 
a»d  Bertrandi,  who  saw  the  incision  outwards  produce  a  hemorrhage 
fram  the  division  of  tlie  epigastric  artery  which  caused  the  death  of  tlie 
patient,  gives  the  same  advice.     In  fine,  it   was  from   fear  of  finding  this 


OPERATIVE    SURGERY.  ^15 

artery  on  either  side  that  J.  L.  Petit,  before  Rougemont  and  Autenrieth, 
Messrs.  A.  Cooper,  Scarpa,  Richeraad,  and  Dupuytren  who  follow  the  same 
practice,  directs  the  incision  to  be  made  directly  upwards.  Desault  and 
Chopart  had,  it  is  true,  already  remarked  that  the  artery  is  on  the  inside 
when  the  cord  is  found  behind  or  on  the  internal  side  of  the  tumor,  and  on 
the  outside  in  the  contrary  case.  But  to  fix  opinion  upon  it,  all  the  anatomi- 
cal knowledge  at  present  acquired  by  the  immense  majority  of  operatoris 
was  necessary.  To  say  that  the  incision  should  be  made  outwards  when  the 
hernia  is  external,  and  inwards  when  internal,  would  be  of  no  avail  unless  it 
were  more  easy  to  distinguish  these  two  varieties  of  the  disease  from  each 
other.  Besides  when  there  are  two  epigastric  arteries,  or  when  this  vessel 
arises  from  the  obturator  at  a  certain  distance  from  the  external  iliac,  it  may 
very  readily  be  found  within  the  internal  inguinal  hernia,  as  is  usually 
remarked  in  external  inguinal  hernia.  The  external  epigastric  artery  in 
the  subject  observed  by  M.  Lauth,  might  have  placed  itself  external  to  an 
oblique  inguinal  hernia.  In  consequence  of  this  uncertainty,  Messrs.  Cooper, 
Scarpa,  Richerand,  and  Dupuytren  justly  prefer  the  method  of  Petit  or  Rouge- 
mont. By  cutting  directly  upwards,  say  they,  whether  the  artery  be  without 
or  within,  whether  two  or  only  one,  whether  the  hernia  be  internal  or  external 
is  of  little  consequence,  no  hemorrhage  is  to  be  feared,  for  this  instrument 
divides  the  tissues  in  the  known  direction  of  the  vessels.  One  objection 
presents,  nevertheless,  which  is,  instead  of  following  a  line  parallel  wdth  the 
axis  of  the  body  the  epigastric  artery  is  directed  obliquely  inwards  and 
upwards  to  reach  the  umbilical  region,  passing  above  the  internal  inguinal 
hernia ;  while  in  external  inguinal  hernia  I  have  seen  it  bent  downwards 
and  inwards  so  that  it  formed  in  some  sort  a  semi-circle,  the  superior  extre- 
mity of  which  might  be  easily  reached  by  a  perpendicular  incision.  Then  as 
it  seldom  fails  to  be  more  or  less  displayed  by  the  origin  of  the  tumor,  it 
cannot  be  known  whether  it  is  really  vertical  or  oblique  in  either  direction. 
It  would  be  equally  possible  to  wound  it  by  cutting  directly  upwards.  I  will 
add,  that  in  internal  inguinal  hernia  the  pubic  branch  furnished  by  the  epigas- 
tric would  almost  necessarily  be  cut,  and  in  cases  where  its  size  is  abnormal  a 
troublesome  hemorrhage  would  result,  as  seems  to  me  to  have  occurred  in 
the  two  observations  noted  by  Mr.  Lawrence,  according  to  the  commentaries 
of  Duncan  and  Home.  No  method  completely  protects  from  hemorrhage, 
yet  a  wound  of  the  epigastric  artery  is  extremely  rare.  On  what  can  this 
depend  ?  First  upon  its  being  pushed  aside  by  the  neck  of  the  sac,  so  that  it 
is  almost  always  situated  two  or  three  lines  from  the  constricting  circle,  and 
most  commonly  this  is  the  greatest  extent  given  to  the  incision ;  secondly, 
when  the  strangulation  is  produced  by  the  ring  of  the  external  oblique,  the 
incision  is  made  on  a  circle  too  far  from  the  artery  in  question,  to  give 
rise  to  apprehensions  of  wounding  it ;  whence  it  follows,  that  in  a  strict 
analysis  the  incision  may  be  made  in  every  direction  without  danger,  pro- 
vided too  great  an  extent  be  not  given  to  it,  and  thus  the  successes  obtained 
at  Vienna  in  the  commencement  of  this  century  by  M.  Rudthoffer,  who 
always  cut  inwards  like  Bertrandi,  are  not  to  be  thought  surprising.  If  we 
add  that  internal  inguinal  hernia  is  very  rare,  and  that  at  present  the  outward 
incision  is  preferred  in  the  great  majority  of  cases,  it  will  be  understood  why 
hemorrhage  as  a  consequence  of  celotomv  is  so  uncommon.     However,  as 


616  NEW  ELEMENTS    OF 

it  has  been  observed  in  several  subjects,  it  is  proper  still  to  think  of  the  means 
of  avoiding  it.  But  in  every  strangulation  caused  by  the  inferior  opening  of 
the  canal,  tlie  incision  from  before  backwards  with  a  convex  bistoury  carried 
on  the  end  of  the  finger  as  directed  by  Bell,  whether  imitating  Messrs. 
Colson  and  Dellouey  or  M.  Dupuytren,  or,  which  is  still  better,  using  the 
point  of  a  straight  bistoury  protected  also  by  the  finger,  and  which  cutting 
from  the  free  edge  of  the  ring  to  a  point  more  or. less  distant  from  its  circum- 
ference, will  be  entirely  free  from  all  danger,  since  by  conforming  to  these 
principles  the  instrument  only  penetrates  as  far  as  the  posterior  face  of  the 
fascia  transversalis.  In  other  cases,  the  debridement  multiple,  either  with  the 
straight  probe  pointed  bistoury  or  the  curved  bistoury,  allowing  only  ofle  or 
two  lines  of  depth  to  each  incision,  is  well  calculated  if  I  mistake  not  to 
render  a  lesion  of  the  epigastric  artery  almost  impossible  in  any  direction.     ' 

If  notwithstanding  all  these  precautions  the  artery  has  been  wounded,  of 
which  Gunz  heard  too  cases  cited  at  Paris,  as  Bertrandi  has  proved  by  opening 
the  body,  and  of  which  Richter,  Leblanc,  Hey,  A.  Cooper,  Scarpa,  Lawrende, 
&c.  have  quoted  cases,  what  is  to  be  done  ?  Mr.  Law  rence  says  that  he  found 
the  epigastric  branch  completely  divided  on  the  bc-dy  of  an  individual  operated 
on  for  strangulated  inguinal  hernia,  whose  death  had  been  produced  by  anotlier 
cause.  In  a  second  case,  the  hemorrhage  was  suspended  by  a  syncope,  and 
the  patient  completely  recovered ;  it  remains  however  to  inquire  whether  the 
blood  really  escaped  from  the  epigastric  artery.  I  have  seen  on  a  subject 
^ho  had  died  in  consequence  of  a  penetrating  wound  of  the  abdomen,  a  com- 
plete division  of  this  vessel  from  which  the  hemorrhage  had  been  but  trilling 
/and  was  spontaneously  arrested.  It  would  then  appear  to  be  possible  that 
i  this  wound  might  take  place  frequently  unknown  to  the  surgeon.  The  ligature 
carried  over  the  root  of  the  artery  as  directed  by  Bogros,  or  through  the  wound 
by  means  of  the  several  instruments  proposed  by  Arnaud,  Schildner,  Richter, 
Desault,  and  many  other  practitioners,  is  too  difficult  of  application  and  otfers 
too  little  certainty  to  induce  the  attempt.  It  would  be  better  to  carry  beyond 
the  ring  a  kind  of  chemise  or  little  sac  of  fine  linen,  the  bottom  of  which  is 
to  be  filled  with  soft  charpie  so  as  to  form  a  tampon  of  greater  or  less  width 
and  thickness,  by  means  of  which  the  parts  may  be  compressed  from  behind 
anteriorly,  or  from  the  peritoneum  towards  the  integuments.  It  was  thus  that 
Mr.  Hey  and  Boyer  acted  in  the  successful  cases  reported  by  them,  or  in 
their  name.  " 

Reduction, — This  hernia  is  the  most  common,  and  it  is  this  which  most 
frequently  contains  the  small  intestine  and  the  adherent  parts  of  the  large 
intestine;  it  is  this  that  the  direction  given  by  M.  Dupuytren  applies,  that  if, 
as  it  sometimes  happens,  a  membrane  of  new  formation  bridles  the  two  ends 
of  the  visceral  loop  so  as  to  prevent  its  elongation,  it  is  necessary  to  destroy 
it.  The  best  mode  of  returning  the  liquids,  and  the  matters  contiiined  in  this 
loop,  is  to  embrace  the  mass  with  the  palms  of  both  hands,  and  press  it  gently 
until  it  is  nearly  empty.  Here  also  care  must  be  taken  not  to  engage  it 
between  the  peritoneum  and  the  fascia  transversalis,  or  in  the  substance  of  the 
abdominal  parietes,  for  it  is  in.  this  species  of  hernia  tliat  Le  Dran,  Caliisen, 
De  la  Faye,  Sabatier,  Pelletan,  Lassus,  Hesselbach,  M.  Delmas,  Mr.  Law 
rence,  and  myself,  have  observed  the  accident  just  noticed.  No  where  in  fact 
does  the  hernial  passage  present  greater  length,  no  where  is  there  found  so 


mt 


?Wf 


OPERATIVE  SURGERY.  6l7 


much  laxitj  in  the  cellular  tissue  which  unites  or  separates  the  peritoneum 
from  the  muscles  and  the  several  constituent  layers  of  the  abdominal  walls, 
no  where  in  fine,  are  bands  more  frequently  found  behind  the  ring,  which  are 
formed  by  adhesion  of  the  coecal  appendix,  a  prolongation  of  the  epiploon,  by 
an  accidental  band,  &c.  It  was  in  this  moreover  that  Dr.  Hey  saw  the  sac 
divided  horizontally  into  two  distinct  pouches  by  epiploon,  an  anterior  one 
containing  only  serosity,  and  a  posterior  in  which  was.  contained  the  intestine. 
In  a  word,  there  is  perhaps  not  a  single  anomaly  or  degeneration  of  the  di- 
gestive organs  or  epiploon  which  has  not  been  observed  in  the  inguinal  hernia. 
It  is  this  besides  which  has  presented  those  appendices  in  the  form  of  a  finger 
of  a  glove  observed  by  Ruysch,  F.  de  Hilden,  Mery,  and  especially  by  Littre, 
and  which  belonged  to  a  more  or  less  elevated  point  of  the  ileum.  When 
inguinal  hernia  is  old  and  of  immoderate  size,  as  it  is  rare  that  the  displaced 
viscera  have  contracted  mutual  adhesions  which  it  is  difiicult  to  destroy,  and 
are  not  in  a  measure  agglomerated  so  as  to  represent  in  certain  cases  a  mere 
fleshy  mass,  reduction  ought  not  always  to  be  attempted.  If  in  this  case  the 
hernial  envelopes  have  been  divided  in  their  whole  extent  only  the  free  parts 
are  to  be  returned,  the  rest  is  left  without;  the  whole  is  to  be  covered  with 
compresses  soaked  in  emollient  fluids,  and  the  horizontal  position,  which  the 
patient  is  to  keep,  brings  them  gradually  within  the  ring  if  not  into  the  inte- 
rior of  the  abdomen  itself. 

It  is  in  this  variety  in  particular  that  Ravaton,  Monro,  Cooper,  Crawther, 
Lawrence,  Boyer,  and  Scarpa,  after  J.  L.  Petit,  direct  the  incision  to  be  made 
without,  passing  through  the  peritoneal  layer,  in  the  mode  which  M.  Raphel 
supposed  that  he  had  originated,  but  which  he  only  combined  with  the  idea  of 
Bell  on  removing  the  stricture  in  general.  An  incision  is  then  made  of  some 
inches  in  length  at  the  root  of  the  tumor,  to  reach  by  degrees  the  neck  of  the 
sac  without  opening  it.  A  grooved  director  is  then  introduced  between  this 
neck  and  the  ring,  which  is  then  divided  conformably  to  the  rules  already  laid 
down.  The  strangulation  being  relieved,  if  the  viscera  can  be  returned  into 
the  abdomen  without  too  much  difficulty,  reduction  is  to  be  attempted  imme- 
diately. In  the  contrary  case  only  those  which  yield  readily  are  to  be 
returned,  and  the  rest  supported  or  retained  by  a  suspensory  or  properly 
arranged  bandage.  If  after  incision  of  the  ring  the  strangulation  remains, 
the  neck  of  the  sac  should  be  perforated,  a  probe  pointed  bistoury  introduced, 
and  it  should  be  divided  with  the  usual  precautions.  The  wound  being  closed 
by  adhesive  strips,  generally  cicatrizes  after  several  days.  In  ordinary  cases, 
when  the  organs  are  reduced,  the  sac  is  sometimes  so  movable,  so  slightly 
adherent,  that  it  is  possible  to  detach  it,  and  form  it  into  a  small  plug,  as 
Garengeot  says,  and  pack  it  into  the  ring  or  excise  it. 

Without  returning  to  what  I  have  said  on  this  subject  in  the  preceding 
pages,  I  cannot  dispense  with  remarking,  that  if  it  is  determined  to  follow  it 
in  inguinal  hernia,  it  is  necessary  previously  to  be  assured  of  the  situation 
occupied  by  the  vas  deferens  and  the  spermatic  vessels.  When  inguinal 
hernia  is  direct,  the  incision  should  be  parallel  with  the  axis  of  the  body.  It 
should  be  oblique  from  above  downwards  and  from  without  inwards,  on  the 
contrary  when  the  tumor  is  external  and  of  small  dimensions ;  but  when  it  is 
very  large,  it  is  found  very  well  to  give  the  incision  the  form  of  a  half  moon 
very  much  elongated,  the  convexity  of  which  shall  look  upwards  and  inwards. 

78  "  ir 

-If 


618  NEW   ELEMENTS   OF 

If  the  operation  is  performed  on  a  woman,  there  will  be  no  precaution  required . 
with  regard  to  the  cord.  If  in  this  hernia  the  ovary  is  retained  near  the  ring, 
or  has  descended  into  the  labia  majora,  of  which  Priscien,  Veyrat,  Pott,  Lassus, 
Haller,  M.  Lallemand,  and  M.  Deneux,  have  reported  examples,  and  if  the 
symptoms  appear  to  depend  in  any  degree  upon  its  presence  in  the  ring,  th^^ 
wisest  plan  would  be  to  remove  it.  The  uterus  and  the  bladder  may  be 
reduced  the  same  as  the  intestines,  or  will  not  fail  to  be  spontaneously  reduced 
in  the  end.  Supposing  the  operation  to  have  been  performed  to  remedy 
symptoms  produced  by  strangulation  of  the  cord,  observed  also  by  M.  Roux, 
the  incision  once  made,  nothing  further  is  required.  In  case  of  hydatids  and 
adipose  tumors,  excision  of  the  morbid  parts  is  to  be  performed;  as  also  for 
lymphatic  ganglions,  if  they  chance  to  be  developed  in  the  inguinal  canal. 

A  more  embarrassing  case  than  all  these  is  that  which  arises  from  the 
presence  of  the  testicle  in  the  interior  of  the  ring  itself.  Almost  always  in 
this  case  the  genital  gland  is  altered  either  in  its  conformation  or  its  structure. 
If  it  is  excised,  the  man  is  deprived  of  an  important  organ ;  if  strangulation  is 
merely  removed,  and  the  testicle  cannot  descend,  the  same  symptoms  may  be 
reproduced,  and  the  patient  only  receive  temporary  relief  from  herniotomy. 
Before  the  operation  it  will  be  the  more  difficult  to  determine  with  certainty;^ 
for  a  real  hernia  maybe  manifested  in  the  place  of  the  testicle  as  in  a  monorchid, 
of  which  M.  Fayes  has  given  an  example.  The  practitioner  is  therefore  to 
determine  by  the  disposition  of  the  parts,  and  the  peculiar  circumstances  in 
which  the  individual  is  placed,  on  the  plan  which  it  is  reasonable  to  pursue. 

ARTICLE  II. 

Cmral  Hernia. 

§  1. — Anatomical  Remarks. 

Crural  hernia  was  scarcely  distinguished  from  inguinal,  until  the  times 
of  Barbette,  Lequin,  Nuck,  and  Verheyen.  Its  natural  seat  is  the  fold  of  the 
groin,  and  the  opening  which  gives  it  passage  is  known  as  the  crural  ring  or 
canal.  By  its  superior  edge,  Poupart's  ligament  is  continuous  with  the 
aponeurosis  of  the  external  oblique  in  the  direction  of  the  skin,  and  the  fascia 
transversalis  in  that  of  the  peritoneum,  and  is  continuous  below  with  the 
fascia  lata  towards  the  thigh,  and  the  fascia  iliaca  towards  the  abdomen-  At 
the  middle  of  the  ligament  of  Fallopius  the  crural  aponeurosis  separates  into 
two  layers.  Its  superficial  lamina  follows  the  course  of  the  ligament  until 
near  the  pubis,  then  separates  from  it,  and  is  applied  upon  the  pectineus 
muscle,  and  continuous  with  the  fascia  pelvica.  The  first,  described  under 
the  name  of  the  falciform  process  by  the  English  surgeons,  may  be  compared 
to  a  triangular  lamina ;  of  its  edges,  the  superior  unites  with  the  ligament,  the 
external  is  continuous  with  the  primary  aponeurosis,  and  the  inferior  or  in- 
ternal is  free  and  more  or  less  concave.  The  second,  generally  thicker,  is 
continuous  inwards  and  upwards  with  the  expansion  of  the  external  pillar  of 
the  inguinal  ring,  or  with  Gimbernat's  ligament,  of  which  we  shall  speak 
presently.  An  oval  opening,  with  its  base  inferiorly  bounded  by  the  free  edge 
of  the  preceding  layer,  results  from  this  disposition^  and  through  this  the 
internal  saphena  vein  joins  the  femoral.     Its  plane  looks  inwards,  forwards, 


OPERATIVE    SURGERY.  6lS> 

and  a  little  downwards.  About  the  middle  of  Poupart's  ligament,  the  iliac 
aponeurosis  dips  down  in  the  same  manner  as  the  inferior  layer  of  the  fascia 
lata,  and  thereby  leaves  between  it  and  this  ligament  a  kind  of  elliptical 
opening,  which  is  the  crural  ring  proper.  This  ring  deserves  all  the  attention 
of  the  surgeon.  A  small  vertical  septum  usually  divides  it  into  two  parts,  the 
one  external,  in  which  is  found  the  femoral  artery  and  vein,  the  artery  without 
and  the  vein  within,  filled  only  by  cellular  tissue  and  a  lymphatic  ganglion. 
To  sum  up ;  the  anterior  vacancy  in  the  coxal  bone  is  converted  into  two  large 
foramina,  by  the  ligament  of  Fallopius.  This  ligament,  which  is  single  until 
the  fascia  iliaca  and  the  inferior  process  of  the  fascia  lata  separate,  so  as  by 
being  depressed  towards  the  pubis,  to  bind  the  muscles  and  nerves  of  the  iliac 
fossa,  seems  in  fact,  to  bifurcate  in  order  to  form  the  crural  canal,  and  thus 
separate  the  femoral  vessels  from  the  parts  I  have  just  described.  Its  hori- 
zontal branch  gives  rise,  in  approaching  the  symphysis  pubis,  to  a  membranous 
expansion,  which  is  fixed  to  the  crest  of  the  pubis  inclining  a  little  towards 
the  thigh,  so  as  to  become  continuous  with  the  inferior  lamina  of  the /«5aa/a^a, 
and  which  is  known  by  the  name  of  Gimbernat's  ligament.  Continuous  above 
with  the  external  pillar  of  the  abdominal  ring,  fixed  below  and  behind  to  the 
crista  ileo-pectinea,  it  presents  outwardly  a  concave  or  crescentic  layer,  which 
reacts  in  an  important  manner  upon  the  organs  concerned  in  crural  hernia. 

Thus  this  canal  is  formed,  externally  by  the  separation  into  two  lamina  of 
the  ligament  of  Fallopius  and  the  fascia  lata.     The  falciform  aponeurosis, 
which  is  shorter  as  it  approaches  its  internal  side,  constitutes  its  anterior 
wall.     Posteriorly  it  is  formed  by  the  muscular  layer  of  the  crural  aponeuro- 
sis.   Interiorly  it  has  really  no  wall,  and  is  bounded  by  the  free  or  sharp 
edge  of  Gimbernat's  ligament.     The  femoral  artery  and  vein  fill  its  external 
half  or  third,  and  conceal  its  longest  wall,  and  cause  its  inferior  orifice  to 
limit  exactly  its  extent  below.     In  its  natural  state  this  canal  is  filled  with 
cellular  tissue,  which  forms  a  communication  between  the  fascia  propria,  or 
the  lamellated  lining  of  the  peritoneum  and  the  fascia  superficialis,  or  the 
subcutaneous  layer  of  the  groin.    A  lymphatic  ganglion,  often  of  consider- 
able size,  usually  closes  its  entrance,  while  its  crural  orifice  is  as  it  were 
curtained  by  a  lamella  of  more  or  less  density  perforated  for  the  commu- 
nication of  the  superficial  lymphatic  ganglion,  with  the  deep  seated  ganglia 
of  this  region.    The  saphena  embraces  the  base  of  its  orifice,  the  two  extre- 
mities of  which  at  the  point  seem  to  cross,  passing  one  before  the  other,  so 
that  the  posterior  is  continuous  with  Gimbernat's  ligament,  and  the  other 
with  the  pubic  extremity  of  the  arch.     In  passing  through  the  crural  canal, 
the  hernial  sac,  already  lined  by  the  fascia  propria,  carries  before  it  and 
appropriates  the  major  part  of  the  cellular  tissue  which  is  found  there,  is 
enveloped  at  its  exit  with  \he  fascia  superfcialis  and  the  whole  subcutaneous 
cellulo-adipose  layer,  carries  before  it  by  the  same  reason  downwards  and 
inwards  or  outwards  the  lymphatic  ganglia^  which  in  some  cases  it  only 
raises  up,  and  which  thus  remain  upon  the  surface  of  the  tumor.     Having 
arrived  without,  the  hernia  tends  much  more  to  the  external  and  superior  part 
thati  in  the  opposite  direction,  which  is  owing  to  the  greater  adhesion  of  the 
fascia  superficialis  inwards  and  downwards  than  towards  the  spine  of  the 
ileum,  and  the  external  portion  of  the  ligament  of  Fallopius.     It  is  thus  that 
the  hernia  has  been  seen  to  return  to  within  two  or  three. inches  of  its  exit  in 


620  NEW   ELEMENTS    OF 

the  direction  of  the  ileum.  Examples  of  it  have  been  reported  by  Arnaud, 
and  more  recently  by  M.  Larrey.  The  sac  runs  along  and  without  the 
femoral  vein  and  artery.  At  its  superior  part  it  is  in  contact  with  the  origin 
of  the  epigastric  artery ;  which  crosses  its  anterior  and  external  portion  more 
or  less  remotely  in  its  passage  to  the  peritoneal  face  of  the  abdominal  mus- 
cles. In  front,  it  is  concealed  first  by  the  ligament  of  Fallopius,  and  a  little 
further  down  by  the  falciform  process  of  the  fascia  lata.  Posteriorly,  it  is 
supported  by  the  crista  and  triangular  surface  of  the  body  of  the  pubis,  the 
pectineus  muscle,  and  more  immediately  by  the  posterior  lamina  of  the  crural 
aponeurosis ;  in  fine,  its  internal  side  is  embraced  by  Gimbernat's  ligament. 
It  must  be  remarked,  besides,  that  in  the  male  it  is  crossed  obliquely  by  the 
spermatic  cord,  from  which  it  is  separated  only  by  Poupart's  ligament. 
The  epigastric  may  arise  an  inch  or  an  inch  and  a  half  higher  than  usual,  and 
also  may  be  furnished  by  the  femoral  artery  below  the  ligament  of  Fallopius  ; 
which  in  the  first  case  may  cause  this  branch  to  be  thrown  on  the  internal 
side  of  the  hernia  instead  of  remaining  externally,  and  in  the  second  may 
bring  the  incision  on  some  point  of  its  external  half,  and  almost  inevitably 
cause  its  division.  A  second  and  more  remarkable  variety  is  one  which  X 
I  have  already  described,  in  which  the  epigastric  artery  arises  from  the  obtu- 
rator at  more  than  an  inch  from  the  external  iliac,  as  seen  by  M.  Hesselbach, 
and  of  which  I  also  have  met  with  an  example.  In  this  case  no  doubt  the 
crural  hernia  would  be  external  to  it.  The  same  would  occur  if  the  epigastric 
arose  from  the  hypogastric,  as  I  have  seen  it.  A  much  more  fearful  arrange- 
ment might  still  be  observed,  if  the  hernia  were  formed  in  persons  having  two 
epigastric  arteries  on  the  same  side,  one  coming  from  the  iliac  the  other  from 
the  pelvic  artery,  as  seen  in  the  individual  mentioned  by  M.  Lauth.  In  man, 
especially,  the  neck  of  the  sac  would  then  have  the  pelvic  epigastric  within, 
and  the  iliac  epigastric  without,  and  the  spermatic  cord  in  front.  A  last 
anomaly  which  has  not  as  yet  been  noticed,  I  think,  is  that  for  the  knowledge 
of  which  we  are  indebted  to  M.  Michelet,  in  which  the  internal  circumflex  of 
the  thigh  arises  from  the  epigastric  itself.  The  artery  in  this  case  may  be 
found  in  front  of  the  body  of  the  hernia,  crossing  obliquely  outwards  and 
inwards,  and  reaching  the  adductor  muscles  of  the  thigh.  But  the  variety 
of  which  most  has  been  said,  is  that  in  which  the  obturator  and  epigastiic 
arise  by  a  common  trunk  from  the  external  iliac ;  this  is  in  fact  the  most 
frequent.  The  examinations  which  I  have  been  enabled  to  make  on  several 
thousands  of  dead  bodies,  either  in  the  hospitals,  the  dissecting  theatres,  or 
the  school  of  practice,  will  not  allow  me  to  say  that  it  happens  once  in  three, 
five,  or  ten  times,  but  about  once  in  fifteen  or  twenty.  It  is  moreover  a  fact 
more  simple  than  is  imagined.  Before  birth  the  obturator  artery  almost  con- 
stantly arises  by  two  roots,  one  coming  from  the  hypogastric,  the  other  from 
the  epigastric ;  but  the  epigastric  root  becomes  soon  obliterated,  the  hypogas- 
tric remains,  and  definitely  forms  the  vessel.  If  the  contrary  happens,  the 
anomaly  in  question  is  observed. 

Many  practitioners  have  thought  that  in  this  case  the  neck  of  the  crural 
hernia  would  have  the  epigastric  artery  external  to  it,  and  the  obturator  in 
front  and  within,  so  as  to  be  surrounded  with  an  almost  complete  arterial 
circle.  As  tlie  epigastric  trunk  is  placed  between  the  peritoneum  and  the 
fascia  transversalis  or  the  ligament  of  Fallopius,  if  the  obturator  comes  from 


OPERATIVE  StIRGERY.  6QrV 

it,  it  is  necessai'ily  situated  in  the  substance  of  the  fascia  propriay  and  in 
order  to  reach  tlie  sub-pubic  foramen,  it  must  follow  the  inferior  semi-circum- 
ference of  the  crural  canal.  The  viscera  in  escaping,  having  from  this  cause 
almost  necessarily  to  throw  it  back,  do  not  appear  to  run  any  risk  of  bringing 
it  on  their  anterior  face.  I  have  not  moreover  as  yet  learned  that  a  wound  of 
it  has  been  verifietl  by  examination  of  the  dead  subject,  although  it  is  said 
to  have  occurred  several  times  in  persons  who  have  survived. 

For  the  sole  reason  that  the  iliac  artei-y  in  entering  the  ring  divides  this 
opening  into  two  parts,  and  that  the  epigastric  artery  is  detached  from  its 
internal  or  anterior  part,  there  must  exist  another  point  externally  of  little 
resistance.  By  introducing  the  finger  it  is  soon  ascertained  that  it  is  really 
possible  to  pass  thereby  from  the  interior  to  the  exterior  of  the  abdomen; 
whence  it  seems  to  result  that  the  hernia  must  sometimes  be  formed  on  the 
iliac  side  of  tlie  epigastric  vessels.  An  external  crural  hernia  therefore,  and 
an  internal  crural  hernia  may  be  admitted.  Only  a  single  example  however, 
has  been  given  of  late,  and  that  by  M.  Cloquet;  Arnault,  most  of  the  patholo- 
gists of  the  last  century,  Sabatier,  and  M.  Walthier  say,  indeed,  that  in 
issuing  from  the  abdomen  the  intestine  passes  obliquely  inwards  on  the  an- 
terior face  of  the  crural  vessels,  and  consequently  leaves  it  to  be  understood 
that  the  epigastric  artery  remains  on  the  internal  side  of  the  neck  of  the  sac  ; 
but  on  this  subject  they  are  confined  to  mere  assertion,  and  there  is  no  proof 
that  they  positively  established  the  fact  by  dissection.  Femoral  hernia  is  not 
enveloped  with  as  many  laminae  as  bubonocele.  There  are  found  only  the 
peritoneum,  the  fascia  propria y  and  the/ascia  superjicialis,  blended  miom.  cel- 
lular-adipose mass,  and  the  integuments.  It  is  in  this  layer,  intermediate  to 
the  skin  and  serous  covering,  that*%*e  found  lymphatic  ganglions,  sound  or 
diseased,  enlarged,  indurated,  swollen  in  any  manner,  inflamed,  or  suppurated  ; 
hydatid  cysts ;  abscesses,  hot,  cold,  or  from  congestion,  which  sometimes 
surround  a  crural  hernia,  so  as  in  some  cases  to  render  the  diagnosis  so  difficult, 
and  the  operation  so  delicate.  It  was  there,  no  doubt,  that  the  pus  collected  in 
the  two  cases  of  cold  or  congestive  abscesses  mentioned  in  the  thesis  of  M. 
Bayeul,  which  were  mistaken  for  hernia.  In  this  layer  also  the  veins  which 
return  from  the  abdominal  integuments  are  observed  as  well  as  the  corres- 
ponding arterioles,  and  where  are  developed  the  tumors  or  adipose  layers 
which  I  have  pointed  out  in  treating  of  hernia  in  general.  As  to  the  saphena 
vein,  although  situate  in  the  intermediate  layer,  it  is  always  thrown  behind  and 
below  the  tumor. 

The  opening  wliich  gives  passage  to  crural  hernia  is  so  firm  and  solid,  the 
tissues  which  receive  and  envelope  it  at  the  thigh  have  in  general  so  much  re- 
sistance, that  it  rarely  acquires  much  volume.  It  is  compelled  to  pass  through 
an  orifice  deeply  situate,  and  is  liable  to  be  stopped  in  the  canal  itself  either 
above,  at  its  middle,  or  at  its  femoral  orifice,  and  its  existence  is  therefore  often 
difficult  to  be  ascertained  in  fat  subjects,  particularly  in  women  in  whom  it  is 
so  frequent.  The  same  causes,  as  maybe  supposed,  render  the  operation  more 
troublesome  than  in  inguinal  hernia.  It  is  besides  owing  to  the  narrowness  of 
the  passages  and  their  want  of  extensibility  that  this  hernia  is  so  easily  stran- 
gulated, and  so  difficult  of  reduction  when  there  is  the  least  constriction.  In 
its  interior,  the  same  organs  have  been  found  as  in  the  neighboring  hernia,  with 
the  same  anomalies,  and  the  same  pathological  alterations.    It  iS  subject  to 


fc 


622  NEW  ELEMENTS  OF 

remark  however,  that  its  sac,  generally  thinner  than  that  of  oscheocele,  con- 
tains usually  but  very  ^ttle  serosi ty,  sometimes  but  a  tew  drops,  and  often 
none  at  all.  Nevertheless  there  have  been  cases  in  which  several  ounces  were 
found  within  it,  tliat  is  an  excess  as  I  have  noticed  in  supra  pubic  hernia. 

§  2.  Operation, 

Celotomy  of  the  hollow  of  the  groin  requires  more  precautions  than  that 
of  the  scrotum;  first,  because  we  more  readily  reach  the  sac  when  no  com- 
plication exists,  and  because  in  the  contrary  case  we  have  all  the  diseases  that 
may  be  manifested  in  this  region  to  distinguish  from  the  hernia  itself;  again, 
because  the  sac  being  very  thin  and  often  blended  by  its  external  face  with  the 
surrounding  cellular  tissue,  is  liable  to  be  opened  before  it  is  perceived,  and 
containing  scarcely  any  serosity  renders  lesion  of  the  intestine  very  easy ;  in 
the  third  place,  because  we  must  go  to  a  great  depth,  and  incise  parts  almost 
necessarily  surrounded  with  bloodvessels. 

The  incision  of  the  integuments  should  and  may  almost  always  be  made  in 
the  direction  of  the  inguinal  groove,  and  of  the  great  diameter  of  the  tumor  at 
the  same  time.  A  simple  incision  is  in  general  sufficient;  however,  if  the 
hernia  is  very  large  and  there  is  difficulty  in  laying  bare  its  neck,  there  is  no 
objection  to  converting  this  first  division  into  a  T  incision  in  the  manner  of 
M.  Boyer,  by  making  another  cut  with  the  bistoury  on  the  superior  lip, 
or  on  the  other,  as  there  may  be  occasion  to  lay  bare  the  internal  or 
external  side  of  the  canal. 

There  is  no  reason  why  in  every  case  a  T  incision  should  be  made,  the  ver- 
tical branch  of  which  is  turned  upwards,  as  directed  by  Sir  A.  Cooper,  in 
order  to  run  no  risk  with  the  internal  saphena  vein.  The  crucial  incision 
directed  in  the  Clinique  of  Pelletan,  which  M  Dupuytren  has  often  employed, 
can  be  but  very  rarely  indispensable.  But  if  there  is  good  reason  to  have 
recourse  to  it,  the  fears  of  the  English  surgeon  in  respect  to  the  saphena 
should  by  no  means  be  an  obstacle,  for  this  vein  is  always  placed  beneath  and 
behind  the  hernia.  After  opening  the  sac,  it  is  as  rare  that  we  are  to  reduce 
the  organs  without  incision  as  M.  Boyer  remarks,  as  it  is  common  to  see  the 
intestine  excoriated,  ulcerated,  or  perforated  in  the  portion  which  suffijrs  the 
constriction.  The  stricture  being  in  general  caused  by  the  sharp  edge  of  the 
falciform  process  of  ihe  fascia  lata,  or  the  concavity  of  Gimbernat's  ligament, 
the  circle  embraced  by  these  two  parts  must  first  be  examined.  Ulceration 
existed  in  this  place  with  the  patient  operated  upon  in  my  presence  by 
M.  Wessely,  with  a  woman  upon  whom  I  operated  myself,  and  with 
several  individuals  operated  upon  by  Rona,  Boyer,  Lawrence,  &c.  The 
attempt  must  not  be  made,  therefore,  to  reduce  the  parts  before  bringing  out 
the  portion  which  was  contained  in  the  canal;  consequently,  incision 
without  opening  the  sac  is  not  applicable  in  this  case.  On  account  of  the 
danger  of  cutting  the  structure  in  crural  hernia,  dilatation  has  been  thought 
of.  Externally  it  is  said  you  have  the  epigastric  artery,  above  the  spermatic 
cord,  within  you  will  wound  the  obturator  if  it  arise  from  the  epigastric. 
Happily  these  dangers  are  much  less  in  practice  than  in  theory.  Sharp  cut 
outwards  and  upwards,  and  although  he  operated  on  a  great  number  of  subjects 
sve  do  not  see  tkit  he  ever  happened  to  wound  the  pudic  artery,  the  tying  of 


OPERATIVE    SURGERY.  623 

which  by  the  way  he  considered  very  easy.  Pott  cut  upwards,  and  the  spermatic 
cord  does  not  appear  to  have  been  wounded  by  him.     Since  Gimbernat,  most 
surgeons  cut  inwards,  and  there  is  no  proof  that  the  sub-pubic  branch  has  ever 
been  divided  in  this  manner.     It  is  sufficient  however  that  the  thing  be  possi- 
ble, not  to  neglect  the  means  of  avoiding  it  with  most  certainty.     The  process 
of  Sharp  is  evidently  the  worst  of  all.     M.  Dupuytren,  who  appears  to  have 
reproduced  it  and  conformed  to  it  for  a  long  time  in  his  practice,  has  modified 
it  in  such  a  manner  that  it  is  no  longer  attended  with  the  same  dangers.    This 
surgeon  carries  the  edge  of  his  curved  bistoury  reversed  on  the  external  edge 
of  the  opening  for  the  saphena  between  the  laminse  of  the  fascia  lata,  so  that 
he  cuts  the  tissues  from  before  backwards  or  from  below  upwards,  and  thus 
desti'oys  the  strangulation  before  arriving  at  the  place  occupied  by  the  artery 
to  be  avoided.     In  this,  his  method  has  but  one  inconvenience ;  which  is,  that  it 
is  not  applicable  to  a  stricture  depending  on  the  neck  of  the  sac.     It  may  also 
be  applied  upon  every  other  point  of  the  ring ;  but  as  the  incision  of  the  falciform 
process  generally  relaxes  the  whole  extent  of  the  opening,  it  has  the  advan- 
tage of  being  sufficient  in  the  greater  number  of  cases.     The  incision  upwards 
and  a  little  inwards  is  not  formidable  in  woman  when  there  is  no  vascular 
anomaly ;  in  man  on  the  contrary  it  may  lead  to  a  wound  of  the  spermatic  ves- 
sels.    Arnault  says  he  was  witness  to  an  operation  in  other  respects  performed 
very  well,  and  of  which  the  patient  died  in  consequence  of  hemorrhage  from  the 
spermatic  artery.     Scarpa  took  pains  to  demonstrate  that  it  is  almost  impossi- 
ble to  cut  in  this  direction  without  incurring  the  danger  pointed  out  by  Arnault. 
Experiments  tried  by  the  latter  in  presence  of  Bassuel,  Boudou,  &c.,  and  the 
plates  of  the  learned  anatomist  of  Pavia  tend  in  fact  to  prove  that  by  cutting 
the  ligament  of  Fallopius  from  below  upwards  to  the  extent  of  two  or  three 
lines,  the  spermatic  artery  is  almost  inevitably  wounded.     Happily,  chance 
or  circumstances  deceived  these  observers,  and  their  fears  are  really  exag- 
gerated.    First,  it  is  not  correct  to  maintain  with  Scarpa  that  the  spermatic 
cord  rests  immediately  on  the  bottom  of  the  gutter  of  Poupart's  ligament. 
Some  muscular  fibres,  and  a  cellulur  tissue  sometimes  quite  abundant,  usually 
separate  them.     It  is  not  under  the  edge  of  the  internal  oblique  but  rather 
between  its  fibres  that  the  cord  passes.     Besides,  this  ligament  has  four  to  five 
lines  of  height  in  the  internal  half  of  the  ring.     Outwards  it  would  be  entirely 
divided  before  running  any  risk,  and  this  is  never  indispensable.     When 
we  give  from  six   to    eight    or  ten    lines    of  extent  to  the    incision,    the 
danger  which  alarmed  Scarpa  and  other  modern  surgeons  cannot  be  denied  to 
exist ;  but  at  the  present  day,  as  the  cut  is  never  more  than  two  or  three  lines 
in  length  these  fears  are  without  much  foundation.    The  case  reported  by  M. 
Lawrence  would  be  moreover  further  proof  of  this,  for  notwithstanding  the 
complete  division  of  the  external  pillar  of  the  external  oblique,  the  cord  was 
not  touched  in  the  subject  of  whom  he  speaks.     Besides,  is  it  very  true  that 
an  artery  of  as  little  importance  is  that  which  goes  from  the  epigastric  to  the 
scrotum,  or  that  the  spermatic  itself  is  capable  of  occasioning  so  dangerous  a 
hemorrhage  ?   It  is  outside  of  the  peritoneum  too  that  it  would  be  found  divided, 
and  on  this  supposition  it  does  not  appear  that,  either  by  means  of  a  ligature 
or  suture,  plugging  or  compression,  it  would  be  very  difficult  to  obliterate  it. 
And  might  not  Arnault  have  been  deceived  as  to  its  being  hemorrhage  under 
which  the  individual  sunk  whose  case  he  relates  ?  Were  there  not  in  this  case 
some  particular  circumstances  which  he  neglected  to  mention  r 


624  NEW  ELEMENTS  OF 

Gimbernat,  whose  labors  had  already  been  made  known  at  MontpeUier  in 
1788,  by  M.  Purcel  y  Venuales,  having  studied  better  than  his  predecessors 
the  anatomical  arrangement  of  the  passages,  thought  that  the  danger  in  the 
process  of  Sharp  and  lesion  of  the  cord  might  be  avoided  by  cutting  inwards. 
His  end  being  to  separate  with  the  bistoury,  curved  or  straight,  the  triangular 
expansion  to  which  his  name  has  been  given,  from  the  inferior  edge  of  Pou- 
part's  ligament  he  carries  the  instrument  to  the  superior  part  of  the  internal 
semi-circumference  of  the  ring,  and  then  directs  it  obliquely  inwards  and 
downwards  as  for  reaching  the  pubis  by  following  the  direction  of  the  exter- 
nal pillar  of  the  inguinal  passage.  In  this  manner  the  epigastric  artery  and 
the  spermatic  vessels  are  certainly  avoided.  Scarpa  and  the  moderns  add 
that  it  will  be  the  same  with  respect  to  the  obturator  when  it  comes  from  the 
supra-pubic  artery,  since  the  incision  follows  in  some  measure  the  same 
course  as  the  vessel ;  but  to  obtain  this  advantage  it  will  not  be  necessary  to 
act  through  Gimbernat's  ligament  at  its  middle,  and  still  less  to  cut  obliquely 
from  below  upwards,  keeping  close  to  the  pubis  as  a  considerable  number  of 
French  surgeons  understand  and  daily  practise.  Although  it  is  preferable, 
yet  what  we  have  said  above  of  the  varieties  sometimes  presented  by  the 
epigastric  and  obturator  vessels,  proves  that  this  method  does  not  entirely 
secure  us  from  hemorrhage.  It  would  even  render  it  very  liable  to  occur,  if 
the  epigastric  artery,  or  one  of  them,  if  there  are  two,  should  be  found  to  the 
inner  side  of  the  neck  of  the  sac,  and  also  in  case  a  large  branch  coming  from 
the  internal  iliac  or  hypogastric  vein  should  ascend  also  on  the  inside  of  the 
neck  of  the  sac,  as  M.  Manec  has  pointed  out  in  his  thesis,  and  wliich  M. 
Meniere  says  that  he  has  seen.  In  this  case,  incision  upwards  may  be  the  most 
certain  to  prevent  hemorrhage,  especially  if,  as  M.  Manec  directs,  the  bistoury 
be  carried  upwards  and  without  the  ring,  in  order  to  divide  Poupart's  liga- 
ment partially  and  perpendicularly  to  its  axis.  Some  condemn  the  incision 
inwards  as  endangering  the  uterus  and  intestine  in  pregnant  women,  or  the 
bladder  when  distended  with  urine.  Hey,  who  quotes  a  case  of  the  latter 
description,  and  who  has  never  divided,  nor  seen  divided,  the  epigastric 
artery,  concludes  therefrom,  notwithstanding  the  remarks  of  Sir  A.  Cooper, 
that  it  is  best  to  cut  the  ring  upwards  and  outwards  according  to  the  practice 
of  Sharp ;  but  it  is  clear  that  a  prudent  surgeon  will  always  avoid  without 
difficulty  the  urinary  reservoir  and  the  gestatory  organ,  so  that  if  the  method 
of  Gimbernat  were  attended  with  no  other  dangers  the  objections  of  the  able 
surgeon  of  Leeds  would  be  of  little  weight.  The  femoral  circumflex  artery 
coming  by  anomaly  from  the  epigastric,  or  vice  versa,  so  as  to  pass  in  front  of 
the  hernia,  is  the  only  one  which  cannot  be  avoided,  unless  discovered  in  lay- 
ing bare  the  sac ;  happily  the  wound  in  it  would  be  necessarily  near  the  sur- 
face, and  it  would  be  easily  seized  and  tied.  On  the  whole,  the  most  certain 
method  of  performing  this  incision  without  danger,  is,  in  my  opinion,  to  cut 
successively  on  several  points  of  the  sharp  edge  of  the  crural  canal,  as  shown 
by  Scarpa,  M.  Manche,  and  M.  Dupuytren  (unless  the  septum  crKrale,  that 
is,  the  process  of  the  fascia  propria  which  closes  the  canal  superiorly,  have  been 
transformed  into  a  fibrous  circle,  the  possibility  of  which  is  pointed  out  by  M. 
J.  Cloquet),  and  only  to  the  extent  of  two  or  three  lines  for  each  division. 
The  anatomical  disposition  of  this  passage,  and  the  operations  which  I  have 
already  performed,  induce  me  to  believe  that  the  stricture  in  this  place  is 


OPERATIVE    SURGERY.  •         625 

always  produced  by  the  free  edge  of  the  falciform,  process,  the  concavity 
of  Gimbernat's  ligament  or  the  neck  of  the  sac,  and  scarcely  ever  by  the 
superior  ring;  so  that  generally  it  should  be  sufficient  to  incise  its  inferior 
opening  at  one  or  more  points  to  produce  a  proper  relaxation,  without  carry- 
ing the  bistoury  into  the  abdomen.  If  this  doctrine  is  not  adopted,  the  inci- 
sion should  be  made  according  to  the  principles  of  the  surgeon  of  Madrid,  or 
from  below  upwards,  if  we  could  cease  to  be  tormented  wdth  the  apprehension 
of  wounding  the  spermatic  cord. 

A  celotomy  recently  performed  at  La  Charite,  proves  nevertheless  that  the 
incision  inwards  may  be  followed  by  hemorrhage.  Arterial  blood  issued  in 
great  quantity  from  the  wound.  An  assistant  was  obliged  to  carry  his  finger 
to  the  bottom  of  the  ring,  and  compress  from  behind  forwards.  M.  Boyer 
immediately  had  recourse  to  a  little  sac  of  linen  carried  even  into  the  iliac 
fossa,  which,  being  then  filled  with  charpie,  was  substituted  for  the  finger  of 
the  assistant.  This  apparatus  was  not  removed  before  five  days.  Hemorr- 
hage did  not  reappear,  an*d  the  patient  was  completely  restored.  It  would  be 
difficult,  I  think,  to  tell  what  artery  was  here  wounded.  Was  it  the  obturator 
coming  from  the  epigastric?  It  would  be  necessary  to  admit  that  it  had 
passed  above  the  neck  of  the  hernia.  Was  it  the  epigastric  or  an  abnormal 
epigastric  as  in  the  case  of  M.  Lauth?  Might  it  not  rather  be  the  small 
branch  naturally  given  off  by  the  supra-pubic  artery  behind  the  symphisis, 
arid  which  being  more  developed  than  usual,  gave  rise  to  this  accident  ?  On 
this  subject  it  is  perceived  that  there  can  only  be  suppositions. 

The  relation  of  the  vessels  with  the  neck  of  the  sac  w411  render  the  mistake 
so  dangerous,  if,  as  seen  by  Richter  and  A.  Cooper,  an  inguinal  hernia  be 
taken  for  a  crural  hernia,  and  reciprocally,  that  the  surgeon  should  never 
lose  sight  of  it.  A  merocele  pushed  in  front  of  the  inguinal  canal  by  old 
cicatrizes  of  the  hollow  of  the  thigh,  as  in  the  case  reported  by  M.  Boulu  in 
the  name  of  M.  Marjolin,  might  easily  give  rise  to  error  on  this  point;  and 
incision  outwards,  as  for  bubonocele,  would  endanger  the  epigastric  artery. 
M.  Roux,  who  incises  like  Gimbernat,  had  occasion  to  esteem  himself  very 
fortunate  in  ascertaining  by  dissection,  that  the  inguinal  hernia,  which  he  had 
taken  for  a  crural  hernia,  was  formed  within  the  artery;  that  is,  was  direct 
or  internal.  If  in  a  similar  case,  Pelletan  had  not  discovered  his  error  on 
arriving  at  the  viscera,  it  is  very  probable  that  chance  would  not  have  served 
him  so  happily,  and  the  epigastric  artery  would  have  run  the  greatest  risk. 
Two  other  kinds  of  incision  have  been  proposed  by  Else  and  A.  Cooper  for 
crural  hernia.  I  have  already  said  something  of  them  in  treating  of  hernia  in 
general,  and  inguinal  hernia  in  particular.  In  the  first,  the  surgeon  cuts  the 
aponeurosis  of  the  external  oblique  above,  and  in  the  direction  of  Poupart's 
ligament,  removes  the  cord  by  pushing  it  inwards  and  upwards,  penetrates  as 
far  as  the  peritoneum,  passes  a  sound  bent  into  a  hook  between  the  neck  of 
the  sac  and  the  ring  from  behind  forwards,  or  from  the  interior  towards  the 
exterior,  and  then  cuts  without  fear  and  as  freely  as  he  desires.  In  the  second 
also,  the  aponeurosis  is  to  be  cut  and  the  cord  removed,  but  the  incision  is 
made  from  the  exterior  towards  the  interior,  although  without  opening  the 
sac.  These  two  processes  which  have  been  several  times  tested  in  the  Lon- 
don hospitals,,  have  too  many  disadvantages  to  be  generally  adopted,  or  for 
me  to  stop  to  describe  or  oppose  them  at  greater  length. 
79 


6£6  NEW    ELEMENTS   OF 

ARTICLE  III, 
Umbilical  Hernia. 

§  1 . — Anatomical  Remarks, 

With  respect  to  hernias  the  umbilicus  is  presented  in  two  very  different 
conditions  at  different  periods  of  life.  Before  birth  it  is  a  ring  with  but  little 
resistance,  giving  passage  at  the  same  time  to  the  three  umbilical  vessels  and  the 
prolcfngation  of  the  bladder,  called  the  urachus.  As  soon  as  the  child  is 
separated  from  its  mother,  the  parts  contained  in  this  ring  contract,  solidify, 
and  cease  to  fill  it  exactly ;  and  it  is  thus  that  the  intestines  tend  continually 
to  escape  during  the  first  months  of  life.  Later,  the  ring  itself  contracts,  closes, 
is  applied  against  the  fibrous  muscles  formed  by  the  relics  of  the  vessels,  so 
that  in  the  end  the  whole  presents  under  the  aspect  of  a  very  dense  inodular 
cicatrix ;  and  in  adults  umbilical  hernias  are  not  made  through  the  ring  itself, 
as  in  infancy,  but  by  penetrating  the  aponeurotic  fibres  some  lines  without 
its  circumference.  Seen  from  the  interior  of  the  abdomen,  the  umbilical 
region  considered  in  man  entirely  developed,  sometimes  presents  a  prominence, 
and  more  frequently  a  slight  tunnel -formed  depression,  upon  which  are  spread 
in  a  radiated  manner  the  suspensory  ligament  of  the  liver  above,  and  the 
remains  of  the  umbilical  arteries  with  the  urachus  below.  These  four  cords 
circumscribe  their  four  triangles,  whose  points  meet  on  the  circumference 
of  the  mesogastric  cicatrix.  In  the  interval,  the  serous  membrane,  always 
easily  recognized  becomes  more  and  more  adherent  as  it  approaches  the  centre, 
so  that  behind  the  ring  it  is  entirely  blended  with  the  tissues  which  it  lines. 
T\\Q  fascia  propria  or  the  sub-peritoneal  cellular  tissue  is  for  the  sanle  reason 
in  very  small  quantity  and  very  compact.  The  fascia  transversalis  does  not 
extend  so  far.  The  fascia  superfcialis  and  the  adipose  cellular  tissue,  as  well 
as  the  integuments  themselves,  have  nothing  in  them  remarkable,  except  that 
they  reach  like  the  corresponding  tissues  behind  as  far  as  the  umbilical 
tubercle,  with  which  they  are  also  very  intimately  blended.  With  this  arrange- 
ment, it  is  evident  that  the  several  points  of  the  umbilical  periphery  do  not 
offer  the  same  resistance  or  the  same  solidity.  On  account  of  the  vein  being 
the  last  obliterated,  of  its  being  naturally  softer  and  less  voluminous,  and 
nothing  tending  to  draw  it  upwards,  the  umbilicus  in  general  remains  weaker, 
thinner,  and  more  easily  dilated  or  passed  through  in  its  superior  half  than 
inferiorly,  where  the  three  branches,  arterial  and  vesical,  are  applied  with  force 
against  each  other,  soon -acquiring  a  solidity  which  closes  it  exactly  in  this 
direction.  But  when  it  is  said  that  umbilical  hernia  in  adults  does  not  take 
place  through  the  ring,  some  explanation,  is  necessary.  If  the  term  exom- 
phalos  is  reserved  for  that  only  which  distends  and  pushes  before  it  the  cica- 
trix, making  it  in  some  measure  disappear,  it  is  true  that  it  is  only  met  with  in 
infants,  because  in  fact  it  is  only  possible  while  the  several  branches  of  the 
omphalo -placental  cord  have  not  yet  become  solid  and  transformed  into  a 
fibrous  knot.  But  if  it  be  umbilical  hernia  whenever  an  organ  has  escaped 
by  the  ring  which  was  filled  by  the  expanded  vessels  during  the  festal  life,j 
undoubtedly  it  is  possible,  and  has  been  met  with  at  every  period  of  life.     M 


OPERATIVE    SURGERY.  627 

in  this  case  the  cicatrix  is  usually  thrown  to  either  side  of  the  tumor  and 
scarcely  ever  upon  its  centre,  this  arises  from  its  being  always  a  little  less 
adherent  on  certain  points  of  its  circumference  than  on  the  rest.     Scarpa 
relates  however,  that  in  one  of  his  patients  the  sac  was  divided  into  several 
apartments,  by  the  ligaments  of  the  niesogastric  muscles.    Moreover,  as  in  this 
place  there  is  no  circle  nor  canal  naturally  open,  if  is  easy  to  see  that  hernia 
should  be  made  almost  as  frequently  through  a  fissure  of  the  aponeurosis  or 
linea  alba  as  through  the  umbilicus  itself;  so  that  Monteggia,  who  was  one  of 
the  first  to  say  that  hernias  of  this  region  happen  without  the  ring,  was  only 
wrong  in  making  that  a  constant  occurrence  which  was  merely  a  very  frequent 
one.     Be  this  as  it  may,  the  viscera  in  this  place  only  pass  through  a  simple 
ring.     There  is  no  umbilical  canal,  and  it  is  almost  unexampled  for  the  arteries 
to  have  preserved  their   cavity  until  adult  life.      Haller,  Boerhaave,  and 
some  others,  contended  that  this  is  not  the  case  with  the  vein,  the  permea- 
bility of  which  however  is  so  rare  that  it  should   cause  no  apprehension  in 
the  operation.     In  the  anomaly  observed  by  M.  Manec,  the  supernumerary 
epigastric  vein  issued  through  the  umbilicus  without  losing  its  volume,  and 
formed  an  irregular  loop  beneath  the  integuments,  re-entered  the  abdomen 
through  the  same  opening,  and  run  into  the  horizontal  fissure  of  the  liver ; 
while  that  published  by  M.  Meniere  ran  directly  beneath  the  liver  without 
deviating  towards  the  skin.     It  is  evident  therefore  tliat  the  risk  of  cutting  this 
vein  is  the  greater  as  nothing  can  indicate  beforehand  in  what  direction  it  will 
be  found.     As  the  viscera  escapes  through  a  simple  circular  opening  and  not 
through  a  canal,  umbilical  hernia  has  not,  as  inguinal  or  crural  hernia,  any 
sheath,  fibrous  or  serous,  which  may  strangulate  it  at  a  variable  distance  from 
its  root.     The  peritoneal  layer  which  is  there  observed  presents,  not  at  all, 
or  very  incompletely,  the  characters  by  which  it  is  known  in  the  groin ;  and 
to  exomphalos  is  strictly  applicable  what  I  have  said  of  the  absence  of  the  sac 
when  treating  of  the  operation  in  general.     It  was  this  which  Lassus  said 
was  deprived  of  it  in  a  case  in  which  it  was  surrounded  with  such  thin  cover- 
ings, that  he  opened  the  intestine  which  had  passed  through  a  rupture  of  the 
epiploon.    The  external  face  of  the  membrane  is  so  closely  united  with  the 
surrounding  laminae,  that  it  is  most  frequently  impossible  to  separate  it  from 
them.     In  reality,  it  is  only  the  portion  which  originally  line  that  point  of  the 
ring,  which  the  organs  have  pushed  before  them  in  forming  the  hernia.     Being 
enlarged  by  simple  distention,  as  a  cell  of  lamellated  tissue  which  enlarges 
to  form  a  cyst,  and  not  by  the  progression  or  accompaniment  of  the  abdominal 
peritoneum,  it  cannot,  as  in  the  groin,  be  distinguished  from  the  other  tissues. 
A  peculiarity  no  less  important  in  practice  is,  that  it  seldom  contains  any 
serosity,  and  therefore  is  almost  constantly  found  in  immediate  contact  with 
the  viscera.    I  must  say  however  that  this  law  has  been  laid  down  in  too  absolute 
a  manner.     In  a  woman  upon  whom  I  operated  some  days  since  for  a  strangu- 
lated exomphalos,  there  was  more  than  six  ounces  of  reddish  serosity  in  the 
hernial  envelopes,  and  about  three  ounces  came  from  another  who  was  operated 
upon  at  Tours  in  1818  by  M.  Piplet  in  my  presence. 

The  organs  which  may  be  displaced  to  form  umbilical  hernia,  in  their  order 
of  frequency  are  the  epiploon,  the  transverse  colon,  the  small  intestine,  the 
stomach,  the  coecum,  the  sigmoid  flexure  of  the  colon,  the  liver,  the  duodenum, 
and  even  the  pancreas.      These  several  parts  are  sometimes  found  in  it  in  so 


628  NEW   ELEMENTS   OF 

great  a  number,  and  forming  so  considerable  a  mass,  their  containing  pouch 
becomes  extremely  thin,  so  as  even  to  burst  at  last,  as  occurred  to  the  patient 
mentioned  by  M.  Boyer,  whose  death  the  operation  could  not  prevent.    More 
than  once  it  has  been  seen,  in  the  foetus  especially,  entirely  deprived  of  cover- 
ing, or  only  covered  with  an  exceeding  thin  membrane.    Mery  and  Balzac 
have  given  cases  of  this  kind.     I  observed  one  myself  in  1819  at  Tours  in  the 
practice  of  M.  Mignot.    It  often  happens,  but  not  always,  as  some  facts  first 
induced  me  to  believe,  that  the  digestive  tube  is  situated,  at  the  beginning  of 
embryo  existence,  in  the  root  of  the  umbilical  cord.    But  if  the  return  of  the 
intestines  does  not  take  place,  or  only  partially  occurs  before  the  end  of  preg- 
nancy, the  child  is  born  with  exomphalos.    The  viscera  in  this  case  should  be 
covered  only  by  the  thin  tunics  of  the  omphalo -placental   cord.     And  we 
easily  conceive  how  distension  may  rupture  this  feeble  barrier,  and  leave  the 
hernia  completely  bare.     The  same  may  also  happen  in  the  first  hours  or  days 
after  birth.  In  this  respect  therefore  an  essential  difference  is  to  be  established 
between  umbilical  hernia  of  the  fostus,  that  of  the  first  moments  of  external 
life,  and  that  of  adult  age.    In  the  first,  the  natural  tunics  of  tlie  cord  form  the 
sac  and  the  envelopes  ;  in  the  second,  the  cicatrix  having  had  time  to  be 
formed,  the  organs  in  issuing  must  cover  themselves  with  the  peritoneum,  the 
integuments,  and  the  intermediate  cellular  tissue;  the  third,  obliged  to  pass 
between  the  vessels  or  along  side  of  the  common  knot  that  unites  them,  is 
moreover  forced  in  the  majority  of  cases  to  break  through  the  interior  of  the 
ring  or  the  environs  of  its  circumference,  to  open  itself  a  passage  and  become 
situate  beneath  tlie  skin,  distending  by  degrees  the  corresponding  peritoneum 
Frequently  too  the  hernia  is  aftected  at  some  distance  from  the  umbilicus  or 
in  its  periphery.     As  long  as  it  ia  only  one  or  two  lines  from  that  point,  its 
texture  and  the  relative  disposition  of  its  elements  offer  nothing  peculiar; 
but  if  it  is  further  removed,  the  sac  and  its  cellular  lining  present  other  cha- 
racteristics.    The  peritoneum  is  then  more  movable  and  less  adherent,  and 
allov.s  itself  to  be  carried  along  and  displaced  without  difficulty;  and  an  um- 
bilical hernia  of  this  description  is  often  found  furnished,  with  an  evident  sac. 
The  fascia  propriay  having  recovered  a  part  of  its  laxity  >  and  its  thickness, 
allows  the  sac  to  be  distinguished  from  the  external  tissues,  and  fat  or  serosity 
sometimes  to  accumulate  in  its  parenchyma;  and  thus  have  fatty  tumors  or 
hernias  been  seen  to  manifest  themselves  around  the  umbilicus.     M.  Fardeau 
cites  one  which  was  prolonged  into  the  interspace  of  the  two  laminae  of  the 
suspensory  ligament  of  the  liver.    M.  Bigot,  M  OUivier  of  Anglers,  Beclard. 
and  before  them  Heister,  Petsch,  Morgagni,  Klinkosch,  Pelletan,  Scarpa, 
Mr.  Lawrence,  M.  Crueilhier,  and  M.  Berard,  have  met  with  others  which 
had  their  root  in  the  sub-peritoneal  layer,  and  I  recently  dissected  one  which 
extended  as  far  as  the  falsiform  curve  of  the  umbilical  vein.     It  was  probably 
above  this  cicatrix,  and  not  through  its  interior,  that  the  hernia  mentioned  by 
M.  Cloquet  escaped,  which  had  pushed  before  it  the  hepatic  ligament  and 
used  it  as  a  sac. 

§  2,  Operation, 

The  operation  for  umbilical  hernials  considered  very  dangerous,  and  appears 
in  fact  to  be  more  so  than  that  for  inguinal  or  crural  hernia.    This  depends 


OPERATIVE   SURGERY.  629 

perhaps  onihe  proximity  of  the  stomach  or  diaphragm  on  the  organs  contained 
in  the  tumor  having  more  immediate  relations  with  the  principal  viscus  of 
digestion,  or  perhaps  on  the  too  advanced  stage  of  the  disease,  when  the  operation 
is  usually  decided  upon.  But  before  looking  for  tJie  causes,  it  would  be  better 
to  establish  tlie  fact  itself,  and  be  positively  assured  that  the  operation  is 
actually  more  dangerous  at  the  umbilicus  than  elsewhere.  If  the  tumor  is  of  mid- 
dling size,  a  simple  incision  parallel  with  the  linea  alba,  is  sufficient  to  lay  it 
bare.  In  the  contrary  case,  Scarpa  to  the  contrary  notvvithstanding,  there  is 
no  objection  to  the  T  incision,  or  even  the  crucial.  This  incision  is  to  extend 
at  both  extremities  a  little  beyond  the  tumor.  In  this  place  the  integuments 
are  in  general  too  tense  to  allow  of  the  precaution  of  a  fold  before  dividing 
tliem.  They  are  then  cut  from  without  inwards  as  if  for  laying  bare  an  artery. 
The  subjacent  layers  are  to  be  cut  in  the  same  manner ;  that  is,  passing  the  bis- 
toury over  them  with  all  possible  lightness.  The  sac  not  being  separable  is 
hard  to  be  discovered,  if  we  persist  in  cutting  layer  by  layer  with  strokes  on  a 
determined  point  the  parts  which  separate  it  from  the  skin.  But  as  it  is  often 
very  near  the  cutaneous  envelope,  and  usually  contains  but  very  little  serosity, 
too  much  caution  cannot  be  used  in  seeking  it.  From  the  moment  the  bottom 
of  tlie  incision  seems  to  be  formed  but  by  a  very  thin  lamella,  the  instrument 
must  be  handled  more  lightly  than  before ;  and  when  the  membrane  just 
divided  is  found  to  be  separated  from  the  parts  it  covers  by  the  least  interspace, 
a  director  is  to  be  carried  beneath  it,  for  we  have  probably  arrived  at  the  sac. 
There  will  be  no  further  doubt  on  the  subject,  if  any  fluid  escapes,  or  if,  as  is 
frequently  observed,  some  fatty  lumps  protrude  through  the  opening.  Having 
arrived  within  the  hernial  pouch,  the  bistoury  conducted  by  the  under  finger, 
if  the  probe  pointed  bistoury  is  used,  otherwise  by  the  grooved  director,  imme- 
diately enlarges  the  first  orifice  and  opens  largely  all  the  coverings  of  the 
tumor.  In  umbilical  hernia,  particularly,  the  epiploon  is  apt  to  be  found 
forming  there  sometimes  a  considerable  mass.  We  must  not  however  be 
deceived  by  appearances.  Beneath  it  is  almost  always  found  a  portion  of 
intestine,  which  it  covers,  forming  in  some  degree  a  second  sac.  For  this 
reason  has  been  seen  here  more  frequently  than  elsewhere  the  intestinal  pro- 
cidentia rupturing  its  epiploic  covering,  passing  through  it,  becoming  stran- 
gulated in  the  ring  thus  made,  and  placing  itself  in  immediate  contact  with  the 
real  sac,  presenting  in  a  word  under  the  edge  of  the  bistoury  the  moment  that 
has  penetrated  into  the  interior  of  the  hernia. 

After  opening  tlie  sac,  the  first  thing  to  be  done  is  to  ascertain  the  arrange- 
ment of  the  displaced  organs.  Consequently  some  point  of  the  epiploon 
which  is  not  adherent  is  sought  with  the  finger,  lifted  up,  unfolded,  and 
extended  on  one  edge  of  the  wound.  The  intestine  is  then  seen  beneath, 
if  it  be  in  the  tumor  at  all.  In  cases  where  this  simple  derangement  of  the 
parts  will  suffice  to  allow  its  reduction,  this  should  be  effected  immediately. 
Hey,  and  almost  every  operator  since  him,  have  insisted  strongly  on  the 
reduction  being  commenced  with  the  intestine,  and  not  with  the  epiploon  as 
recommended  by  Pott.  The  intestinal  portion  having  come  out  last,  being 
situated  more  deeply,  and  in  general  easier  pushed  back,  is  most  conveniently 
reduced  first.  However,  if  an  opposite  disposition  is  met  with,  and  the 
omentum  has  more  tendency  to  return  than  the  intestine,  I  do  not  see  why 
we  should  persist  in  following  the  rule  laid  down  by  Hey.    When  the  intes- 


630  NEW   ELEMENTS    OF 

) 

tine  is  gangerous,  and  this  should  rarely  be  the  case,  since,  as  is  well  knowR 
mortification  is  infinitely  slower  in  manifesting  itself  in  hernias  of  the  large 
intestine  in  entero-epiploceles,  and  especially  in  hernias  purely  epiploic  than 
in  enterocele,  it  must  be  recollected  tliat  stercoral  fistulas  or  preternatural 
ani  at  the  umbilicus  are  seldom  cured.  This  arises,  as  Scarpa  has  clearly 
established,  from  there  being  no  membranous  funnel  formed  at  the  expense 
of  the  sac  behind  the  umbilical  circle.  How  could  it  be  formed  in  fact,  since 
the  serous  surface  of  the  pouch  is  intimately  adherent  to  it,  is  formed  there, 
developed  at  once,  and  not  borrowed  from  the  internal  peritoneum  as  in 
inguinal  or  crural  hernia?  Gangrene,  or  a  perforation  of  the  intestine,  seems 
therefore  to  require  that  invagination  or  the  suture  be  resorted  to  immediately, 
and  that  we  should  not  attempt  the  establishment  of  an  abnormal  anus.  I 
would  say,  however,  that  in  the  operation  performed  by  M.  Pipelet,  which  I 
have  mentioned  above,  a  gangrenous  eschar  of  the  intestine  was  removed,  and 
a  fistula  established,  which  being  left  to  itself  ultimately  closed  and  cica- 
trized completely.  It  was  also  in  a  case  of  umbilical  hernia  that  M.  Chemery 
Have  performed  invagination  with  success,  and  the  singular  operation 
reported  by  Scarpa,  who  took  it  from  the  old  Journal  de  Medicine. 

The  incision,  when  necessary,  is  so  easily  performed  and  attended  with  sa 
little  danger  that  it  is  seldom  dispensed  with.  It  may  be  done  on  almost  any 
point  indifferently.  Strictly  speaking,  it  may  be  possible  to  touch  the  liver, 
to  wound  the  umbilical  vein  or  arteries,  and  even  the  urachus ;  but  to  hap- 
pen it  must  almost  be  done  on  purpose,  unless  in  case  of  anomalies  which  are 
too  rare  to  be  reckoned  among  the  dangers.  We  must  not,  however,  forget 
the  abnormal  veins  described  by  MM.  Manec  and  Meniere.  Although  it  is 
not  sensibly  more  advantageous  to  incise  the  umbilical  ring  downwards  than 
in  any  other  direction,  I  see  no  inconvenience  in  following  the  advice  of 
authors  who  recommend  for  greater  safety  to  direct  it  upwards  and  to  the 
left.  By  incising  largely,  the  risk  of  weakening  too  much  the  parietes  of  the 
abdomen,  and  exposing  the  patient  to  an  almost  certain  relapse,  will  be  easily 
avoided  it  seems  to  me,  if,  instead  of  making  a  single  incision  of  half  an  inch 
in  depth,  three  or  four  are  made  of  one  or  two  lines  only  on  different  points, 
as  in  the  patient  upon  whom  I  operated  with  M.  Gresely ;.  if,  in  a  word,  the 
'•  debridement  multiple"  be  adopted  in  umbilical  hernia  as  in  those  which 
have  been  treated  of  heretofore.  Although  there  is  no  such  thing  in  exom- 
phalos  as  strangulation  by  the  neck  of  the  sac,  and  although  the  ring  producing 
the  stricture  is  generally  round,  prudence  does  not  the  less  dictate  to  see^ 
before  proceeding  to  the  reduction,  in  what  condition  is  the  strangulated  por- 
tion of  intestine.  If  we  operate  without  laying  bare  the  whole  of  the  tumor, 
after  the  method  of  Franco,  Rousset,  or  Pigray,  it  must  be  recollected  that  the 
ring  is  seldom  distinct  from  the  sac,  and  unless  we  combine  as  directed  by 
M.  Raphel,  the  process  of  Bell  with  this  method,  we  shall  not  succeed  in 
removing  the  strangulation  without  at  the  same  time  penetrating  the  interior 
of  the  5ac.  This  mode  of  acting  is  still  less  proper  for  the  umbilicus  titan 
elsewhere,  although  Scarpa  recommends  it  with  a  kind  of  complaisance,  and 
Sir  A.  Cooper  had  recourse  to  it  twice  with  success  in  similar  cases.  Imme- 
diate union  may  be  attempted  with  more  advantage  and  facility  after  umbilical 
celotomy  than  in  the  after  treatment  of  hernias  of  the  groin.  The  whole 
pouch,  formed  in  some  measure  of  a  single  layer,  has  a  much  less  tendency 


OPERATIVE    SURGERY.  631 

to  roll  Upon  itself,  and  a  much  greater  to  reapply  itself  to  the  points  it  origi- 
nally occupied.  I  cannot  advise  it,  however,  because  in  my  opinion  the 
operation  renders  the  radical  cure  so  much  the  more  probable  as  the  wound  is 
cicatrized  in  a  manner  more  completely  mediate.  For  the  rest,  this  is  the 
part  of  the  body  where  the  organs  have  the  most  need  of  being  sustained  by 
moderate  compression,  after  being  returned  into  the  abdomen,  and  this,  no 
doubt,  because  the  opening  which  afforded  them  passage,  is  usually  very 
large,  and  because  especially  it  forms  a  ring,  a  complete  circle,  which  passes 
directly  through  the  abdominal  wall. 

Art,  4. —  Ventral  Hernias, 

Hernias  in  the  linea  alba,  whether  above  or  below  the  umbilicus,  differ  too 
little  from  those  we  have  just  examined  to  require  a  special  description.  If 
they  happen  to  become  strangulated,  which  is  almost  unheard  of,  their  opera- 
tion will  have  nothing  in  it  peculiar.  The  same  must  be  said  of  the  hernia  of 
the  flank  or  loin,  described  by  J.  L.  Petit,  observed  once  at  Mont  Rouge  by 
MM.  Cloquet  and  Cayol  in  a  man  seventy-five  years  old,  on  another  occasion 
by  Lassus  in  a  subject  who  had  one  on  each  side ;  since  then  by  Pelletan  in  a 
woman  who  had  the  belly  simultaneously  studded  with  hernial  protrusions. 
Ventral  hernias,  properly  so  called,  that  is,  those  which  are  formed  without 
the  linea  alba,  umbilicus,  and  other  natural  openings  in  the  abdomen,  either 
from  a  simple  fissure  in  the  aponeurosis  or  muscles,  or  in  consequence  of  a 
cicatrized  wound  of  the  parts,  as  Schmucker,  Desault,  Lassus,  Richerand, 
Anderson,  and  a  host  of  others  have  observed,  are  scarcely  ever  strangulated ; 
or  if  strangulation  does  take  place  it  is  almost  constantly  possible  to  reduce 
them  by  the  taxis,  by  position,  and  other  resources  pointed  out  in  the  preced- 
ing articles.  It  is  seen  nevertheless  in  the  English  journals  of  late  years  that 
neither  Mr.  Key  nor  Mr.  Bransley  Cooper  could  reduce  a  strangulated  ventral 
hernia  until  after  subjecting  it  to  an  operation  and  cutting  the  stricture,  when 
the  patient  was  happily  restored.  Supposing  all  these  species  of  tumors  to 
require  celotomy,  we  should  act  as  in  cases  of  umbilical  hernia,  and  they  will 
require  no  other  cure  than  the  course  of  the  epigastric,  lumbar,  or  anterior 
iliac  may  demand. 

Obturator  hernia,  of  which  examples  are  given  by  Arnault,  father  and  son, 
Duverney,  Garengeot,  Verdier,  Pipelet,  and  Eschenbach  ;  since  observed  by 
A.  Cooper,  H.  Cloquet,  Hesselbach,  and  Marechal,  and  which  seem  to  be 
sometimes  susceptible  of  strangulation,  would  be  a  little  more  embarrassing. 
The  opening  which  affords  it  passage  being  then  transformed  into  a  kind  of 
canal,  the  pelvic  orifice  of  which  is  formed  by  the  pubis  outwards  and  up- 
wards, and  by  the  obturator  membrane  in  the  rest  of  its  extent,  is  limited  by 
the  thickness  of  the  obturator  muscles.  In  this  case,  the  viscera  are  sur- 
rounded by  the  pectineus  anteriorly,  the  adductor  magnus  posteriorly,  and  the 
adductor  brevis  and  longus  interiorly  and  superiorly.  Being  obliged  to  pass 
through  these  several  muscles,  or  to  separate  them  to  become  evident  at  the 
internal  and  inferior  extremity  of  the  hollow  of  the  groin,  obturator  hernia 
does  not  appear  susceptible  of  being  strangulated  but  at  its  entrance  into  the 
obturator  canal,  as  really  occurred  in  the  cases  of  it  w^hich  have  been  reported. 
It  seems  that  the  sub-pubic  artery  being  always  found  on  its  external  side. 


632  OPERATVE  SURGERY^ 

either  above,  below,  or  directly  ■without,  the  incision  must  be  made  on  its 
internal  semi-circumference.  I  know  that  this  operation  was  first  attempted 
by  Garengeot  on  one  of  his  patients,  rue  du  Sepulcre,  and  more  recently  by  a 
German  surgeon  in  a  very  similar  case ;  but  when  we  think  of  the  parts  to  be 
passed  through  to  arrive  at  the  seat  of  strangulation,  of  the  depth  of  the  obtu- 
rator membrane,  and  of  the  difficulty  of  discerning  the  place  occupied  by  the 
vessels,  and  that  the  bladder  or  vagina  may  be  touched,  it  is  quite  allowable 
not  to  recommend  it.  Ischiatic,  perineal,  vulvary,  and  vaginal  hernias  also 
enter  entirely  into  the  domain  of  surgical  pathology,  and  have  no  other  rela- 
tion with  operative  surgery  than  inasmuch  as  the  taxis,  position,  and  retaining 
bandages  methodically  applied,  form  their  principal  remedy. 


OPERATIVE   STRGERY.  63S 


CHAPTEH  IV. 

SEXUAL  ORGANS. 

The  genital  system  of  either  sex  calls  so  often  for  the  assistance  of  opera- 
tive surgery,  that  it  alone  could  furnish  the  surgeon  matter  for  many  volumes. 
I  must  be  permitted  to  say  a  few  vi^ords,  in  anticipation,  upon  some  of  the 
least  familiar  of  its  diseases. 

Vegetations. — In  1825, 1  was  conducted  by  Mme.  Delon,  a  midwife,  to  the 
house  of  a  lady,  aged  about  30  years,  and  who  for  some  months  preceding 
had  had  a  pyriforme  tumor,  red,  and  of  but  little  consistency,  about  the  size 
of  a  nut,  the  lower  extremity  of  which  was  swelled  or  rounded  and  slightly 
projecting,  attached  by  its  root  to  the  urethra,  at  a  depth  of  4  lines.  I  seized 
it  with  a  curved  hook,  drew  it  a  little  towards  me,  and  excised  it  on  the  spot 
without  giving  the  least  pain  to  the  patient,  who  was  well  on  the  next  day. 
In  1 829  I  met  with  a  case  precisely  similar.  By  a  reference  to  the  Lancet 
it  will  be  seen  that  Mr.  Wardrop  has  noticed  three  others.  Similar  vegetations 
have  been  mentioned  as  occurring  in  females  by  Vogel,  Rosenmuller,  Chaus- 
sier ;  and  every  thing  leads  to  the  belief  that  excision  is  the  true  remedy  for 
this  affection. 

It  appears  that  men  are  equally  liable  to  them.  I  know  of  two  instances. 
In  one,  the  excrescences,  three  in  number,  scarce  equalled  in  size  the  bulk  of 
a  grain  of  barley.  In  the  case  of  the  second  patient,  a  young  Englishman,  who 
w^as  pointed  out  to  me  by  Mr.  Beaumont,  a  student  of  medicine,  there  were 
likewise  several,  but  they  were  still  smaller.  They  were  similarly  inserted 
behind  the  meatus  urinarius.  None  of  them  reappeared  after  being  injured  or 
excised.  Are  not  the  polypi  of  the  urethra,  about  which  M.  Nicod  has  for 
several  years  entertained  the  public,  and  about  which  he  has  again  published 
an  essay,  of  this  genus  of  production  ? 


SECTION  I. 

Sexual  organs  of  the  Male. 

»^rt,  l.—The  Scrotum, 

§  1.  Anatomical  Observations, 

As  I  remarked  when  speaking  of  inguinal  hernia,  it  is  almost  always  easy, 
with  a  little  attention,  to  distinguish  six  or  seven  concentric  tunics,  or  coat3 
in  the  scrotum;  1st,  the  skin;  2d,  the  subcutaneous  layer,  which  covers  at 
once  the  two  testicles;  3d,  the  deep  lamella  of  the  cellular  layer,  which, 
enveloping  the  whole  extent  of  the  cord  and  of  the  testicle,  come  together  to 
constitute  the  dartos  and  the  septum,  in  such  a  manner  as  to  separate  the  t,wo 
seminal  glands  from  each  other.  Beneath  these  three  first  layers,  which  may 
80 


634  NEW  ELEMENTS  OP 

be  called  the  general,  we  have  presented  to  us  the  mferior  or  special  sheaths,  Isf, 
that  which  is  continuous  with  the  circumference  of  the  abdominal  ring ;  2d, 
the  cremaster  muscle,  which  immediately  after  it  envelopes  the  testicle 
completely,  and  goes  down  to  the  bottom  of  the  scrotum  of  the  corresponding 
side  ;  3d,  the  fascia  transversalis,  which  constitutes  what  is  properly  called 
the  sheath  of  the  cord,  which  sheath  contains  within  it  the  fascia  propria,  the 
cellular  tissue,  and  the  spermatic  nerves  and  vessel,  with  the  vas  deferens, 
and  which  ceases  at  the  adherent  margin  of  the  seminal  gland.  We  have 
already  seen  that  but  few  vessels  are  distributed  to  these  numerous  layers ; 
they  are,  externally,  the  same  branches  of  the  scrotal  or  external  pudic 
arteries,  placed  transversely  or  obliquely  between  the  cremaster  muscle  and 
fascia  transversalis ; — the  inguinal  branch  given  off  by  the  epigastric  and 
the  spermatic  artery  enclosed  in  the  sheath  of  the  ring.  In  the  centre  of  all 
these  coats,  there  exists  yet  another  called  elytroid  or  vaginal,  which  sepa- 
rates them  from  the  testicle.  It  is  a  small  sac  adherent  on  its  external 
surface,  soft,  smooth,  bedewed  with  serosity  without,  and  which  may  be 
divided  in  the  mind  into  two  portions,  as  the  pleura  is  ;  the  one  portion  pari- 
etal, spreading  over  the  inner  surface  of  the  external  coverings,  the 
other  portion  visceral,  which  invests  the  testis  as  far  as  its  adherent 
margin,  at  which  the  two  sides  of  this  layer  form  by  their  approximation  a 
septum,  before  they  spread  out  to  become  continuous  with  the  parietal  layer. 
Superiorly  the  elytroid  tunic  is  prolonged  into  the  inguinal  canal,  crossing  it 
to  become  blended  with  the  peritoneum,  of  which  it  is  but  an  appendage. 

In  fact,  previous  to  birth  there  is  no  serous  coat  in  the  scrotum,  which  at 
that  period  is  composed  in  reality  only  of  integuments  and  subcutaneous 
layer  or  fascia  superficialis.  It  is  indispensable  that  he  who  would  form  an 
accurate  idea  of  what  is  observed  in  later  years  should  recollect  this  dispo- 
sition of  parts.  The  testicle,  which  during  foetal  existence  was  hidden 
underneath  the  kidney,  or  below  the  Fallopian  ligament,  drags  with  it  the 
peritoneal  coat  by  which  it  was  covered  in  the  abdomen,  and  to  which  it 
adhered  intimately  only  at  its  posterior  margin,  and  when  it  makes  its 
appearance  externally  turns  it  over  upon  itself.  As  it  continues  its  descent, 
the  testicle  carries  before  it  both  the  fascia  transversalis,  the  small  oblique 
muscle,  and  the  fibro  cellular  divi^ion  of  the  obliquus  externus.  These  ail 
press  upon  the  three  primitive  tunics  of  the  scrotum ;  but,  inasmuch  as  the 
deeper  of  these  three  latter  had  previously  contracted  adhesions  to  the 
inferior  surface  of  the  penis,  a  septum  consequently  results  which  is  soon 
much  increased  in  thickness  by.  the  correspondent  sides  of  the  distinct 
pouches  whj^h  have  descended  from  the  abdomen.  The  portion  of  peritoneal 
prolongation,  which  is  contained  in  the  inguinal  canal,  and  which  embraced 
the  side  of  the'cord  in  its  upper  portion,  confined  within  a  contracted  space, 
and  having  no  longer  any  functions  to  perform,  is  speedily  closed  and  obliter- 
ated, and  even  so  blended  with  the  surrounded  tissues,  as  that  in  adult  age 
no  other  vestiges  of  it  are  discoverable  save  the  funnel-shaped  depression 
observed  at  the  visceral  opening  of  the  track  of  the  testicle,  so  that  the 
exterior  serous  pouch  is  then  completed,  occluded,  or  made  to  terminate  in  a  cul- 
de-sac  both  above  and  below.  Certain  writers  have  been  of  Hunter's  opinion, 
and  it  is  one  which  even  at  this  day  is  pretty  generally  acceded  to,  that  the 
exterior  layer,  now  known  as  the  fascia  superficialis  enters  the  belly  through 


OPERATIVE  SURGERY.  635 

the  inguinal  ring  to  be  attached  to  the  adherent  margin  of  the  testicle :  that  the 
prolongation,  called  gubernaculum  testis  by  the  English  surgeons,  forms  by 
its  extension  the  dartos  and  the  septum ;  in  a  word,  that  its  function  is  to  draw 
down  the  glands  to  the  bottom  of  the  scrotum.  M.  Blandin  lias  thought  that 
he  perceived,  in  the  natural  enlargement  of  the  parietes  of  the  abdomen  after 
birth,  the  explanation  of  the  descent  of  the  seminal  glands,  and  of  the  imagi- 
nary expansion  of  the  gubernaculum  testis.  But  M.Manec  has  noticed,  and 
I  verify  his  observation  by  my  own,  in  the  case  of  an  adult  whose  testis  was 
still  within  the  abdomen,  that  the  fascia  superficialis  passes  before  the  abdomi- 
nal ring,  in  the  external  oblique  muscle,  and  does  not  penetrate  into  it.  I  may 
add,  that  this  ring  is  then  separated  from  the  external  tissues,  by  the  very 
external  layers  which  are  to  be  extended  at  a  later  period  around  the  cord, 
to  form  its  fibrous  tunic,  and  that  the  idea  of  Hunter  seems  to  me  wholly 
without  foundation. 


§  2.  Hydrocele. 

It  frequently  happens  that  serum  accumulates  or  spreads  between  the 
different  layers  of  the  scrotum.  If  it  be  betwixt  the  integuments  and  cellular 
tissue,  or  between  the  cellular  tissue  and  the  prolonged  aponeurosis  of  the 
external  oblique,  the  hydrocele  will  evidently  be  diffuse — will  rarely  remain 
limited  to  one  pouch  of  the  scrotum  only.  If  on  the  contrary  the  fluid 
passes  between  the  fibrous  tunic  and  the  cremaster,  or  between  the  cremaster, 
the  fascia  transversalis,  or  even  the  fascia  propria,  the  hydrocele,  although  owing 
to  infiltration,  may  nevertheless  be  arrested  at  one  of  the  halves  of  the  scro- 
tum. It  is  doubtless  owing  to  their  puncturing  to  this  depth,  that  young  men, 
who  with  the  hope  of  avoiding  military  service,  endeavor  to  simulate  inguinal 
hernia  by  inflating  the  testicular  tunics  with  air,  succeed  occasionally  in 
deceiving  professional  persons.  If  the  infiltration  occurs  in  the  tissue  of  the 
cordi  that  is  to  say  between  the  lamellae  which  connect  its  vessels  and  its 
excretory  duct,  we  may  still  have  a  diffused  hydrocele,  but  one  which  is 
limited  by  the  thickness  of  the  cord  without  entering  the  scrotum.  When, 
instead  of  its  being  disseminated  in  a  number  of  distinct  meshes,  the  serum 
is  deposited  in  one  or  several  particular  sacs,  that  form  of  the  aff*ection  results 
which  is  called  hydrocele  from  effusion.  Whenever  the  effusion  is  carried 
on  in  one  or  other  of  the  places  just  indicated,  viz  :  between  the  tunics  of  the 
scrotum  or  in  the  thickness  of  the  cord,  it  takes  the  name  of  encysted  hydro- 
cele. This  latter  species  is  most  often  seen  around  the  spermatic  vessels  and 
duct,  for  the  simple  reason  that  the  areolar  tissue  is  here  particularly  encoun- 
tered. The  name  of  encysted  hydroceles,  which  has  been  given  by  many  to 
those  serous  accumulations  which  are  seen  to  occur  in  the  thickness  of  the 
epididymis  of  the  testis  itself,  or  between  that  fibrous  tunic  called  the 
alhiiginea  and  the  serous  layer  which  covers  it,  might  perhaps  in  strictness  be 
retained  with  propriety.  But  as  these  are  real  diseases  of  the  prolific  organ, 
more  than  one  inconvenience  would  result  from  their  conjunction  with  hydro- 
cele properly  so  called. 

The  vaginal  tunic,  being  the  only  one  naturally  free,  and  exhaling  continu- 
ally an  aqueous  vapor,  is  that  which  is  most  often  the  seat  of  the  effusion  in 
question ;  so  much  so,  indeed,  that  the  word  hydrocele,  unaccompanied  by 


636  NEW  ELEMENTS  OF 

anj  other  epithet,  is  employed  only  to  designate  this  particular  variety.  The 
parts  composing  the  scrotum  in  which  a  hydrocele  of  the  tunica  vaginalis 
has  for  a  long  time  existed  undergo  at  times  numerous  changes.  Dr.  Mott 
has  met  with  a  scrotum  in  which  an  envelope  existed,  formed  almost  entirely 
of  small  calculi  or  stony  projections.  An  osseous  degeneration  of  the 
same  tissue,  has  been  recorded  by  Wagner,  Beclard,  M.  Cloquet  and  M. 
Yvan ;  at  other  times  the  degeneration  observed  resembles  cartilage,  or  is  of 
a  lardaceous  nature,  which  may  increase  in  hardness  and  thickness,  and  form 
at  length  a  truly  hard  and  tough  shell.  The  internal  surface  has  been  found 
villpus,  knobbed,  tuberculous,  or  covered  with  fungous  growths.  The  liquid 
enclosed  in  these  cases  is  far  from  being  always  limpid  or  of  a  lemon  color. 
It  is  in  certain  cases  reddish,  or  deep  brown  more  or  less  dark,  resembling 
chocolate ;  again  it  is  of  a  decided  yellow,  and  much  more  thick  in  consistence 
than  is  usual.  Beclard  and  M.  Cloquet  have  remarked  in  it  small  crystals  of 
a  micaceous,  greasy,  or  chalky  material.  MM.  Murat  and  Baillie  have  noticed 
therein,  small,  smooth,  floating  cartilages,  and  it  is  even  said  real  calculi ; 
sometimes,  also,  a  viscous,  stringy  substance,  whose  presence  was  generally 
coincident  with  extensive  disorganization  of  the  lining  membrane.  The  serous 
expansion  of  the  scrotum  may  ofter  or  encounter  more  resistance  in  one  way 
than  in  anotlier.  In  this  case  it  happens  sometimes  that  its  dilatation  is 
unequal ;  so  that  the  tumor  carries  the  testicle  before  it,  even  to  its  external 
surface,  spreading  out  the  cord,  either  as  Scarpa  thinks  by  effecting  its  decom- 
position, or  in  giving  it  a  riband-like  appearance,  instead  of  leaving  it  within 
which  is  asserted  by  M.  Dupuytren.  It  is  owing;  to  this  unequal  dilatation, 
that  a  hydrocele  often  presents  inequalities  on  the  exterior,  or  is  divided  into 
two  or  more  portions,  having  the  form  of  a  double  bag. 

It  is  to  be  observed,  however,  that  to  separations  in  the  fascia  propria,  or  the 
cellulo -fibrous  tissue  which  immediately  surrounds  the  tunica  vaginalis, 
similar  protuberances  are  owing. 

Operation. — Hydrocele  from  infiltration  requires  no  instrumental  aid,  unless 
it  be  decided,  after  a  fruitless  exhibition  of  appropriate  topical  applications, 
to  treat  it  by  slight  punctures  or  scarifications,  or  by  two  deep  incisions 
made  on  either  side  of  the  median  line  on  its  inferior  surface,  which  are  still 
advised  by  Sabatier,  and  which  formerly  were  in  such  high  estimation. 

In  a  hydrocele  from  effusion,  whether  one  in  which  the  fluid  occupies  the 
tunica  vaginalis,  or  be  contained  in  several  cysts,  it  appears  to  be  now  gene- 
rally admitted  that  the  patient  is  never  relieved  either  by  local  topical, 
applications,  or  general  treatment.  It  would  be  incorrect,  however,  to  receive 
this  assertion  in  too  unlimited  an  extent.  It  is  certain,  on  the  contrary,  that 
hydrocele  of  the  tunica  vaginalis  itself  even  has  disappeared  under  the 
agency  of  certain  cataplasms,  lotions,  and  other  topical  measures.  The  the- 
sis of  M.  Lesuer,  for  instance,  shows  that  in  the  Hotel  Dieu  of  Paris,  leeches 
and  revulsives  have  triumphed  frequently  over  the  disease.  By  the  work  of 
M.  Sabatier,  again,  it  will  be  seen  that  M.  Dupuytren  lias  cured  many  by 
means  of  blistering  the  tumor,  and  M.  Manoury  and  many  other  practi- 
tioners have  cited  numerous  facts  in  support  of  the  practice.  On  the 
authority  of  M.  Bertrand,  moxa  in  the  hands  of  others  has  not  been  less 
efficacious.  M.  Grsefe  of  Berlin  has  recently  revived  the  boasted  prescrip- 
tipn  of  Keate  in  1788,  consisting  of  a  solution  of  the  mur.  ammon.  in  alcohol 


OPERATIVE    SURGERY.  63T 

or  the  acetate  of  squills.  I  have  myself  twice  seen  a  hydrocele  removed  by 
the  use  of  such  astringent  cataplasms  as  are  advised  by  M.  Brodie,  and  by 
frictions  with  the  mercurial  ointment;  but  these  exceptionable  instances 
of  success  are  very  rare,  and  met  with  only  in  long  standing  cases,  in  which, 
the  hydrocele  was  small,  or  could  be  traced  either  to  a  traumatic  lesion  or  to 
an  irritation  whose  principle  it  was  possible  to  discover.  In  the  two  cases 
which  I  saw  eft'ected  the  disease  was  but  of  two  months  existence,  and  origi- 
nated in  a  blenorrhagic  swelling  of  the  testicle.  Latterly,  blisters,  the 
muriate  of  ammonia  in  aqueous  solution,  afterwards  red  wine,  and  the  most 
powerful  astringents  were  vainly  employed  in  two  of  my  patients,  in  whom 
nevertheless  the  hydrocele  had  existed  but  six  weeks,  and  was  owing  to  a 
bruise  of  the  testicle;  leeches  and  emollients  had  been  previously  applied, 
but  with  a  similar  want  of  success;  the  operation,  however,  was  very  readily 
triumphant.  Spontaneous  cures  are  occasionally  met  with  in  hydrocele. 
Bertrand  and  Sabatier  have  seen  it  following  vioknt  straining  in  coughing 
or  micturition.  Loder  speaks  of  a  patient  in  whom  the  kick  of  a  horse  had  a 
similar  result.  The  tunica  vaginalis  is  ruptured,  infiltration  of  the  scrotum 
and  penis  follows,  the  effused  fluid  is  speedily  absorbed,  and  the  hydrocele 
disappears  finally,  or  for  a  few  months  only,  as  in  the  case  recorded  by  M, 
Boyer.  Two  new  occurrences  of  this  nature  have  been  published  in  La 
Lancette  by  M.  Serre  of  Montpelier.  A  third  is  contained  in  an  essay  by 
M.  Bertrand.  I  have  also  learned  from  M.  Double,  a  house  pupil,  that  in 
a  patient  under  the  care  of  M.  Roux,  at  la  Charite,  no  vestige  whatever  of 
the  disease  remained  on  the  day  on  which  it  was  to  have  been  operated 
upon.  Notwithstanding  all  this,  the  operation  when  preferred  is  so  simple, 
and  its  effect  so  uniform,  that,  even  supposing  we  could  by  the  aid  of  topical 
applications  succeed  in  curing  a  certain  number  of  cases  of  hydrocele,  it 
would  still  deserve  to  be  uniformly  put  in  practice.  The  steps  in  its  per- 
formance have  singularly  varied  since  the  days  of  Celsus. 

Incisions  into  the  tumor,  the  excision  of  a  portion  of  the  sac,  scarifications 
on  its  internal  surface,  cauterization  by  the  red  hot  iron,  or  caustics,  the  use 
of  tents,  pledgets  of  lint,  canulas,  setons,  and  of  various  injections,  all  have 
been  so  highly  lauded,  as  to  constitute  numerous  plans  of  practice,  the  greater 
part  of  which  modern  surgery  has  now  discarded. 

Cauterization,  as  described  by  iEtius  after  Leonides,  was  in  use  very  long 
before  the  time  of  Guy  de  Chauliac,  to  whom  Sabatier  seems  disposed  to 
award  its  employment.  By  some  it  was  effected  by  establishing  an  eschar 
on  the  inferior  part,  by  others  on  the  superior  part  of  the  tumor,  which  eschar 
was  renewed  until  it  reached  the  fluid.  Certain  other  operators  preferred  to 
effect  the  object  by  means  of  heated  metal,  or  by  that  L  shaped  cautery 
spoken  of  by  Paulus  ^ginetus.  The  practice,  which  has  a  thousand  times 
been  revived,  has  been  particularly  commended  by  Else  in  England,  Du- 
saussoy  in  France,  and  by  Eilrich  in  Germany.  The  second  of  these  writers 
imagines  that  the  effect  of  the  escharotic  is  not  merely  to  produce  sphacelus 
of  the  scrotal  tunics,  but  that  it  induces  simultaneously  a  gangrenous  inflam- 
mation of  the  whole  tunica  vaginalis,  which  is  seen  to  fall  away  in  flakes 
after  the  separation  of  the  eschar.  Humpage  had  conceived  a  method  of 
creating  it  by  placing  some  of  the  spirit  of  salt  (an  aqueous  solution  of  hydro- 
chloric acid)  around  a  circular  plaster,  which  was  to  serve  as  a  protection  to 


€38  NEW   ELEMENTS  OF 

the  tissues  in  the  vicinity  of  the  cauterized  circle.  Be  this  as  it  may,  it  is,  under 
whatever  form  it  be  executed,  a  treatment  which  ought  to  be  definitively  pro- 
scribed. 

I  should  think  quite  as  unfavorably  of  the  tents  of  the  canulas,  which  are 
much  less  dangerous  and  barbarous,  were  it,  not  that  some  highly  distin- 
guished practitioners  of  our  day  continue  to  advocate  their  employment.  The 
use  of  these  measures,  so  far  from  being  original  with  Franco,  Fabricius  ab 
Aquapendente,  or  with  Moimiches,  as  Sabatier  and  M.  Boyer  would  lead  us 
to  suppose,  goes  back,  in  fact,  at  least  to  the  time  of  G.  de  Salicet,  who  in 
speaking  of  hydrocele  makes  use  of  these  words :  ''  Let  the  scrotum  be 
punctured  with  a  lancet,  and  the  water  drawn  off,  and  then  let  a  tent  be  placed 
in  the  aperture,  so  that  when  you  will  you  may  freely  draw  oft'  that  which  is 
within  the  enlargement." 

Instead  of  a  proceeding  so  simply,  F.  de  Hildus  has  proposed  to  place  a 
ligature  round  the  tunica  vaginalis,  incise  it  and  to  leave  there  a  pledget  of 
lint ;  which  proceeding  Bell  has  copied  under  this  latter  point  of  view. 
Monro  recommended  that  the  serous  tunic  of  the  testicle  should  be  irritated 
with  the- point  of  a  trocar;  Larrey,  that  one  of  gumelastic  should  be  allowed 
to  remain  within  it  for  several  days.  If  it  be  incontestibly  true  that  the  use 
of  these  measures  is  attended  with  a  certain  ratio  of  success,  it  is  not  the  less 
true  that  suppuration  in,  and  not  simple  adhesion  between  the  surfaces  often 
results  from  them ;  and  that  they  are  not  so  constantly  successful  as  to  bear 
any  comparison  with  the  methods  at  present  resorted  to.  The  same  is  to  be 
said  of^setons,  about  which  M.  Sabatier  has  found  no  mention  made  by  the 
ancients,  which  Sprengel  refers  to  Lanfranc,  and  M.  Cooper  attributes  to 
Franco,  although  it  was  in  all  probability  alluded  to  by  Galen,  when  he  says 
that  we  must  draw  off  the  water  from  the  scrotum  either  with  a  syringe  or  by 
means  of  a  seaton. 

It  is,  besides,  at  the  instance  of  the  phycisian  of  Pergamus,  that  Guy  de 
Chauliac  advises  us  to  seize  the  scrotum  with  flat  forceps,  having  an  opening 
at  their  extremity,  so  as  to  permit  the  passage  through  them  of  a  long  heated 
needle,  to  the  eye  of  which  is  attached  the  seton  which  is  to  be  left  in  the 
wounds  until  the  water  is  evacuated.  It  would  appear  moreover,  as  lias  beeu 
remarked  by  Le  Clerc,  that  C.  Aurelianus  had  intended  to  indicate  it.  Pey- 
rilhe  also  thought  that  he  discovered  in  the  works  of  Paulus  ^gineta  a  refe- 
rence to  tlie  same  idea.  Notwithstanding  this  method  received,  until  towards 
the  end  of  the  seventeenth  century,  the  commendation  of  all  authors,  it  was 
nearly  wholly  abandoned  when  Pott,  sixty  years  ago,  undertook  to  re-establish 
it.  The  method  of  proceeding  which  he  adopted,  and  which  has  since 
been  modified  by  Roe  of  Edinburgh,  needs  not  here  to  be  brought  for- 
ward, and  the  less  so  that  it  is  not  probable  that  setons  will  henceforth  be 
employed  by  any  one.  Should  it  however  be  thought  fit  to  return  to  its 
use,  its  name  alone  serves  to  explain  it;  and  it  needs  but  to  be  remembered 
that  a  long  pledget  of  cotton,  or  any  other  material,  or  a  thin  riband,  is  to  be 
passed  through  the  swelling,  that  all  may  understand  the  mode  of  conducting 
a  similar  operation.  There  now  remains  for  comment,  incision,  excision,  and 
injections. 

ist.  Of  Incision, — This  operation,  which  since  the  time  of  Celsus,  of  Paulus 
^ginetus,  of  the  Arabians,  of  Guy  de  Chauliac,  has  been  practised  in  every 


OPERATIVE    SURGERY.  639 

age,  Is  performed  with  a  strait  or  convex  bistoury.  The  patient  is  placed  on  hi& 
back,  and  his  limbs  moderately  flexed.  The  surgeon  grasps  the  posterior 
surface  of  the  scrotum  with  his  left  hand,  and  thus  make&  tense  the  tumor. 
With  the  right  hand  he  makes  an  incision  on  its  interior  face  in  tlie  upper  part 
from  without  inwards,  if  the  convex  bistoury  be  employed;  andbypuncturing, 
if  he  makes  use  of  the  straight  bladed  instrument,  The  opening  ought  to  be 
large  enough  to  admit  the  finger,  or  if  by  accident  the  incision  be  too  small  to 
permit  this,  a  director  must  take  its  place.  A  button,  or  probe-pointed  bis- 
toury serves  to  complete  the  division  of  all  the  anterior  portion  of  the  cyst,  pro- 
ceeding with  the  incision  from  within  outwards,  and  from  above  downwards. 
As  the  object  is  to  produce  adhesion  between  the  two  layers  of  the  tunica  vagi- 
nalis by  exciting  suppurative  inflammation,  the  wound  is  to  be  filled  with  lint 
and  dressed  daily,  that  it  may  fill  up  only  from  below  towards  the  edges.  By 
these  means  a  very  permanent  cure  is  generally  effected;  only  it  sometimes 
happens  that  small  spots  in  the  membrane  escape  the  irritation,  and  by  giving 
rise  afterwards  to  small  cysts,  permit  a  partial  reproduction  of  the  disease. 
In  France  at  least,  since  we  possess  methods  so  much  more  simple,  the  pain  and 
risk  which  attend  it  sometimes,  and  the  length  of  the  treatment,  have  caused  it 
to  be  generally  rejected ;  so  that,  notwithstanding  the  reasoning  of  M.  Rust 
and  M.  Gama,  who  still  give  it  the  preference,  it  seems  proper  to  consider  it 
only  as  an  occasional  resource :  as,  for  example,  in  case  of  encysted  hydrocele, 
of  multilocular  hydrocele,  and  of  hydrocele  complicated  with  extensive  lesion  of 
the  tunica  vaginalis  or  of  the  testicle  itself. 

2d.  Excision. — It  would  appear  that  excision  also  has  been  practised  since 
the  time  of  Leonides.  We  read  in  ancient  authors,  and  in  Paulus  ^ginetus 
amongst  others,  that  after  having  laid  open  the  tumor,  some  of  them  were  in 
the  habit  of  seizing  the  lips  of  the  tunica  vaginalis,  and  rolling  it  within  upon 
hooks  in  order  to  tear  it  away.  It  is  to  Douglas,  however,  that  the  merit  of 
directing  to  this  method  the  attention  of  surgeons  in  the  last  century,  and  the 
important  rank  which  it  still  holds  amongst  us,  is  due.  Imbert  de  Lonny,  by 
combining  it  with  the  use  of  tents,  thought  that  he  had  instituted  a  new  practice, 
which  has  not  been  adopted.  It  may  be  done  in  various  ways.  It  was  the  practice 
of  the  English  surgeon,  to  begin  by  circumscribing  within  two  semilunar  inci- 
sions, an  elliptical  portion  of  the  integuments  on  the  fore  part  of  the  scrotum. 
This  portion  he  removed,  opened  into  the  tunica  vaginalis,  which  he  afterwards 
gradually  dissected  until  near  the  adhesions  to  the  testicle,  so  as  immediately 
to  excise  both  sides  by  the  assistance  of  good  scissors.  M.  Boyer  advises  a 
simple  incision  the  whole  length  of  the  hydrocele,  then  that  we  should  dissect 
the  tunica  vaginalis  as  far  away  as  possible  from  the  side  of  the  seminal 
gland  before  we  give  exit  to  the  liquid  within,  and  then  to  open  the  cyst  and 
cut  away  a  portion.  Lastly,  it  has  been  found  more  simple  by  M.  Dupuytren, 
to  grasp  the  whole  tumor  below  with  the  left  hand,  so  as  to  project  the  anterior 
wall  as  much  as  possible,  to  make  the  incision  either  on  the  plan  of  Douglas  or 
Boyer,  as  it  appeared  to  him  adviseable  or  not  to  remove  a  portion  of  the  inte- 
guments ;  then  to  isolate  as  it  were  the  tunica  vaginalis  by  pressing  it  from 
behind  forewards  treating  it,  in  a  word,  almost  as  one  drives  a  kernel  from  its 
fruit  by  pressure  with  the  fingers.  This  done  he  opens  into  the  cyst  and  ex- 
cises it  as  we  have  before  mentioned.  The  wound  is  immediately  filled  with 
dry  lint  after  eitlier  method  of  operating,  and  the  dressing  is  the  same  as  after 


640  NEW  ELEMENTS   OF 

simple  incision.  From  this  detail,  it  will  be  seen  tl)at  the  operation  by 
excision  is  a  painful  one,  and  necessarily  a  longer  one  than  the  others.  It  has 
the  advantage  of  preventing  all  return  of  the  disorder,  since  it  irrecoverably 
destroys  the  membrane  in  which  it  takes  place.  Still  as  it  is  almost  impos- 
sible to  take  away  the  whole  tunic,  it  does  not  appear  how  it  should  place  the 
patient  irrecoverably  beyond  the  possibility  of  a  relapse.  It  has  been  besides 
observed,  by  M.  Boyer,  that  hydrocele  returns  sometimes  after  excision  as 
well  as  after  incision ;  and  the  method,  at  least  as  a  generally  applicable  one, 
is  to  be  proscribed.  It  is  applicable  only  in  those  rare  cases  in  which  the 
vaginal  tunic  is  hardened,  has  degenerated  into  a  cartilaginous  or  fibro  carti- 
laginous state  is  studded  wilJiin  or  without  with  bony  or  calcareous 
spots ;  considerably  thickened  when  it  forms  a  hard  and  solid  shell ;  or  when 
for  some  reason  we  have  grounds  for  suspecting  that  the  internal  sur- 
face is  not  likely  to  take  on  adhesive  inflammation ;  or  when  lastly,  it  exists 
as  a  foreign  body  in  the  scrotum  which  it  is  necessary  to  remove. 

3d.  Injection. — Most  modern  authors,  proceeding  on  the  assertion  of  A. 
Monro,  attribute  to  an  army  surgeon  of  the  same  name  as  that  author,  the  em- 
ployment of  injections  in  the  radical  cure  of  hydrocele.  They  had  however 
been  proposed,  and  the  proposal  acted  upon  long  before.  Celsus  tells  us  that 
where  the  water  is  in  a  pouch,  we  must  after  evacuating  it  inject  with  solutions 
of  nitre  or  saltpetre.  Lembert  of  Marseilles,  in  his  commentaries  and  obser- 
vations published  in  1677,  distinctly  says  that  the  best  method  to  be  followed 
in  the  cure  of  hydrocele,  consists  in  evacuating  the  water  through  a  canula,  so 
that  the  cyst  may  be  inflamed  by  an  injection,  through  the  same  canula,  of  the 
aqua  phagedenica.  With  so  much  confidence  had  his  trials  inspired  him  in  this 
species  of  medication,  that  he  declares  his  intention  to  use  no  other.  The 
praises  lavished  upon  this  process,  first  by  Monro,  then  by  Sharp  and  Earle, 
having  been  invalidated  by  the  failures  of  many  other  surgeons,  it  did  not  take 
in  England,  and  indeed  has  been  only  of  general  adoption  within  thirty  years 
past  in  France,  As  it  is  now  almost  the  only  one  practised,  I  shall  dwell  upon  it 
in  an  especial  manner,  and  give  a  more  detailed  account  of  this  than  any  of 
the  other  methods. 

The  inutility  of  the  precautions  laid  down  by  Benjamin  Bell,  who  instead 
of  the  ordinary  one,  advises  the  use  of  a  flat  trochar,  and  recommends  that 
previous  to  making  the  puncture  the  skin  and  the  teguments  subjacent  be 
divided  with  a  lancet.  Being  now  universally  acknowledged,  I  shall  neither 
stop  to  discuss  them  nor  the  directions  of  Scacchi,  who  has  highly  vaunted 
the  excellence  of  an  elastic  canula  surmounted  by  a  cutting  extremity,  in  as 
much  as  the  trochar,  commonly  called  the  hydrocele  trochar,  with  or  without 
teeth  on  one  surface  of  the  sheath,  is  considered  amply  sufiicient  for  all  cases. 
If  however  no  variations  are  now  made  in  the  best  instrument  for  puncturing 
the  cyst  and  withdrawing  the  fluid,  the  case  is  nowise  the  same  as  to  the  irri- 
.iiting  agent  to  be  employed  for  the  injection.  The  ancients,  as  we  have  seen, 
'.ad  recourse  to  solutions  of  more  or  less  acridity.  Lembert  employed  lime 
water  containing  corrosive  sublimate.  The  surgeon  of  whom  Monro  speaks 
employed  alchohol,  either  pure  or  diluted  with  water.  During  the  same 
period  red  wine  was  tried.  Earle  has  much  recommended  port  wine  weakened 
with  a  decoction  of  rose  leaves,  while  Juncker,  of  Berlin,  approved  of  medoc 
and  water,  and  many  others  were  content  with  solutions  of  the  caustic  potash, 


OPERATIVE  SURGERV.  641 

MM.  Boyer,  Richerand,  Dupuytren,  and  Roux,  have  permanently  decided 
on  the  use  of  red  wine,  either  simple  or  mixed  with  a  little  brandy  or  alcohol, 
in  which  the  leaves  of  the  Provins  roses  had  been  boiled.  I  have  seen  used 
by  M.  Jules  Cloquet,  and  have  myself  employed,  camphorated  alcohol  in  one 
case,  and  in  others  brandy,  pure  or  camphorated,  to  effect  tlie  same  result. 
Some  physicians  at  Angers,  as  it  appears,  have  employed  injections  of  nothing 
but  cold  water.  Beclard,  has  cited  some  cases  v/hich  were  attended  with 
success  by  these  means,  and  M.  Cuvellier  in  his  thesis,  has  related  a  greater 
number  still.  Jn  one  case  related  by  Schreger  air  alone  was  not  less  suc- 
cessful. It  is  easy,  when  we  reflect  on  the  object  to  be  accomplished,  to 
conceive  that  any  of  the  above  methods  are  in  themselves  of  such  a  nature 
as  to  bring  about  the  desired  end.  All  that  is  necessary  is  to  irritate  the 
tunica  vaginalis,  and  excite  in  its  interior  an  adhesive  inflammation.  Now  to 
produce  such  a  result,  cold  water,  wines  of  all  kind,  brandy,  caustic  solutions, 
in  short  any  liquid  whatever,  as  well  as  the  beak  of  a  canula,  of  a  tent,  the 
presence  of  a  foreign  body  be  it  what  it  may,  are  evidently  proper.  The 
thing  is  to  know  what  best  succeeds,  and  creates  at  the  same  time  the  fewest 
inconveniences.  Experience  having  decided  in  favor  of  red  wine  enlivened 
with  a  little  alcohol  in  which  roses  have  been  boiled,  I  do  not  see  why  we 
need  go  on  to  make  trial  of  others.  I  must  remark  however,  that  alcohol, 
which  many  have  rejected  from  a  belief  that  it  was  of  two  irritating  a  nature, 
and  capable  of  causing  dangerous  inflammation,  produces  effects  no  more 
alarming  than  those  of  common  wine,  and  that  if  I  do  not  myself  use  it, 
it  is  because  I  have  seen  it  fail  of  effect  three  times  in  eleven  cases  upon  which 
I  operated;  whilst  wine,  which  was  used  exclusively  by  M.Gouraud  whilst  I 
was  at  the  hospital  of  Tours,  and  which  is  employed  by  M.  Richerand  at  the 
hospital  St.  Louis,  and  at  the  Hopital  de  Perfectionnement  by  MM.  Bougon 
and  Roux,  and  which  I  have  myself  used  in  about  sixty  cases  of  which  I  have 
an  account,  has  failed  five  times  only. 

Hie  Operation. — Prqyarations.  Before  the  scrotum  is  evacuated  a  syringe 
must  be  at  hand  capable  of  holding  about  two  pints,  and  in  perfect  order. 
A  quart  or  two  of  liquid,  placed  as  has  just  been  said,  and  a  chafing  dish  of 
live  coals  to  heat  it,  should  be  likewise  ready ;  several  basins  are  likewise 
necessary,  either  to  contain  the  wine  for  the  injections  or  to  receive  the  fluid 
of  the  hydrocele.  When  all  the  preparations  are  thus  completed,  the  patient 
is  to  be  placed  upon  a  table  protected  by  cloths,  or  on  the  bed,  and  the 
surgeon  supports  the  scrotum,  as  in  the  operation  of  excision  or  incision ; 
assures  himself  anew  that  it  is  really  a  hydrocele  before  him,  and  not 
any  other  disease ;  and  that  the  testicle,  and  the  different  components  of  the 
cord,  are  in  such  and  such  a  state,  and  in  no  other.  To  be  certain  on  this 
point,  he  suddenly  raises  the  scrotum,  places  the  cubital  edge  of  one  hand 
perpendicularly  on  its  anterior  surface,  so  as  to  intercept  the  light  of  a 
candle  held  on  the  opposite  side,  in  such  a  manner  as  that  the  rays  of  light 
must  pass  through  the  serous  cyst  to  reach  his  eye.  The  natural  transpa- 
rency of  the  fluid  contained  within  the  cyst,  then  enables  him,  when  perfect, 
to  detect  the  precise  location  of  the  testicle,  and  even  of  the  spermatic  cord. 
If  any  doubt  still  remains,  it  is  proper  to  employ  the  little  instrument  invented 
by  M.  Segalas  for  seeing  into  the  bladder,  or  a  tube  of  wood  or  gum- 
elastic,  a  foot  in  length  and  several  lines  in  diameter  will  answer  the  purpose. 
81 


642  NEW  ELEMENTS  OF 

The  operator  then  takes  the  trocar,  fitted  with  its  canula,  in  his  right  handy 
and  plunges  it  at  one  blow  into  the  centre  of  the  liquid  on  the  anterior, 
lower,  and  exterior  surface  of  the  tumor.  To  this  precise  spot  a  preference 
should  be  given,  because,  in  the  natural  state  the  testicle  and  its  dependencies 
are  situated  within,  below,  and  behind;  and  because  it  is  the  best  mode  of 
hitting  the  middle  of  the  tunica  vaginalis.  It  is  useless  to  saj,  that  if  before 
commencing  the  operation  we  could  have  been  aware  of  the  different  distri- 
bution of  parts,  the  instrument  should  have  been  introduced  in  another 
direction  at  a  more  suitable  spot.  The  want  of  resistance,  the.  escape  often- 
times of  a  drop  of  the  fluid  between  the  canula  and  the  wound  and  the 
depth  to  which  we  have  arrived,  are  sufficiently  indicative  of  the  trocar  having 
entered  the  cyst.  The  surgeon  then  takes  hold  of  the  tube  with  the  index 
and  middle  fingers  of  the  left  hand,  near  the  skin,  and  on  the  instant  with- 
draws the  canula  sufficiently  far  to  allow  the  liquid  freely  to  flow  out.  When 
the  sac  is  in  some  measure  empty,  he  presses  upon  it  in  all  directions,  taking 
care  that  the  point  of  canula  follows  the  retraction  of  the  part,  lest  it  should 
become  fixed  between  the  other  enveloping  tunics.  Up  to  this  point  the  beak 
of  the  instrument  must  not  be  pressed  against  the  morbid  cavity  in  such  a 
way  as  to  interfere  with  the  exit  of  the  fluid. 

An  assistant  now  fills  the  instrument  with  the  injection,  which  is  to  be  at 
a  temperature  of  about  32°  cent.;  more  if  the  tissues  in  the  individual  seem  indo- 
lent, or  if  the  liquid  itself  be  not  of  a  very  stimulant  nature;  a  little  less 
if  the  circumstances  of  the  case  are  reverse;  so  warm,  in  short,  as  that  the 
hand  may  be  able  to  endure  the  heat  though  with  slight  inconvenience.  The 
syphon  of  the  syringe  is  now  to  be  introduced  into  the  external  opening  in 
the  canula,  to  which  it  ought  to  have  been  previously  fitted  to  be  sure  of  its 
accurate  adaptation.  The  assistant  then  slowly  pushes  down  the  handle  until 
the  syringe  is  emptied.  The  operator,  holding  the  canula  at  its  root,  prevents 
it  from  moving  within  the  sac  or  from  withdrawing  into  the  thickness  of  the 
scrotum,  whilst  as  the  assistant  removes  the  syringe  he  applies  the  index 
finger  to  the  orifice,  and  thus  prevents  the  escape  of  the  liquid.  A  second  and 
a  third  fresh  supply  of  the  injections  are  forthwith  similarly  introduced,  if 
necessary  to  enlarge  the  tumor  to  the  dimensions  it  possesses  before  the  opera- 
tion. It  is  retained  each  time  for  about  two  minutes  in  the  tunica  vaginalis  by 
some,  by  others  for  five,  and  there  are  again  others  who  prefer  its  continuance 
for  even  six  or  seven. 

There  are  some  who  recommend  that  the  tunica  vaginalis  be  filled  a  third 
time  before  it  is  finally  emptied.  It  is  prudent  to  press  out  from  it  the  few 
remaining  drops  of  the  liquid,  and  even  the  air  which  may  have  obtained  admit- 
tance before  the  canula  is  withdrawn.  It  is  customary  in  the  after  treat- 
ment, to  surround  the  scrotun  with  compresses  steeped  in  the  same  wine  as 
that  injected,  which  are  to  be  renev/ed  thrice  in  the  twenty-four  hours,  until  the 
fifth  or  sixth  day ;  that  is,  until  the  inflammation  has  attained  the  desired  acute- 
ness,  when  they  may  be  replaced  by  emollient  poultices.  In  some  individuals 
the  inflammation  is  at  its  height  on  the  morning  after  the  operation;  in 
others  it  is  not  reached  before  the  fourth,  fifth,  and  even  the  sixth  day. 
In  one  patient  upon  whom  I  operated  in  November  last,  no  swelling  or  pain 
supervened  during  the  two  following  weeks.  Symptoms  of  inflammation 
appeared  only  about  the  tenth  or  twelfth  day,  although  the  person  was  young. 


OPERATIVE    SURGERY.  643 

easily  excitable,  and  of  a  nervous,  rather  than  a  lymphatic  temperament. 
He  had  suffered  the  operation  on  the  other  side  the  year  before,  but  with  no 
greater  inconvenience.  In  both  instances  the  success  was  complete.  When 
this  happens  the  tumor  is  hot,  red,  painful,  and  resumes  nearly  its  original  size. 
A  febrile  movement,  or  even  a  pretty  severe  attack  of  fever,  with  all  the 
symptoms  of  evident  constitutional  reaction  accompany  the  local  irritation, 
while  at  other  times  the  system  seems  wholly  insensible  to  what  is  passing 
within  the  scrotum. 

The  matter  efifused  into  the  midst  of  the  tunica  vaginalis  offers  this 
peculiarity,  that  it  is  soft,  pasty,  or  semifluid,  and  forms,  in  the  strictest  sense 
of  the  word,  matter  or  plastic  lymph.  In  a  considerable  number  of  cases 
there  is  along  with  it  a  certain  proportion  of  serum;  but  scarcely  ever  albu- 
minous shreds  or  true  pus  are  secreted. 

The  eflfusion  continues  during  the  advance  of  the  inflammation.  Its  reabsorp- 
tion  is  effected  by  degrees,  so  that  in  about  twenty  days,  a  month,  or  six  weeks, 
the  parts  may  be  restored  to  their  natural  size,  affecting  apparently  the  enve- 
lopes of  the  scrotum,  which  were  more  or  less  thickened,  and  the  testicle,  the 
swelling  of  which  is  an  almost  necessary  consequence  of  the  primary  disease  or 
the  subsequent  operation.  Whilst  the  more  fluid  parts  of  the  effused  matter 
are  being  absorbed,  its  solidifiable  portion  becomes  organized  ;  vessels  traverse 
it,  and  insensibly  it  becomes  blended  with  the  two  sides  of  the  tunica  vagi- 
nalis. Being  ultimately  resolved  into  cellular  tissue,  it  so  perfectly  unites  the 
two  layers  of  the  serous  tegument  which  had  secreted  it  as  to  leave  behind 
no  cavities  between  the  testicle  and  the  neighboring  layers,  which  is  in  fact 
saying  the  result  is  a  total  obliteration  of  the  cyst  itself.  This  is  the  pro- 
fessed aim  of  all  surgeons,  be  the  operation  to  which  they  resort  what  it  may. 
It  is  this  result  which  one  and  all  have  pretended  they  could  attain  by  extolling 
the  varied  practises  of  cauterization,  incision,  the  use  of  pledgets  of  lint  merely, 
or  lint  smeared  with  medicinal  preparations,  ligature,  excision,  the  introduction 
of  tents,  ribands,  canula  of  elastic  gum  or  of  metal,  setons,  or  any  irritating 
liquid  whatsoever.  And  from  this  statement  it  follows  that  it  is  in  reality 
admissible,  since  the  object  is  the  same,  for  anyone  to  modify  the  treatment  of 
hydrocele  at  pleasure,  according  to  his  peculiar  views  or  the  personal  ex- 
perience he  may  have  acquired. 

From  a  remark  made  by  Pott  it  would  seem  that  he  did  not  consider  the 
disappearance  of  the  vaginal  cavity  as  indispensable.  An  opinion  upon  this 
subject,  has  since  been  formally  promulgated  in  England,  which  is  in  oppo- 
sition to  that  of  almost  every  other  practitioner  of  the  day. 

Mr.  Ward  has  in  fact  asserted  positively  that  hydrocele  is  sometimes  re- 
covered from,  even  when  tlie  serous  tunic  of  the  scrotum  preserves  its  original 
dimensions.  Mr.  Ramsden  is  of  the  same  opinion,  and  if  I  may  judge  from  an 
essay  by  Mr.  Walsh,  Mr.  Kinderwood,  another  surgeon,  has  predicated  on 
the  fact,  a  new  method  of  operating  yet  more  simple  than  any  of  which  I  have 
spoken.  His  plan  is  to  divide  the  whole  of  the  tissues  down  to  the  tunica  vagi- 
nalis, of  which  membrane  a  small  portion  is  to  be  dissected  off  and  excised, 
and  then  the  liquid  having  escaped,  the  edges  of  the  wound  are  to  be  reunited 
by  the  aid  of  a  stitch.  Although  I  do  not  participate  in  the  hopes  of  Mr. 
Walsh  and  his  countrymen  on  the  subject  of  this  operation,  I  cannot  omit  to 
state  a  fact  recently  collected  at  Pitie,  which  strongly  corroborates  the 


6*44  NEW    ELEMENTS    OF 

opinion  entertained  by  Pott.  The  patient  of  whom  I  speak  was  upwards  of 
fifty  years  old.  His  hydrocele  was  of  the  size  of  the  two  fists;  I  operated 
upon  him  by  the  vinous  injection.  On  the  twenty-sixth  day  after  the  opera- 
tion, when  the  scrotum  had  regained  nearly  its  natural  size,  the  man  fell  a 
victim  to  an  apoplectic  attack.  Curious  to  investigate  the  pathological  phe- 
nomena, I  dissected  the  parts  with  great  care,  and  was  astonished  to  find 
the  elytroid  tunic  entire,  its  polish  natural,  and  containing  nothing  save  at  the 
lower  part  a  slightly  greenish  mass  of  filamentous  and  gelatinous  texture, 
which  had  no  adhesion  whatever  to  the  inner  surface  of  the  serous  membrane. 
The  testes  and  general  teguments  of  the  scrotum,  were  in  all  other  respects 
perfectly  healthy. 

When  the  inflammation  begins  to  abate,  which  it  does  toward  the  eighth  or 
tenth  day,  poultices  are  generally  useless,  and  compresses  moistened  either 
with  wine  or  the  aqua  vegeto  mineralis,  ought  to  be  substituted  for  them. 
As  the  resolution  of  the  swelling  is  sometimes  accomplished  with  extreme 
slowness,  it  is  proper  to  hasten  it  by  suitable  measures.  Poultices  of  flax  seed 
moistened  with  the  extraction  saturni,  I  have  often  seen  successful.  Upon  the 
whole,  those  remedies  which  have  seemed  to  me  the  most  eff*ectual  have  been 
mercurial  ointment,  and  unguents  made  with  the  iodites  and  hydriodates, 
alone  or  combined  with  opium,  rubbed  in  small  quantities  on  the  testicles. 
A  very  important  precaution  throughout  the  whole  course  of  treatment  is  to 
keep  the  testes  securely  supported  by  a  suspensary  bandage  nicely  adjusted. 
Although  it  is  rare  to  see  the  inflammation  proceed  so  far  as  to  cause  ab- 
scess, yet  this  accident  is  nevertheless  sometimes  encountered.  The  scrotum 
becomes  red,  pouts,  fluctuates  in  one  spot  of  its  extent,  presenting  every  symp- 
tom of  a  true  phlegmon,  or  a  posterne.  The  indication  in  this  untoward  event 
is  the  same  as  in  all  inflammatory  abscesses  in  general.  Leeches,  if  it  be 
thought  possible  to  prevent  suppuration,  poultices,  and  the  puncture  of  the  ab- 
scess when  its  existence  is  evident,  are  iis  principal  means  of  treatment.  On 
the  other  hand,  the  tumor  having  diminished  about  one-third,  one-half,  or  three- 
quarters  of  the  original  bulk,  remains  stationary  in  that  spot,  and  the  cure  is 
incomplete.  Then  it  is  that  topical  astringents  or  discutients  are  singu- 
larly serviceable ;  frequently  have  they  been  known  to  conquer  the  indolence 
of  the  disease,  and  complete  the  recovery  at  the  very  moment  when  recovery 
was  despaired  of.  If  however  nothing  should  be  successful,  all  that  remains 
is  to  try  the  injection  again,  unless  the  solution  should  be  taken  to  prefer 
incision  or  excision.  The  method  of  injecting,  as  I  have  described  it,  calls  for 
no  other  precautions  than  those  in  the  majority  of  cases.  If  however  the 
volume  of  the  tumor  be  very  great,  such  for  example  as  to  equal  the  size  of 
an  adult  head,  or  larger,  it  would  be  prudent  to  follow  the  advice  given  by 
Schmucker,  Boyer,  and  so  strenuously  insisted  on  by  M.  Bertrand  ;  that  of 
making  small  palliating  punctures  in  the  scrotum  before  the  irritating  liquid 
is  thrown  in,  in  order  to  permit  the  scrotum  to  contract  upon  itself,  and  thus 
diminish  the  extent  of  surface  to  be  inflamed.  If  it  were  necessary  to  fill 
with  warm  wine  the  enormous  cysts  which  some  individuals  carry  about  with 
them,  we  should  have  reason  to  fear,  1st,  the  reaction  from  so  extensive  an 
inflammation ;  and  2d,  that  it  would  be  beyond  the  powers  of  the  organizm  to 
effect  the  reabsorption  of  all  the  consequent  effusion.  I  operated  once  without 
any  such  precautions  upon  a  man  48  years  of  age,  whose  hydrocele,  a  very 


OPERATIVE   SURGERY.  645 

long  standing  one,  was  twenty -four  inches  in  circumference.    No  accident 
however  occurred,  and  the  cure  was  effected  in  the  usual  space  of  time. 

During  the  tlirowing  in  of  the  stimulant  injections,  the  patient  usually  suffers 
pain  of  greater  or  less  intensity,  which  takes  the  course  of  the  cord  and  sper- 
matic vessels,  and  which  is  considered  advantageous,  as  proving  the  success  of 
the  operation  and  that  the  irritation  has  reached  a  proper  height ;  which  it  is 
satisfactory  to  find  extending  even  into  the  side,  or  lumbar  region,  so  that  when 
it  is  absent,  an  augury  unfavorable  to  success  is  predicted.  As  all  persons  are 
not  gifted  with  equal  sensibility,  and  as  the  tunica  vaginalis  may  be  either  very 
thin,  or  more  or  less  altered  in  structure,  this  pain  is  experienced*  in  no 
uniform  degree.  In  aged  persons,  and  in  long  standing  cases  when  a  decided 
thickening  of  the  cyst  may  be  expected,  it  is  well  to  heat  the  wine  strongly, 
and  to  render  it  rather  more  irritating  than  for  those  in  reverse  conditions.  It 
is  not  to  be  supposed  merely  because  the  pain  spoken  of  is  not  present  that 
the  operation  will  be  unsuccessful :  experience  has  shown  a  hundred  times 
the  fallacy  of  such  conclusions. 

Unless  the  operator  is  extremely  careful  the  point  of  the  canula  slips  out 
of  the  cavity  of  the  tunica  vaginalis  with  the  greatest  ease,  during  the  empty- 
ing and  contraction  of  the  scrotum,  by  the  evacuation  of  the  serum  or  fluid  of 
the  injection.  An  accident  so  trivial  in  appearance  as  this,  exposes  the  patient 
however  to  the  most  painful  consequences.  The  point  of  the  instrument, 
becoming  insinuated  between  the  tunics  of  the  scrotum,  the  assistant  unawares 
almost  inevitably  forces  into  them  the  irritating  liquid.  The  layers,  connect- 
ed by  an  extremely  lax  cellular  tissue,  oft'er  but  a  feeble  resistance  to  the  fluid 
which  distends  them.  The  result  is  a  violent  inflammation,  which  almost 
invariably  ends  in  gangrene,  if  not  previously  in  the  loss  of  the  patient.  To 
a  case  of  this  kind  M.  Boyer  was  a  witness ;  the  surgeon  had  committed  the 
canula  to  the  charge  of  his  assistant,  while  he  himself  threw  in  the  injection. 
The  assistant  not  having  following  the  retraction  of  the  integuments  by  pressure 
with  the  fingers,  the  wine  all  passed  without  the  tunica  vaginalis ;  gangrene 
supervened,  of  which  the  patient  died.  In  1824  I  saw  a  similar  occurrence 
at  the  outdoor  clinique  of  the  school  of  medicine,  where  the  injection  was 
forced  into  the  thickness  of  the  scrotum.  The  integuments  and  subjacent 
tissues  sloughed  in  almost  the  whole  extent  of  the  scrotum.  The  constitu- 
tional symptoms  notwithstanding  were  mitigated  and  the  patient  recovered. 
This  then  is  a  serious  accident  against  which  we  must  strive  to  guard.  Its 
occurrence  may  instantly  be  apprehended  by  the  local  pain  given  by  the 
assistant  in  his  attempts  to  force  in  the  injection,  by  the  resistance  he  meets 
with,  and  by  the  elevations  around  the  canula,  which  moreover  is  not  felt  freely 
moving  at  its  point  within  the  elytroid  tunic.  The  mischief  being  done, 
we  must  without  hesitation  scarify  deeply,  and  in  several  places,  the  scrotal 
integuments  in  all  their  thickness,  and  even  a  little  beyond  the  line  of  infil- 
tration. The  antiphlogistic  treatment,  and  emollient  poultices  should  first 
be  employed,  after  which  if  gangrene  occurs  or  extends  in  spite  of  these 
measures,  local  resolvents  must  be  had  recourse  to. 

This  occurrence  may  also  happen  even  when  the  injection  has  been  fairly 
carried  within  the  tunica  vaginalis.  This  is  a  fact  not  spoken  of  by  writers, 
but  which  apparently  is  not  infrequent.  Many  persons  have  told  me  of  cases 
under  their  observation,  and  well  informed  pupils  assure  me  that  they  have 


646  NEW   ELEMENTS   OF 

witnessed  it  in  three  hospitals  in  Paris,  in  one  year.  I  have  myself  recorded  two 
remarkable  examples.  A  man,  sixty  years  old,  who  had  a  double  hydrocele  of 
moderate  size,  was  operated  on  by  myself  at  the  Hospital  St.  Antoine,  in  the 
Spring  of  1829.  The  puncture  and  injection  were  made  only  on  the  right  side. 
At  first  he  experienced  nothing  beyond  the  customary  pain.  The  first, 
second,  and  third  day,  the  swelling  of  the  scrotum  progressed  in  its  accus- 
tomed manner. 

Nay,  the  inflammation  was  even  feeble ;  but  on  the  fourth  day  we  observed 
a  mortified  point  on  the  inferior  surface  of  the  swelling,  whence,  although  I 
lost  no  time  in  scarifying  the  parts,  the  gangrene  marched  on  to  such  a  degree 
as  to  involve  the  scrotum  entirely  to  the  roots  of  the  penis,  and  giving  birth 
to  its  usual  concomitant  symptoms. 

We  were,  however,  fortunate  enough  to  conquer  it.  The  sphacelated 
shreds  came  away  by  little  and  little ;  the  globular  tunica  vaginalis,  bare  to 
the  bottom  of  the  wound,  appeared  to  fill  up  with  a  softish  matter,  as  if 
nothing  uncommon  had  happened,  and  after  much  careful  attention  a  cure 
was  effected  ;  upon  that  side  also  on  which  no  operation  had  been  performed. 
In  the  second  instance,  treated  at  La  Pitie,  in  the  month  of  November,  1831, 
no  cause  had  occurred  for  suspecting  that  such  a  circumstance  had  existed, when 
on  the  fourth  day  I  saw  appear  on  the  front  of  the  scrotum  a  large  slough, 
unattended  by  pain,  redness,  or  any  notable  sign  of  inflammation.  No  re- 
action was  set  up ;  the  mortified  tissues  were  gradually  cast  off,  and  cicatri- 
zation was  insensibly  perfected.  To  what  cause  are  we  to  attribute  the 
reason  of  this  gangrene  ?  Certainly  not  to  effusion  from  the  canula  of  a 
portion  of  the  urine  between  the  layers  which  separate  the  tunica  vaginalis 
from  the  skin. 

It  is  conceivable,  that  by  too  great  a  distension  of  the  cyst  by  the  injec- 
tion it  might  easily  be  separated,  so  as  to  permit  the  transudation  of  a  few 
drops  of  the  irritating  liquid.  I  should  not  be  astonished  if  this  had  really 
been  the  case  with  the  second  patient  of  whom  I  have  spoken.  But  as  in  both 
cases  the  symptoms  were  delayed  until  the  fourth  day,  it  is  scarce  possible 
to  admit  such  a  solution.  The  wiser  course  would  be,  at  least  in  my  two 
patients,  to  refer  the  cause  to  their  feebleness  and  a  want  of  reaction,  or  the 
state  of  alarm  into  which  they  were  brought.  Divarications  of  the  tunica 
vaginalis  across'  its  fibro-cellular  lining,  which,  as  M.  Dujardin  has  said  in 
his  essay,  must  be  easily  effected,  may  naturally  produce  the  occurrence  I 
have  alluded  to,  and  to  them  it  has  doubtless  been  more  than  once  owing. 
This  simple  statement,  affords  in  my  opinion  a  sufiicient  reason  why  surgeons 
should  avoid  distending  the  cy^t  by  their  injection  beyond  what  was  effected 
by  the  hydrocele  itself. 

I  think  also,  that  the  use  of  too  large  a  canula,  by  its  leaving  an  aperture 
large  enough  to  allow  the  after-exudation  of  a  few  drops  of  liquid  from  the 
tunica  vaginalis,  between  its  exterior  surface  and  the  skin,  is  likely  to  bring 
about  the  difficulty  in  question,  and  that  for  this  reason  it  should  not  hit 
employed. 

Two  other  accidents  are  also  liable  to  occur  in  performing  the  operation 
for  hydrocele.    The  one  hemorrhage,  the  other  puncture  of  the  testicle. 

The  form.er,  first  pointed  out  by  J.  L.  Petit,  and  on  which  Scarpa  has  so 
particularly  insisted,  can  result  only  from  three  causes;  1st,  from  a  wound 


OPERATIVE   SURGERY.  '  647 

of  the  arterial  branches  sent  off  to  the  scrotum  by  the  external  or  internal 
pudics,  and  the  epigastric ;  2d,  from  an  injury  of  the  vessels  of  the  testicles ; 
3d,  from  sanguineous  exhalation  on  the  inner  surface  of  the  tunica  vaginalis. 
From  none  of  these  causes  it  is  easy  to  conceive  any  immediate  danger.  In 
a  natural  state  at  least,  none  of  the  vessels  are  so  large  as  to  render  its  being 
opened  justly  alarming.  As  to  the  steps  to  be  followed,  they  are  reduced  to 
opening  the  bleeding  place  largely,  provided  the  duration  of  the  evacuation  is 
such  as  to  threaten  serious  consequences. 

The  second  accident,  viz.,  puncture  of  the  testicles,  arises  only  in  cases 
where  it  has  been  impracticable  to  ascertain  accurately  the  situation  of  the 
cord,  or  the  seminal  gland  itself.  Dupuytren,  Boyer,  and  almost  all  surgeons 
of  extensive  experience  have  witnessed  the  event.  The  pain  which  it  causes, 
besides  being  extremely  acute,  is  of  a  peculiar  character.  The  organ  some- 
times becomes  violently  inflamed,  and  may  go  on  to  suppuration.  Still  the 
accident  is  less  dangerous  than  might  at  first  sight  be  imagined.  A  patient, 
in  whom  this  happened,  and  in  whose  testicle  the  end  of  the  canula  stuck  so 
fast  as  only  to  be  detached  by  the  injections,  experienced  none  of  the  usual 
concomitant  symptoms  of  the  operation  by  injection.  Whereas  in  another  an 
abscess  ensued,  which  I  opened,  and  which  for  several  weeks  made  me  appre- 
hensive of  the  loss  of  the  prolific  gland. 

Congenital  hydrocele,  upon  which  Vigneni  of  Tours  entertained  the  first 
fixed  views,  requires  a  somewhat  diflferent  treatment.  It  is  often  sufficient 
to  return  the  fluid  into  the  abdomen,  and  to  prevent  its  return  into  the  scro- 
tum by  a  firm  compress  maintained  for  several  weeks  on  the  abdominal  ring. 
Some  authors  think  so  well  of  this  proceeding  as  to  suppose  it  renders  all 
others  useless.  There  are  individuals  who  cannot  bear  the  remedy,  or  in 
whom  it  is  resisted  by  the  disease ;  such  for  example  as  those  in  whom  the 
testicle,  notwithstanding  the  accumulation  in  the  tunica  vaginalis,  has  re- 
mained in  the  abdominal  ring,  of  which  cases  it  would  appear  thatM.  Dupuy- 
tren has  encountered  a  number.  It  is  curable  by  injection,  like  the  common 
hydrocele,  but  its  easy  introduction  into  the  peritoneum,  would,  it  is  clear, 
expose  the  patient  to  very  formidable  risk,  unless  means  were  to  be  adopted 
to  prevent  the  occurrence.  If  then  it  is  determined  to  practise  it,  we  should, 
in  conformity  with  the  advice  of  Desault,  have  an  assistant  to  compress  care- 
fully the  inguinal  canal  during  the  operation  to  cut  off  all  communication 
with  the  cavity  of  the  abdomen,  which  compression  might  be  subsequently 
continued  by  means  of  an  appropriate  bandage,  until  the  obliteration  of  the  cyst. 

A  young  man,  seventeen  years  of  age,  on  whom  every  other  method  of  cure 
had  been  tried  in  vain,  was  treated  in  this  manner,  in  the  hospital  of  Tours 
by  M.  Mignot,  in  1818,  and  with  complete  success.  It  is  still  to  be  feared 
that  in  spite  of  the  pressure  the  inflammation  may  travel  from  the  tunica 
vaginalis  to  within  the  peritoneum ;  but  it  is  well  to  state  that  these  artificial 
inflammations  are  for  the  most  part  rarely  dangerous,  not  spreading  as  those 
do  which  spring  up  spontaneously  beyond  the  seat  of  the  material  irritation. 
It  would  even  seem  that  the  introduction  of  a  quantity  of  wine  into  the  abdo- 
men is  not  necessarily  fatal.  M .  Jules  Cloquet  has  published  a  case  in  which 
a  large  part  of  the  injection  passed  into  the  pentoneum  notwithstanding  the 
care  of  the  surgeon,  but  in  which  the  symptoms  were  never  such  as  to  threaten 
the  life  of  the  patient. 


648  NEW   ELEMENTS   OF 

If  the  hydrocele  be  an  encysted  one  of  the  cord,  injection  might  equally  be 
tried ;  but  as  these  cysts  are  usually  composed  of  cells,  and  it  is  to  be  appre- 
hended that  one  of  them  may  extend  into  the  inguinal  canal  and  be  ruptured  in 
the  abdomen  at  the  time  of  the  operation,  it  is  proper  I  think  to  give  the 
preference  to  incision ;  until  at  least  we  have  attained  a  positive  certainty 
that  there  is  but  one  cell,  and  the  limits  of  that  one  exactly  defined. 

In  the  female y  hydrocele  is  so  rare  a  disease,  and  of  so  little  moment, 
although  mentioned  by  jEtius,  by  Paul  after  Aspasius,  and  by  most  subse- 
quent writers,  that  it  may  be  treated  by  injections,  excision,  cauterization, 
and  incision,  and  with  a  like  chance  of  success  as  in  the  other  sex. 

The  labors  just  published  by  M.  Sacchi,  added  to  the  observations  of 
Paletta,  Scarpa,  and  Monteggia,  while  they  prove  that  its  most  common  seat 
is  in  the  canal  of  Nuck,  show  also  that  it  should  be  treated  in  women  as  in 
men.  In  children  the  liquid  of  the  injection  should  be  less  stimulating,  and 
heated  to  the  temperature  only  of  28  or  30°.  Old  persons  in  whom  the  tis- 
sues possess  but  a  feeble  vitality,  and- the  tunica  vaginalis  particularly  is 
little  disposed  to  take  on  the  adhesive  inflammation,  are  ordinarily  advised 
to  dispense  with  a  radical  cure,  and  to  confine  themselves  to  evacuating  the 
fluid  at  intervals  by  a  simple  puncture. 

Where  hydrocele  is  complicated  with  a  hernia,  it  is  obviously  proper  to 
restore  the  intestine  before  making  the  puncture  or  injecting.  Supposing  the 
hernia  to  be  irreducible,  every  possible  precaution,  at  least,  must  be  taken  to 
determine  the  precise  seat  of  the  serous  effusion. 

If  the  descended  intestine,  accompanied  by  hydrocele  should  become 
strangulated,  it  would  be  possible  to  cure  both  diseases  at  one  operation  by 
kelotomy,  properly  so  called  ;  taking  care  to  open  the  tunica  vaginalis  freely, 
as  well  as  the  hernial  sac.  Where  it  appears  in  an  old  sac,  as  Le  Dran  de- 
scribes in  a  cyst  upon  this  sac  or  any  part  of  the  scrotum,  the  same  precautions 
and  treatment  will  be  demanded  as  in  ordinary  encysted  hydrocele. 

When  we  are  not  permitted  to  attempt  the  radical  cure,  we  have  always  the 
palliative  one  to  suggest.  This,  which  consists  in  evacuating  the  elytroid 
cavity  by  a  puncture,  repeated  as  often  as  the  swelling  becomes  inconvenient, 
has  the  additional  advantage  of  resulting  in  some  cases  in  an  ultimate  radical 
recovery.  A  young  physician  has  recently  related  to  me  the  case  of  a  patient, 
who  in  eicht  days  was  cured  of  a  hydrocele  which  had  lasted  three  years,  by 
running  a  long  needle  accidentally  into  the  scrotum.  I  am  not  sure  that 
acupunctu ration  is  not  considered  as  one  of  the  radical  methods  of  cure  in 
India.  Moro,  in  England,  has  recently  published  a  fact  not  less  remarkable ; 
that  of  a  hydrocele  which  he  cured  in  six  days  by  piercing  the  scrotum,  in- 
cluding the  tunica  vaginalis,  with  a  needle,  which  was  left  in  the  part  as  a 
seton.  Lastly,  it  yet  remains  to  be  seen  whether  methodical  compression  by 
retractive  plasters  would  not  sometimes  succeed  in  dispersing  the  aftection  in 
persons  who  will  not  submit,  or  who  cannot  be  submitted  to  any  of  the  methods 
generally  practised  for  obtaining  radical  cures. 

§  3.  Ectomiay  or  AmjiUtation  of  the  Scrotum. 

The  scrotum  is  at  times  attached  by  a  degeneration,  known  to  authors  by  the 
names  of  "  Glandular  disease  of  Barbadoes,"  or  of  "  Andrum,"  of  "  Elephan- 


'operative  surgery.  649 

tiasis,  or  sarcoma  lardacea  of  the  scrotum,  and  for  which  ablation  or  removal 
is  about  the  only  cure.  M.  Larrey  states  that  he  has  often  observed  it  in 
Egypt,  and  calls  it  "  oscheochalasia."  This  degeneration,  so  common  in 
India  and  some  countries  of  Africa,  has  long  remained  unknown  amongst  us. 
A  proof  of  this  is  afforded  by  the  history  of  the  poor  Marabout,  so  naively 
related  by  Dionis.  By  those  who  would  see  the  most  accurate  details  on  the 
subject,  the  labors  of  M.  Roux,  the  essay  of  M.  Delpech,  the  w^ork  of  M. 
Boyer,the Clinique  Chirurgical  of  Baron  Larrey,  &c.,  maybe  consulted  with 
advantage.  Although  surgeons  were  formerly  in  the  habit  of  removing  the  tes- 
ticles as  well  as  their  covering  in  performing  this  operation  for  the  destruc- 
tion of  the  disease  of  which  we  are  speaking,  the  distinguished  professor  of, 
Montpelier  was  not  the  only  person  who  had  remarked,  that  amidst  this 
singular  disorganization,  the  genital  organs  remained  for  the  most  part  unal- 
tered, nor  was  he  the  first  who  projected  the  idea  of  preserving  them  and 
confining  himself  to  the  removal  of  the  morbid  tissues.  Numerous  older 
writers,  confounding  sarcocele  and  the  other  scrotal  diseases  under  the 
general  head  o(  Jieshy  hernia,  ]\a.Ye  expressly  advised  the  protection  of  the 
testicles,  when  found  sound  amid  disease  of  the  tissues.  *'  Let  the  skin,"  says 
G.  de  Salicet,  *'  be  sliced  with  a  razor,  then  the  carnosity  thou  findest  there 
be  raised  from  the  testicle,  and  leave  the  (testicle)  if  it  be  not  wounded." 
Altliough  M.  Roux,  on  the  occasion  of  a  fact  such  as  that  which  now  engages 
our  attention,  had  first  proclaimed  the  principles  on  which  M.  Delpech  has 
so  strongly  insisted,  the  case  of  the  latter  gentleman,  is  still  the  most 
remarkable  yet  known. 

The  patient  was  named  Authier,  an  old  soldier,  and  had  long  labored  under 
an  elephantiasis  of  the  scrotum,  which  had  attained  an  enormous  size,  and 
was  said  to  weigh  sixty  pounds.  The  surgeon  preserved  all  the  integument 
which  could  be  saved  from  the  root  of  the  tumor,  of  which  he  formed  several 
portions  of  such  a  shape  as  to  allow  of  his  covering  with  them  afterwards  the 
testicles  and  virile  member ;  dissected  off  these  flaps  and  turned  them  up,  one 
on  the  hypogastrium,  the  others  on  the  inner  side  of  either  thigh ;  exposed  by 
the  dissection,  the  penis,  cord,  and  both  testicles,  each  covered  only  by  its 
proper  tunic ;  wrapped  the  upper  portion  of  integument  around  the  penis  as  a 
cap  to  cover  it ;  brought  the  latteral  portion  in  like  manner  over  the  testicles; 
and  thus  by  the  aid  of  numerous  stitches,  contrived  to  form  a  new  scrotum, 
and  a  sort  of  sheath  for  the  generative  organ.  This  splendid  operation  was  to 
all  appearance  attended  with  complete  success.  But  the  patient,  who  was 
naturally  very  intemperate,  and  had  moreover  caught  cold  in  going  from 
Montpelier  to  Perpignan,  was  attacked  after  the  lapse  of  some  months  with 
internal  inflammation,  wliich  proved  fatal. 

"We  are  told  by  M.  Larrey,  that  in  1816,  in  the  presence  of  MM.  Ribes  and 
Puzin,  he  pierformed  an  operation  very  similar  to  the  above,  from  which  it 
differs  only  in  so  much  as  tiiat  the  tumor  was  but  five  or  six  inches  in  diameter. 
It  would  appear  also  that  the  same  surgeon  had  recourse  to  it  in  Egypt,  in 
which  during  his  residence  he  thinks  he  has  seen  tumors  of  this  character 
weighing  one  hundred  pounds.  It  would  seem,  too,  that  an  operation  which 
made  a  great  noise  in  its  time,  performed  by  Imbert  de  Lones  on  the  minister 
Charles  Delacroix,  was  called  for  by  a  similar  affection,  and  that  it  would  have 
been  possible  to  have  saved  tlie  testicle  by  simple  ectomia  of  the  scrotum  on 
82 


650  NEW  ELEMENTS  0^ 

the  plan  of  Delpecb,  instead  of  sacrificing  it.  It  is  proper  to  remark  that  this 
affection  does  not  appertain  exclusively  to  the  male  sex.  and  that  on  a  female 
the  operation  would  be  infinitely  more  easy,  and  less  dangerous.  In  fact  as 
no  important  organ  exists  in  the  mass  which  is  to  be  removed,  the  extirpation 
becomes  quite  as  easy  as  that  of  a  sarcoma,  or  cancer;  on  any  other  part  of  the 
body,  and  this  it  is  which  accounts  so  perfectly  for  the  success  obtained  by  M. 
Talrich,  in  the  case  which  M.  Delpech  has  recorded. 

Our  aim,  in  an  ectomia  of  the  scrotum,  being  to  remove  all  that  is  diseased 
and  to  preserve  unimpaired  all  that  is  sound,  the  steps  of  the  operation  will 
manifestly  be  liable  to  various  modifications  according  to  an  infinity  of  circum- 
stances :  such  as  the  size  of  the  tumor,  the  involvement  of  one  or  both  scrotal 
sacs,  and  the  facility  which  one  situation  or  another  affords  for  obtaining  the 
requisite  quantity  of  integument  for  covering  the  denuded  parts  we  are  unwil- 
ling to  remove. 

All  therefore  which  can  be  said  as  to  the  manual  proceeding,  is  that  the 
healthy  coverings  are  to  be  looked  for  at  the  root  of  the  tumor,  so  as  to  cut 
from  them  flaps  of  a  form  and  size  sufficient  and  suitable  before  we  proceed 
to  the  removal  of  the  diseased  mass ;  that  avoiding  these  we  are  to  penetrate 
to  the  sheath  of  the  cord,  or  to  the  tunica  vaginalis,  on  the  one  side  and  oa 
the  other  as  far  as  the  fibrous  envelope  of  the  penis,  where  the  affection  extends 
in  that  direction ;  the  object  being  to  strip  these  organs  of  all  which  surrounds, 
and  leave  behind  no  remnant  of  morbid  structure ;  and  with  the  understanding 
that  if  the  testes  are  found  seriously  affected  their  extirpation  is  to  be  on  the 
spot  effected.  An  alteration  is  to  be  looked  for  in  the  increased  length  of  the 
spermatic  cords. 

It  remains  to  be  known  whether  this  alone  will  justify  the  removal  of  the 
seminal  organs  if  otherwise  healthy.  M.  Delpech  is  of  opinion  that  it  will  not, 
and  that  they  will  ere  long  resume  their  natural  condition.  I  agree  with  him 
in  opinion,  that  Mr.  Key  might  have  avoided  their  excision  in  the  patient 
under  his  care  during  the  last  year,  whom  he  relieved  of  an  enormous  scrotal 
tumor.  Can  the  same  t)e  said  of  the  Marabout,  operated  on  by  M.  Clot  on 
the  2rth  March  1830,  in  whom  the  tumor  weighed  one  hundred  and  ten 
pounds,  without  counting  a  quantity  of  serum  whicli  escaped  during  and  after 
the  operation.  If  with  a  tumor  so  large  no  hope  of  saving  the  testicles  could 
have  been  entertained,  it  might  I  think  have  been  accomplished  in  the  person 
from  whom  Raymond  removed  one  of  the  weight  of  twenty-nine  pounds  only. 
The  Egyptian  patient  of  M.  Clot  completely  recovered. 

To  conclude ;  the  only  general  rule  which  can  be  laid  down  on  the  subject 
of  ectomia,  is  the  following.  Remove  the  entire  thickness  of  the  degenerated 
tissues,  and  preserve  uninjured  the  important  organs  within,  provided  they 
be  in  a  natural  condition. 

Nothing  can  be  said  about  the  dressings,  unless  that  the  flaps  are  to  be  laid 
down  with  all  possible  exactness  over  the  parts  they  are  intended  to  cover ; 
that  sutures,  twisted  or  simple,  are  almost  indispensably  necessary  to  preserve 
coaptation.  They  are  to  be  covered  with  lint,  and  surrounded  by  compresses, 
adapted  to  effect  a  moderate  pressure  in  an  equal  and  uniform  manner  upon 
all  the  outer  surface,  so  that  between  them  and  the  subjacent  tissues  no  spot 
shall  remain  uncovered. 


OPERATIVE    SURGERY.  .  651 


c  §  4.  Castration, 

This  is  an  operation  which  has  for  a  long  time  been  advised  only  as  a 
remedy  for  intractable  diseases  of  the  generative  glands.  Happily  in  our 
day  it  is  performed  no  longer  for  objects  of  luxury,  as  was  hitherto  done  all 
over  Europe.  We  no  longer  hear  the  act  of  Semiramis,  who  directed  the 
castration  of  all  the  feeble  men  of  her  territories,  in  hopes  of  having  none  but 
robust  and  vigorous  offspring,  palliated  by  modern  surgeons ;  nor  do  they  main- 
tain, as  did  Brunus  of  Longo-buco,  the  right  of  masters  to  emasculate  their 
servants  in  order  to  render  them  safer  protectors  for  their  wives.  Even 
Italy  herself  has  abandoned  the  brutal  system ;  introduced  into  her  realms  by 
the  popes,  under  the  pretence  of  giving  to  man  a  softer  and  more  melodious 
voice. 

For  objects  like  these  castration  is  no  longer  in  use  except  in  the  East,  and 
in  countries  where  slavery  and  polygamy  are  still  permitted. 

As  a  therapeutical  resource  it  has  often  been  put  it  practice  in  the  radical 
cure  of  hernia  and  of  hydrocele.  It  was  in  old  times  a  method  much 
resorted  to,  although  by  G.  de  Salicet,  those  who  practiced  it  in  his  day  were 
denounced  as  ignorant ;  and  during  the  period  of  the  writings  of  Cantemire 
the  Albanians  themselves  looked  upon  it  as  useless  and  dangerous.  If  the 
practice  was  still  prevalent  among  us  within  half  a  century,  it  would  only,  as 
was  observed  when  speaking  of  hydrocele  and  hernia,  be  among  quacks  and 
persons  ignorant  of  medical  science.  It  is  now  never  resolved  upon  unless 
for  diseases  of  the  testicles  themselves,  and  exclusively  for  such  as  are  thought 
otherwise  incurable.  It  is  employed  for  instance  in  cases  where  a  bruise, 
laceration,  or  some  traumatic  lesion  has  entirely  disorganized  the  gland,  when 
it  has  began  to  secrete  pus,  or  has  become  the  seat  of  scirrhous,  cerebriform, 
colloid,  melanotic,  or  tubercular  degeneration ;  but  still  with  the  certainty  that 
by  no  other  treatment  could  the  health  of  the  patient  be  preserved.  It  is  essen- 
tial, to  aiford  any  hope  of  success,  that  the  affection  be  entirely  local,  uncom- 
plicated with  the  viscera,  and  that  no  trace  of  it  should  elsewhere  exist.  Even 
were  the  viscera  to  be  found  unaffected,  it  would  be  imprudent  to  perform  the 
operation  in  a  case  in  which  the  cord  was  involved  to  any  distance  within  the 
ring.  Still,  if  the  degeneration  were  only  colloid  or  tubercular — the  result 
of  previous  inflammations — with  no  mixture  of  scirrhous,  encephaloid,  or  me- 
lanotic disease,  we  might  perhaps  follow  the  cord  either  into  the  iliac  fossa, 
as  did  Le  Dran,  or  at  least  adopt  the  recommendation  of  Lapeyronie  and 
seek  for  it  in  the  depth  of  the  inguinal  canal. 

Four  different  methods  were  in  use  among  the  ancients  for  performing  cas- 
tration upon  healthy  persons  whom  they  wished  to  emasculate.  Attrition, 
which  consisted  in  violently  bruising  the  organs  and  thus  produce  its  atrophia; 
crushing,  which  was  effected  by  squeezing  it  between  blocks  of  wood ;  ex- 
traction, or  tearing  it  forth ;  and  lastly  excision^  were  alternately  preferred.  Of 
all  these,  still  partially  retained  in  veterinary  medicine,  the  last  alone  remains — 
and  is  that  called  by  Paul,  ectomia — ^in  human  medicine.  The  term  cas~ 
tration,  can  then  be  understood  to  mean  at  the  present  day  neither  attrition, 
squeezing,  or  extraction  of  the  testicle.  Ectomia  itself,  which  is  by  no  means 
similarly  performed  by  all  surgeons,  is  thought  by  ma;iy  capable  of  being 


652  NEW  ELEMENTS^OF 

superseded  by  other  methods  infinitely  more  simple,  and  which  I  cannot 
allow  myself  to  pass  over  in  silence. 

Hie  method  proposed  hy  M.  Maunoir, — Dr.  Maunoir,  a  distinguished  sur- 
geon of  Geneva,  conceived  early  in  tlie  present  century  the  plan  of  curing 
sarcocele  without  the  removal  of  the  testicle,  by  baring  the  root  of  the  cord 
by  the  division  of  its  enveloping  coats,  separating  the  vessels,  and  including 
them  in  ligatures.  Many  successful  results  are  stated  to  have  been  obtained 
in  this  way;  and  within  a  short  time  a  case  has  been  quoted  at  the  academy 
of  medicine,  in  which  the  operation  was  attempted  with  success.  All  that 
can  be  attributed  to  this  proceeding  is,  that  by  suspending  the  flow  of  blood 
to  the  affected  gland  it  may  become  atrophied,  which  appears  to  offer  no 
great  gain  to  the  patient.  Reason  would  lead  us  to  believe  that,  although  it 
might  succeed  in  certain  cases  of  degeneration  resulting  from  a  simple  chronic 
inflammation,  in  a  genuine  sarcocele  it  would  prove  insufiicient.  To  varico- 
cele, which  is  serious  enough  to  expose  a  patient  to  some  risk,  it  would  seem 
much  better  adapted.  For  this  all  the  ancients  performed  it,  preferring 
however  to  tie  the  veins.  Paulus  ^ginetus  describes  it  in  detail,  in  these 
words;  "  we  must  protect  the  scrotum  and  the  cremaster,  tie  the  veins  in  two 
places,  and  cut  them  between  the  ligatures."  The  same  advice  is  given  by  F. 
de  Piemont  and  P.  Forestus.  And  since  1820,  Sir  C.Bell  has  satisfactorily 
shown  that  no  inconvenience  results  from  the  artery  and  vein  in  a  single 
ligature.  It  is  surprising  that  the  Academy,  and  also  M.  Amussat,  who 
thought  himself  the  inventor,  should  have  imagined  this  to  be  of  recent  origin 
when  communicated  to  that  body  in  1828  and  1829. 

Mr.  Morgmi's  method. — In  England  a  somewhat  different  course  was 
adopted.  Instead  of  interfering  with  the  vessels  Mr.  Morgan  recommended 
the  attacking  of  the  vas  deferens  itself.  Messrs.  Lambert  and  Key,  who  adopted 
the  principle  of  this  surgeon,  each  cite  a  successful  case  in  its  favor.  After 
having  denuded  the  spermatic  cord,  they  seek  for  and  detach  the  vas  deferens, 
and  excise  a  portion  of  it  two  inches  in  length,  close  the  wound  immediately, 
and  a  permanent  cure  is  speedily  effected. 

Did  either  of  these  methods  encourage  the  hope  of  restoring  the  organ  to  its 
original  liealthy  condition,  or  of  preserving  the  exercise  of  its  functions,  it 
would  richly  deserve  to  be  adopted  notwithstanding  its  uncertainty.  Un- 
fortunately this  is  not  the  case,  and  they  will  never  I  fear  obtain  that  rank 
in  science  to  which  some  are  willing  to  exalt  them. 

Castration  properly  so  called  comprises  three  distinct  periods;  1st,  that 
of  the  incision  of  the  integuments  and  covering  tissues ;  2d,  the  section  of  the 
cord  and  the  application  of  styptic  measures ;  3d,  the  dressings. 

Period  the  1st. — It  is  unnecessary,  as  has  been  said  by  Paul,  to  excise 
any  portion  of  integuments  which  remain  healthy,  or  have  contracted  no 
adhesions  to  the  tumor,  or  when  the  tumor  is  one  of  small  bulk.  Beyond 
this  the  first  incision  may  be  indifferently  executed,  either  by  a  flap,  or  from 
above  downwards  to  deeper  parts,  as  is  done  by  most  modern  surgeons.  The 
incision  is  in  either  case  to  extend  from  a  little  above  the  ring  and  descend 
to  the  bottom  of  the  scrotum.  Although  some  little  more  advantage  be  gained 
by  embracing  the  tumor  at  its  posterior  part,  than  by  making  tense  the  integu- 
ments in  front  of  the  testicle  during  their  division,  as  is  recommended  by  M. 
Dupuytren,  this  is  more  a  matter  of  taste  than  of  necessity.    When  once  the 


OPERATIVE   SURGERY.  653 

skin  and  its  lining  tissues  are  divided,  nothing  is  easier  than  to  insulate  the 
testicle  by  free  strokes  either  with  the  fingers  in  imitation  of  Benjamin  Bell, 
with  scissors,  or  what  is  infinitely  better  with  a  convex  bistoury,  until  the 
whole  circumference  shall  have  been  completed. 

The  assistant  tlien  separates  the  lips  of  the  wound,  while  the  operator  with 
one  hand  seizes  the  tumor,  or  vice  versa,  in  order  to  stretch  the  parts  to 
separate  them  in  the  suitable  direction  whilst  tlieir  adhesions  are  destroyed 
with  the  other  hand.  The  only  precaution  necessary  to  be  taken,  is  that  of 
not  carrying  the  knife  too  near  the  penis  or  septum  of  the  dartos  for  fear 
of  wounding  the  urethra  or  the  testicle  of  the  other  side.  There  are  many 
surgeons  who  are  of  opinion  that  this  plan  should  always  be  followed,  however 
large  the  sarcocele,  unless  the  integuments  are  diseased.  The  proceeding 
is  liable  to  real  inconveniences,  and  to  remove  a  certain  portion  of  skin  with 
the  testicle,  when  the  bulk  of  the  cancer  exceeds  certain  dimensions,  which  is 
the  mode  advocated  by  Sharp  and  De  la  Faye,  and  long  before  practised  by 
Paul  of  Egina,  is  undoubtedly  a  preferable  one. 

An  elliptical  incision,  carried  like  the  former,  from  above  the  ring  to  the 
lower  part  of  the  scrotum,  should  in  that  case  be  made  to  include  a  cuta- 
neous portion,  large  or  small  according  to  the  size  of  the  testicle.  In  the 
fear  that  pus  might  stagnate  in  the  incision,  and  wishing  to  avoid  the  scar  in 
front,  and  being  also  of  opinion  that  the  morbid  alterations  of  the  skin  were 
more  frequently  met  with  below  than  above,  Aumont  has  recommended  that 
the  incision  be  made  on  the  inferior  surface  of  the  tumor,  and  not  on  the 
anterior  as  it  is  usually  made.  There  is  no  doubt  that  this  advice  may  be 
followed;  I  have  seen  it  done  by  M.  Roux,  and  have  twice  done  it  myself. 
When  the  integuments  are  perfectly  sound  in  that  part  in  which  it  is  usual  to 
incise  them,  while  they  are  more  or  less  disorganized  in  the  opposite  situation, 
this  method  may  even  be  strictly  accurate.  But  how  childish  is  it  to  attach 
the  least  importance  to  the  scar  being  in  front  rather  than  behind,  under  the 
idea  that  it  is  more  visible  from  above  than  below !  With  regard  to  the  stag- 
nation of  pus,  experience  is  sufficiently  ample  to  prove  the  facility  with  which 
matter  will  escape  by  the  incision  when  made  according  to  the  old  method  ; 
whilst  that  of  M.  Aumont  presents  so  serious  an  objection  in  the  greater  dif- 
ficulty with  which  the  cord  is  insulated  to  within  the  inguinal  canal,  that  I 
once  saw  M.  Roux  sincerely  regret  that  he  ever  adopted  it. 

Period  the  9>d. — As  soon  as  the  dissection  has  surrounded  the  tumor, 
and  the  cord  is  denuded  to  the  extent  of  the  disease,  the  surgeon  is  to  attend 
to  separating  the  parts  which  it  is  his  intention  to  remove. 

Upon  this  point  of  practice  it  is,  that  the  greatest  discrepancy  in  medical 
opinions  exists,  from  which  two  very  different  methods  have  resulted.  In 
one,  the  cord  or  its  vessels  is  tied  before  the  section  of  it  is  made ;  in  the 
other,  a  plan  totally  opposite  is  pursued ;  each  containing  many  diversified 
proceedings. 

Method  1st,  is  that  recommended  by  Paul  of  Egina,  who  included  the 
whole  cord,  by  the  advice  of  Celsus,  in  one  strong  ligature,  placed  between 
the  diseased  mass  and  the  ring.  Most  operators  at  every  period  have  pur- 
sued the  same  course ;  though  some,  following  Purmann,  advise  the  location 
of  the  ligature  as  near  as  possible  to  the  ring ;  while  others  again,  with  Bar- 
bette and  Bertrand  apply  it  immediately  beyond  the  epididymis.    Some, 


654  [^NEW   ELEMENTS   OF 

Haenel  among  the  number,  place  it  at  a  distance  intermediate.  Some  are 
found  who,  at  the  recommendation  of  Franco  and  Pearson,  draw  the  ligature 
at  once  with  great  tightness,  while  others,  as  0.  Acres,  compress  it  just 
enough  to  impede  tlie  flow  of  blood.  Gcauthier,  for  instance,  is  among  those 
who  tighten  it  only  by  degrees,  increasing  a  little  each  day  until  it  cuts 
through  the  tissues  completely.  Pare,  and  a  large  number  of  others,  advise 
us  to  pass  a  string  several  times  doubled  across  the  cord,  cut  it  into  halves,  and 
separately  tie  each  portion.  Ravaton,  wishing  to  leave  the  vas  deferens 
entirely  free,  places  his  ligature  in  the  same  way  as  Pare,  but  ties  that  por- 
tion only  which  appears  to  him  to  contain  the  vessels.  Some  surgeons, 
agreeing  with  Birch  as  quoted  by  Sprengel,  carry  a  ligature  up  underneath 
the  parts  to  a  considerable  height,  and  put  on  another  an  inch  below  it,  with 
which  they  compress  the  vessels  before  cutting  through  the  parts  beneath. 
Lastly,  we  must  further  remark,  that  it  has  been  deemed  advisable  by  Theden 
and  Flajani,  to  interpose  a  small  compress  between  the  ligature  and  spermatic 
cord,  while  by  Pelletan  a  simple  plate  of  lead  is  preferred  to  the  compress. 

Method  2d. — Those  who  first  remove  the  organ  are  not  less  divided  in 
opinion  as  to  the  attention  to  be  afterwards  paid  to  the  cord.  Cheselden,  from 
an  observation  he  had  made  of  the  vessel  being  entangled  by  the  ligature  on 
tiie  cord  slipping  before  it,  and  the  hemorrhage  checked,  was  one  of  the  first 
to  propose  the  ligature  of  the  arteries  only.  Le  Dran  preferred  to  protect 
them  with  a  ligature  placed  beneath,  to  rub  them  between  the  fingers  at  some 
distance  below,  but  to  tighten  the  ligature  only  in  case  the  friction  should 
prove  insufficient  to  arrest  the  hemorrhage.  White  and  Korb  assert  the  suc- 
cessful imitation  of  this  practice.  J.  L.  Petit  applied  a  small  graduated 
compress  upon  the  ring  and  employed  no  ligatures,  while  Ponteau  was 
content  to  turn  the  end  of  the  spermatic  fasciculus  over  on  the  pubis.  Runge 
equally  dispensed  with  a  ligature,  by  twisting  the  cord  on  itself  several  times 
after  a  cautious  dissection  before  he  cut  away  the  gland.  Smett,  Schliting, 
and  a  multitude  of  others,  declare  that  all  these  are  futile  precautions :  that 
men  who  in  fits  of  anger  or  despair  castrate  themselves  employ  no  such 
measure,  and  yet  do  not  perish  from  hemorrhage.  It  would  be  a  mistake  to 
fancy  that  this  diversity  of  opinion  existed  no  longer  in  our  own  time.  Liga- 
ture of  the  mass  retains  many  advocates,  though  there  are  many  surgeons  who 
do  no  more,  than  to  insulate  and  tie  each  vessel  separately  before  cutting  away 
the  testicle  from  tl  e  cord.  Bicnat,  M.  Roux,  and  Sir  C.  Bell,  have  advised  us 
to  cut  every  thing  away  but  the  seminal  canal,  then  to  seize  and  tie  its  arteries, 
and  afterwards  to  cut  the  vas  deferens  itself.  Others  cut  away  the  sarcocele 
as  soon  as  they  have  dissected  it  away  from  its  connections  and  coverings,  and 
immediately  search  either  with  a  hook,  tenaculum,  or  with  forceps,  for  the 
bleeding  vessels  in  the  upper  cut  extremity  of  the  cord.  It  is  surprising 
that  so  much  discussion  should  have  been  carried  on,  and  still  continued,  as  to 
the  relative  value  of  a  measure,  the  choice  of  which  is  itself  such  a  perfect 
matter  of  indifference.  In  most  individuals,  the  artery  or  arteries  of  the  cord 
being  so  small  as  to  be  left  to  themselves  after  they  are  divided  without  any 
danger,  it  appears  to  me  that  Le  Dran's  friction,  Petit's  compression,  torsion, 
or  the  turni.ig  over  of  Runge,  will  all  answer,  and  may  be  tried  by  any  one 
so  disposed  without  risk.  Nor  can  I  deny  the  probability  of  equal  success 
of  ligature,  in  the  manner  of  Boyer,  Dupuytren,  Delpech,  and  Roux,  who  have 


OPERATIVE   SUKGERY.  655 

adopted  the  principles  of  Cheselden  and  Bromfield.  The  cure  will  ensure 
equally  well  whether  the  cord  be  entirely  constricted  or  only  partly;  and 
whether  the  pressure  be  gradual  or  immediate.  The  chief  point  is  simply  to 
ascertain  which  is  the  easier  and  safer  of  the  two,  to  tie  the  whole  in  one 
ligature,  or  to  apply  no  ligatures  until  after  the  removal  of  the  mass. 

Siebold,  had  the  other  antagonists  of  the  former  method,  ground  their 
rejections  to  it  on  the  danger  which  is  sometimes  incurred  by  including  in  one 
ligature  the  vas  deferens,  the  strings  of  nerves  from  the  venal  plexus  which 
accompany  it,  the  branch  sent  off  by  the  genito-crural  nerve,  and  the  other 
tissues  whose  incision  is  not  indispensable,  on  the  fact  that  such  a  ligature 
must  produce  violent  pain,  and  incur  the  risk  of  convulsion  and  even  of 
tetanus,  and  lastly,  on  the  length  of  time  which  sometimes  elapses  before  it 
cuts  through  the  part  and  can  be  removed  from  the  wound.  Some  have  even 
added,  that  constriction  of  so  great  a  quantity  of  different  substances,  will 
soon  produce  loosening  of  the  string,  which  would  be  insufficient  to  close  the 
arteries. 

To  this  it  maybe  replied,  that  the  strangulation  does  but  cause  an  acute  pain 
for  a  second,  even  when  it  ruptures  the  continuity  of  the  nervous  filaments 
and  of  the  vas  deferens ;  that  hemorrhage  has  never  been  seen  to  proceed 
from  vessels  thus  strangulated  ;  that  tetanus  and  other  nervous  calamities  are 
no  more  to  be  feared  from  this  than  from  any  other  method ;  that  the  patient 
treated  by  this  method  by  Morand,  and  who  died  of  locked  jaw,  the  disease 
was  induced  by  a  wholly  different  cause;  and  that  in  addition  to  all  this,  a 
case  has  been  published  in  the  Review  Medical  by  M.  Couronnee,  of  a 
person  who  died  with  tetanus  following  castration,  although  the  spermatic 
cord  was  not  included  in  a  general  ligature.  I  have  seen  the  thing  done  at 
least  twenty  times  within  four  years,  at  the  military  and  civil  hospital  at  Tours, 
by  M.  Gouraud ;  by  Richerand  and  Cloquet  at  the  Hospital  St.  Louis;  by  M. 
Bougon  at  the  Hospital  of  the  School ;  and  likewise  by  many  other  practi- 
tioners. I  have  done  it  myself  in  nine  cases ;  and  in  all  these  cases,  fifty  or 
more  in  number,  the  general  ligature  was  employed  without  the  occurrence  of 
a  single  accident  which  could  be  referred  to  its  use.  The  observation  of 
Mursinna,  Wilmer,  Loder,  and  Dietz,  have  likewise  refuted  the  objections  of 
Siebold  on  this  head. 

Suitable  precautions  being  taken,  a  successful  result  from  separate  ligatures 
is,  it  is  true,  not  less  frequent;  but  it  is  clearly  attended  with  rather  more 
difficulty,  as  it  is  not  always  easy  to  discover  the  vessels,  as  the  frequent 
searches  for  the  purpose  lengthen  the  operation  uselessly,  and  as  dangerous 
hemorrhage  has  sometimes  arisen  from  the  ends  of  the  arteries  after  this 
treatment. 

There  is  peculiar  to  this  mode  an  inconvenience  which  may  equally  create 
anxiety,  and  which  I  saw  happen  in  a  person  on  whom  M.  Roux  operated. 
Whilst  the  professor  was  in  search  of  the  artery,  the  seminal  fasciculus 
escaped  from  his  fingers,  and  ascended  high  up  beneath  the  preserved 
integuments ;  haste  was  made  to  seize  it  with  forceps  and  to  bring  it  without, 
to  be  included  in  ligatures  which  were  placed  rather  uncertainly.  The  he- 
morrhage appeared  to  be  suspended,  but  towards  evening  an  abundant  flow 
of  blood  became  evident,  was  repeated  frequently  throughout  the  night,  and 
threatened  to  prove  fatal.    Much  has  been  said  by  authors  about  this  dispo- 


656  NEW  ELEMENTS  OF 

i 

sition  in  the  cord  to  retract  itself;  and  hence  the  use  of  preventive  ligatures 
and  a  host  of  other  precautions  designed  to  guard  against  a  similar  move- 
ment. 

Nevertheless,  no  constituent  part  of  the  cord  is  contracted.  The  testi- 
cular vessels  and  vas  deferens,  lengthened  more  or  less  by  being  dragged 
down  by  the  suspended  weight,  only  appear  capable  of  retreating  towards  the 
abdomen  when  they  are  relieved  of  their  burden.  It  does  not  appear  how  the 
enveloping  or  covering  tunics  can  operate  the  least  reaction  in  this  direction. 
The  fibres  of  the  cremaster  at  the  utmost  could  raise  it  but  a  few  lines.  It 
is  incorrect  then  to  say  that  when  once  free  the  cut  extremity  ought  to 
ascend  considerably  upwards.  Nor  is  this  tendency  in  it  now  for  the  first 
time  denied.  A  long  while  ago  the  error  had  been  corrected  by  M.  Flaubert, 
a  distinguished  provincial  surgeon ;  M.  Senateur  has  stated  in  his  essay  many 
facts  to  overthrow  it,  and  Mr.  Charles  Bell  has  combatted  it  in  England.  The 
following  is  all  that  happens :  if,  by  the  long  standing  of  the  sarcocele,  its  size, 
or  any  other  cause,  the  cord  has  been  considerably  elongated,  as  soon  as  its 
division  is  affected  it  tends  indeed  to  gain  the  inguinal  passage ;  but  the  parts 
do  but  yield  to  their  own  elasticity,  and  only  to  approach  a  little  nearer  to 
their  primitive  situation.  Nothing  like  this  happens  when  no  elongation  of 
the  cord  exists,  when  the  diseased  testicle  maintains  its  original  distance 
from  the  ring;  and  then  the  retraction  spoken  of  is  in  nowise  to  be  appre- 
hended. To  conclude  our  investigation,  it  can  only  become  of  consequence 
in  a  few  individuals  as  when  we  cannot  separate  the  cancerous  mass  at  least 
an  inch  from  the  ring ;  whence  it  follows  that  it  is  scarcely  necessary  to  heed  it 
when  the  cord  itself  is  unaffected  by  the  disease.  Arnaud,  Marechal,  Garen- 
geot,  Bertrandi,  and  others,  having  remarked  its  root  to  be  surrounded  by 
fibrous  tissues  and  tense  lamina,  thought  that  the  ring  should  be  relieved  of 
these  bridles,  so  as  to  prevent  strangulation,  to  which  they  attributed  nu- 
merous dangers ;  but  which  must  be  of  rare  occurrence,  since  it  is  unnoticed 
by  any  modern  authors,  notwithstanding  the  general  neglect  of  the  advice 
given  by  Garengeot. 

The  manner  of  dividing  the  cord  could  undergo  but  little  alteration.  ^  The 
hot  iron  preferred  by  Roger  de  Parme,  Brunus,  and  others,  finds  defenders  no 
longer.  The  scissors  recommended  by  Scultetus  are  evidently  less  conve- 
nient than  the  bistoury.  In  using  the  latter  instrument,  the  recommendation 
of  Leblanc  to  make  the  incision  in  the  form  of  the  mouthpiece  of  a  flute  is 
useless.  While  the  testicle  is  supported  by  an  assistant,  the  surgeon  seizes 
hold  of  the  cord  with  the  left  hand  a  little  below  the  ring  or  the  spot  upon 
which  the  ligature  is,  and  cuts  it  at  one  blow  from  behind  forward,  or  from 
before  backward,  perpendicularly  to  its  axis.  It  is  not  likely  that  hereafter 
the  division  of  this  organ  will  be  trusted  to  the  thread  as  a  means  of  detaching 
the  parts  by  insensible  degrees,  as  if  we  were  treating  a  polypus,  which  is  the 
plan  proposed  by  Runge  or  Leblanc.  If  the  lips  of  the  wound,  by  being  too 
large  and  extensive,  should  be  longer  than  is  proper  to  admit  of  their  approx- 
imation, it  would  be  proper  to  resect  them  immediately,  otherwise  they  will 
roll  inwards  and  render  the  healing  long  and  difficult.  This  tendency  of  the 
sides  of  the  scrotum  to  be  turned  inward  seems  naturally  explicable  by  the 
arrangement  of  their  anatomical  elements ;  the  remains  of  the  cremaster,  if 
it  be  not  wholly  destroyed,  and  the  layer  which  constitutes  the  dartos,  being 


OPERATIVE    SURGERY.  657 

to  a  certain  extent  endowed  with  the  power  of  contraction,  retreat  more  or 
less  upon  themselves,  dragging  necessarily  the  cutaneous  tissues  with  them  in 
the  same  direction. 

Procedure  of  Zeller  or  of  Kern. — A  certain  surgeon,  Acoluth,  fearing  hemor- 
rhage beyond  all  things,  conceived  the  idea  of  obtaining  a  gradual  sloughing 
of  the  tumor,  by  drawing  down  the  tumor  from  below  and  strangulating  it  at 
its  root  by  a  silken  ligature  placed  above  it.  Aristotle  and  after  him  Haly 
Abbas,  advise  the  excision  of  the  testicle  by  a  razor  carried  beneath  the  sus- 
pending part.  In  Germany  the  plan  is  somewhat  differently  effected.  Having 
noticed  the  fact  that  maniacs  and  others  amputate  their  own  testicles  and 
scrota  at  a  single  stroke,  it  occurred  to  Zeller  to  convert  the  idea  into  a 
regular  method  of  operation.  His  plan  is  to  embrace  the  whole  sarcocele 
with  the  left  hand,  causing  an  assistant  to  draw  up  the  integuments  on  the 
upper  side  with  his  hand,  he  cuts  away  at  a  single  stroke  of  a  scalpel  or  bis- 
toury the  whole  cancerous  mass  stripped  of  its  coverings,  and  merely  places 
a  sponge  dipped  in  cold  water  at  the  bottom  of  the  wound  to  guard  against 
hemorrhage.  A  surgeon  of  Vienna,  since  desirous  of  extending  the  method, 
has  put  it  frequently  in  practice,  and  as  he  says  with  uniform  success ;  but 
with  a  most  important  modification  however,  since  he  never  lets  go  the  cord 
until  it  is  surrounded  by  a  strong  ligature. 

The  method  of  Zeller  allows  of  the  removal  of  the  testicle  with  won- 
derful celerity,  and  renders  castration  as  simple  as  it  is  easy.  And  I  have 
thought  that  as  the  integuments  have  not  been  dissected  off,  it  is  possible  to 
close  the  wound  much  more  quickly  than  by  the  usual  method.  But  it  ren- 
ders general  ligature  of  the  mass  of  the  cord  rather  more  difficult,  and  evi- 
dently ceases  to  be  applicable  where  the  disease  is  rather  large  or  its  envelopes 
are  in  a  morbid  condition.  Instead  of  occupying  the  scrotum,  or  banging 
pendulous  without,  the  organ  to  be  removed  may  be  retained  within  the  thick- 
ness of  the  abdominal  parietes  in  the  inguinal  canal,  either  because  it  had 
never  descended  into  the  scrotum,  or  because  it  had  afterwards  accidentally 
reascended,  of  which  a  remarkable  instance  is  related  by  Rossi.  In  some 
manner.or  other  it  may  then  change  into  sarcocele,  as  proved  by  the  examples 
adduced  by  Chopart,  Boyer,  and  Robert.  Then  we  see  how  difficult  and 
dangerous  must  be  the  operation.  How  are  we  to  judge  before  hand  of  the 
condition  of  the  cord  ?  how  define  exactly  the  extent  of  the  disease  ?  It  is 
to  be  feared  also  that  the  peritoneum  may  be  opened  contrary  to  our  wish,  as 
happened  to  M.  Nsegele,  or  that  it  might  be  necessary  designedly  to  cut  through 
it  in  order  to  remove  the  entire  disease. 

Under  these  circumstances  it  is  necessary  to  cut  through  layer  after  layer 
all  the  coats  which  envelope  the  tumor ;  isolate  it  gradually  by  a  cautious  dis- 
section, and  keep  carefully  in  mind  the  proximity  of  the  peritoneum,  of  the 
epigastric  artery,  and  even  of  the  iliacs  themselves.  The  cord  being  arrived 
at,  I  think  it  most  prudent  to  include  the  whole  in  a  general  ligature  than  to 
tie  each  vessel  separately.  But  if  the  tissues  should  be  much  altered  by  the 
chronic  inflammation,  and  confounded  with  neighboring  parts,  this  species  of 
ligature  would  then  deserve  the  preference,  and  the  string  should  be  passed 
with  the  assistance  of  crooked  needles.  ^In  a  case  related  by  M.  Puisser,  it 
was  necessary  to  divide  the  cord  more  than  three  inches  above  the  ring,  and 
the  patient  notwithstanding  recovered  equally  well. 
83 


658  NEW   ELEMENTS    OP 

The  wound  resulting  from  the  ablation  of  a  testicle,  by  any  method  of 
operation,  contains  always  a  number  of  vessels  which  claim  the  surgeon's 
attention  before  he  proceeds  to  dress  it.  Exclusive  even  of  those  of  the 
cord,  one  or  two  are  usually  to  be  found  without,  and  these  generally 
the  largest;  the  inferior  angle  of  the  incision  has  some  also,  which  are  given 
off  from  the  pudic  by  the  superficial  perineal  artery.  It  is  not  uncommon 
to  find  one  on  the  inner  surface,  which  is  a  branch  of  the  artery  of  the 
septum  of  the  dartos.  Usually  before  the  operation  is  over  these  vessels 
have  done  bleeding,  and  in  some  people  we  look  for  them  afterwards  in  vain ; 
hence  the  caution  to  pause  and  twist,  or  tie  them  as  they  are  cut.  However, 
if  they  do  not  reappear  beneath  the  sponge  used  to  detect  them  on  the  surface 
of  the  cut,  they  rarely  result  in  hemorrhage  when  abandoned.  Also,  if  they 
be  tied,  and  they  are  then  thought  secure,  we  must  be  aware  that  during  the 
night  following,  or  in  three  or  four  hours  afterwards,  the  dressings  become 
soaked  with  blood  without  the  existence  of  actual  hemorrhage. 

TheManner  of  Dressing. — The  ancients  often  had  recourse  to  sutures,  and 
endeavored  to  effect  union  immediately  after  the  removal  of  the  testicle. 
Towards  the  end  of  the  17th  century  however,  union  by  the  second  intention 
was  alone  attempted.  A  number  of  English,  German,  and  American  surgeons, 
M.  Delpech,  and  other  surgeons  practising  in  the  south  of  France,  are  it  is 
true,  endeavoring  to  establish  the  former  method  ;  but  I  have  not  seen  either 
in  Serre's  book,  or  in  any  foreign  works,  any  well  established  fact  of  complete 
cicatrization  directly  occurring  in  such  a  wound. 

To  be  really  indispensable,  sutures,  simple  or  twisted,  must  be  confined 
to  cases  in  which  no  ligatures  are  put  on  any  of  the  vessels  and  mere  torsion 
has  been  practised,  so  that  the  cut  edges  may  be  placed  together  accurately, 
and  the  preserved  integuments  upon  the  subjacent  tissues ;  whence  arise  nu- 
merous difiiculties  to  be  overcome  and  more  pain  to  be  endured.  The  usual 
mode  of  practice  offers  infinitely  fewer  difiiculties.  A  fine  peice  of  linen, 
pierced  with  numerous  holes  and  spread  with  cerate,  is  spread  like  a  veil  over 
the  wounded  surface :  over  which  some  small  balls  of  lint  are  to  be  laid.  The 
sides  of  the  scrotum  are  likewise  to  be  protected  by  lint,  lest  they  should 
strike  the  upper  parts  of  the  thighs.  Several  lint  compresses  (plumasseaux) 
are  to  be  laid  over  the  whole.  Some  long  compresses,  a  large  suspensory  or 
double  spica  bandage  completes  the  apparatus  and  the  dressing. 

The  accidents  which  it  is  to  be  feared  may  occur  are  the  same  that  follow 
all  other  great  surgical  operations  sometimes,  and  require  the  same  treatment. 
Hemorrhage  when  it  happens  does  not  always  acquire  the  precipitate  re- 
moval of  the  dressings  to  discover  its  origin  and  secure  the  vessels.  It  is 
often  all-sufficient  for  arresting  the  bleeding,  to  sprinkle  or  bathe  them  in  cold 
water,  or  with  the  aq.  saturni,  and  renew  the  application  every  hour  at 
least.  Should  the  flow  continue,  however,  to  such  an  extent  as  to  weaken 
the  patient  or  lead  to  the  belief  of  an  internal  effusion,  we  must  take 
off  the  apparatus  without  hesitation,  remove  the  clots  of  blood,  and  tie  the 
open  artery  or  arteries ;  or  else  when  the  danger  is  urgent,  resort  to  styptics, 
the  tampon,  or  even  the  actual  cautery  itself.  Where  a  general  ligature  has 
been  applied  to  the  cord,  and  the  constriction  has  not  been  quite  sufficient 
to  strangulate  entirely  the  tissues,  the  end  of  the  cord  may  return  its  vitality, 
and  be    converted   into  a  reddish  or  cauliflower    excrescence,  which,  as 


OPERATIVE    SURGERY.  659 

was  remarked  by  J.  L.  Petit,  and  as  I  myself  saw  happen  in  a  person  operated 
on  by  M.  Cloquet  at  the  Hospital  St.  Louis,  may  connect  itself  with  the  neigh- 
boring edges  of  the  wound,  so  as  in  the  sequel  to  give  rise  to  some  difficulties. 
It  is  indeed  probable,  even  then,  that  the  ligature  would  end  by  cutting  through 
the  stem  on  which  it  is  placed,  and  all  that  would  be  necessary  would  be 
to  repress  the  growth  of  the  vegetation  by  astringents  or  caustics. 

If  in  spite  of  every  precaution  the  edges  of  the  wound  should  turn  out- 
wards, and  the  suppuration  prove  too  copious,  we  should  endeavor,  to  approx- 
imate its  fundus,  and  by  maintaining  compression  on  its  sides,  to  bring  about 
their  union  by  the  second  intention  as  speedily  as  possible. 


Art,  2. — TTie  Copulative  Organ. 

§  1.  Phymosis. 

Contraction  of  the  prepuce  is  a  disease  which  presents  itself  to  the  surgeon 
under  three  principal  forms.  When  congenital^  it  is  troublesome  only  as  an 
impediment  to  the  flow  of  urine  ;  in  adult  age  from  the  pain  which  is  occa- 
sioned by  it  during  coition ;  as  an  effect  of  active  inflammation  it  may  give 
rise  to  serious  accidents ;  when  accidental,  hut  of  a  chronic  character,  the 
entire  prepuce  may  be  hardened  and  thickened,  so  as  to  form  a  hard,  inelas- 
tic, lardaceous  shell,  extending  beyond  the  gland  to  a  greater  or  less  distance, 
which  it  closely  embraces. 

A  congenital  phymosis  which  depends,  as  is  the  case  in  children,  on  an 
undue  length  of  integuments,  demands  no  other  operation  than  that  known 
?ind  practised  by  religious  precept  among  the  Jews  and  nations  of  the  East, 
called  circumcision.  Neither  do  those  cases  which  result  from  acute  in- 
flammation, such  as  chancres  and  venereal  lesions  of  any  kind  whatever,  call 
for  the  emplojrment  of  instruments,  unless  they  render  the  original  affection 
too  difficult  to  be  cut,  or  cannot  be  conquered  by  injections,  topical  applica- 
tions, and  other  appropriate  means. 

The  third  species  is  one  but  little  noticed.  When  it  is  of  long  standing, 
and  of  such  a  nature  as  to  cause  difficulty  in  voiding  the  urine,  no  other  aid 
can  be  rendered  than  that  which  is  affi)rded  by  the  division  of  the  contracted 
circle.  The  operation  is  in  all  cases  the  same,  and  it  is  needful  only  to 
remark,  that  when  performed  upon  a  prepuce  on  whose  inner  surface  ulcera- 
tions exist,  the  wound  itself  will  commonly  ulcerate,  and  that  then  the  use  of 
antisypliilitic  measures,  local  and  general,  must  not  be  forgotten. 

Anatomical  Observations. — The  penis  is  inclosed  in  a  tegumentary  layer, 
soft  and  flexible,  which  in  its  reflexion  to  form  the  prepuce,  becomes  insen- 
sibly a  mucous  membrane  on  the  corona  glandis ;  and  is  lined  throughout 
with  a  lamellar  tissue  so  supple,  lax,  and  distensile,  that  it  may  be  drawn 
backwards  or  forwards  to  a  distance  of  several  inches.  This  arrangement,  so 
consonant  with  the  functions  of  the  penis,  renders  it  easy  to  lengthen,  too 
much  or  too  little,  the  external  layer  of  the  preputial  sheath,  although  by 
itself  is  total  division  would  have  been  exactly  of  the  right  dimensions ;  that 
is  to  say,  if  during  the  incision  the  skin  is  drawn  forward,  it  will  be  seen  to 
draw  back  and  uncover  a  portion  of  the  copulative  organ ;  while  on  the  other 


660  NKW  ELEMENTS  OF 

hand,  much  more  retracted  in  an  opposite  direction,  it  would  return  apd  cover 
the  posterior  extremity  of  the  wound.  The  vessels,  which  come  off  from  the 
dorsal  arteries  of  the  penis,  and  sometimes  from  a  prolongation  of  the  artery 
of  the  septum  or  the  superficial  perineal  branches,  are  found  principally  on 
the  upper  part  and  inferior  extremity  of  its  vertical  diameter;  so  that  in  pro- 
portion as  we  deviate  from  the  median  line  is  the  risk  of  hemorrhage  increased. 
Happily,  as  their  volume  is  inconsiderable,  they  need  give  no  anxiety  in  this 
respect,  and  scarcely  merit  attention.  Lastly,  let  it  be  remembered,  that  in  its 
downward  reflection  to  form  the  frenum  preputii,  the  prepuce  gradually  ex- 
tends its  adhesions  from  the  corona  glandis  towards  the  meatus  urinarius^  to 
such  a  degree  as  to  offer  a  much  greater  length  in  this  direction  than  in 
the  dorsal  side. 

The  Operation. — Superior  Method,  The  operation  forphymosis,  as  simple  as 
any  in  surgery,  requires  for  its  performance  a  narrow  bistoury,  either  straight 
or  slightly  concave,  or  a  pair  of  scissors :  a  director  grooved  to  its  extremity 
and  not  ending  in  a  cul-de-sac,  dressings  forceps,  artery  forceps,  a  lint  com- 
press besmeared  with  cerate,  two  or  three  small  soft  compresses,  and  a  narrow 
bandage  about  a  yard  in  length.  The  concealed  bistoury  of  Bienaise,  employed 
by  Lapeyronie,  as  well  as  all  instruments  specially  devised  for  this  object, 
are  wholly  useless. 

The  patient  is  to  be  seated  on  a  chair,,  unless  he  prefers  being  in  bed.  The 
surgeon,  in  a  convenient,  position,  passes  the  director  beneath  the  prepuce 
down  to  the  bottom  of  the  gland.  The  assistant  who  supports  the  penis  is 
now  desired  to  attend  to  the  director  also,  and  to  preserve  it  and  the  integu- 
ments in  a  proper  position.  The  bistoury,  gliding  over  the  groove  in  the 
director,  reaches  the  base  of  the  cutaneous  fold  or  replication ;  when  its  point 
is  turned  towards  the  skin,  so  as  to  pierce  the  prepuce  from  within  outwards,  ^ 
and  then  rapidly  to  cut  it  through  from  behind  forwards.  The  incision  by 
puncture  of  the  deep  seated  parts  near  the  skin  possesses  the  advantage 
mentioned  by  M.  Richerand,  that  the  patient  by  shrinking  involuntarily  him- 
self, completes  the  operation  without  trouble  to  the  surgeon.  In  order  to 
dispense  with  the  grooved  director  many  persons  follow  the  advice  of  Saba- 
tier,  conduct  the  bistoury  flatwise  in  between  the  glands  and  its  sheath,  and 
then  act  as  has  just  been  directed. 

Some  also,  to  avoid  wounding  any  parts  over  which  it  passes,  place  a  small 
wax  ball,  smeared  with  oil  or  cerate,  at  the  end  of  the  bistoury,  which  when  it 
arrives  at  the  bottom  of  the  cul-de-sac,  passes  easily  through  the  wax  and  the 
integuments  to  be  divided  together.  Scissors  are  now  scarcely  any  longer 
made  use  of;  acting  as  they  must  on  very  soft  and  unstable  parts,  they  rarely 
effect  more  than  a  partial  division  only  at  the  first  cut ;  and  the  more  so  that 
the  incision  must  be  made  from  before  backwards.  They  are  consequently 
employed  only  to  rectify  the  incision  made  by  the  bistoury  when  it  has  not 
equally  effected  both  layers  of  the  prepuce,  or  when  it  is  wished  to  add  to  its 
length.  ,       >.' 

Some  other  surgeons  think  it  necessary  to  adopt  infinitely  more  minute 
precautions,  for  the  purpose  of  limitirtg  the  too  great  extent  of  the  wound, 
whether  inwardly  or  outwardly.  For  example,  it  is  the  advice  of  M.  Ricord 
that  we  should  seize  the  tegumentary  fold  with  two,  or  even  three  dressing 
forceps,  in  three  different  places  from  its  free  extremity  to  its  base,  so  as  to 


Ol»ERATIVE  SURGERY.  661 

Stretch  it  sufficiently,  and  to  allow  its  section  to  be  made  by  the  knife,  or 
scissors,  xvithout  danger  of  the  two  layers  sliding  over  one  another.  Besides 
the  inconvenience  of  such  a  multiplicity  of  instruments,  which  require  to  be 
managed  by  as  many  assistants,  it  has  moreover  this  objection,  that  it  is  very 
rarely  admissible  for  a  prepuce  sufficiently  contracted  to  call  for  the  opera- 
tion ;  for  phymosis  would  never  admit  the  introduction  of  three  dressing  forceps 
and  a  cutting  instrument.  When  we  have  been  careful  to  drawback  the  skin, 
that  no  folds  or  twisting  may  exist  on  the  free  edge  of  the  prepuce,  and  the 
assistant  or  surgeon  has  been  watchful  sufficiently  to  stretch  the  part,  the 
obstacle  (which  the  plan  of  Lisfranc,  as  described  by  M.  Ricord  is  well  cal- 
culated to  obviate)  will  be  but  little  to  be  feared.  The  former  of  these 
surgeons,  with  a  view  of  avoiding  the  angular  projections  of  the  wound, 
advises  us  to  do  no  more  than  excise  a  semilunar  portion  on  the  anterior  and 
dorsal  border  of  the  part,  which  he  does  with  scissors  curved  on  their  flat 
surface  ;  and  which  excision  he  repeats  in  several  places  along  the  membranous 
circumference,  if  the  first  section  seem  insufficient.  This  procedure,  which 
is  useful  when  the  prepuce  is  long  and  the  malady  slight,  should  however  be 
superseded  by  the  removal  of  a  triangular  portion  of  the  contracted  ring 
when  any  solid  advantage  is  to  be  gained  by  a  loss  of  substance.  This  latter 
excision  would,  in  fact,  be  indispensable  in  operating  on  a  phymosis  resulting 
from  chronic  induration,  as  I  myself  once  did  at  the  Hospital  St.  Antoine,  on 
an  individual  who  had  the  sheath  of  the  glans  converted  into  a  really  fibro- 
cartilaginous shell. 

By  a  preference  to  the  dorsal  region,  which  is  advised  by  most  operators, 
we  are  liable  to  extraction  of  the  sides  of  the  incision  and  their  lateral  sepa- 
ration from  each  other,  so  as  to  give  rise  to  a  very  ugly  looking  rim  or  edge, 
which  is  also  sometimes  a  ver^'^  troublesome  one. 

Subsequent  excision  of  the  angle  of  each  portion  does  but  very  imperfectly 
remedy  the  defect  of  which  I  speak,  and  in  all  cases  is  far  from  sufficient.  To 
this  result,  the  method  invented  by  M.  Cloquet  gives  an  infinitely  less  predis- 
position. It  is  performed  by  making  the  incision  at  the  lower  and  the  upper 
part  of  the  prepuce.  The  bistoury  is  carried  on  one  side  or  the  other  of  the 
frenum,  which  is  itself  afterwards  divided  if  it  appears  to  be  lengthened  too  far 
forward.  Besides  having  fewer  vessels  to  encounter  in  this  than  the  former 
direction,  the  wound  becomes  transverse  by  the  retraction  of  its  edges,  which 
is  all  in  favor  of  the  aperture  we  desire  to  augment,  and  does  not  leave  a  de- 
formity as  in  the  preceding  case,  equally  as  troublesome  as  the  original  affec- 
tion. It  would  appear  that  phymosis  was  thus  remedied  by  the  ancients,  for 
in  speaking  of  it  Celsus  remarks,  "  subter  a  summa  ora  cutis  inciditur,  recta 
linea  usque  ad  frenum,  atque  ita  superius  tergus  relaxatum  cedere  retro  po- 
test." I  have  performed  this  operation  eight  times,  and  experience  leads  me 
to  the  belief  that  it  will  be  a  substitute  for  the  other. 

Instead  of  making  the  incision  on  the  median  line,  either  above  or  below,  we 
are  sometimes  induced  by  the  presence  of  veneral  tubercles  or  ulcers  to  place 
it  on  the  side,  or  on  both  sides  of  the  organ ;  but  to  render  this  necessary,  the 
prepuce  should  be  extensively  altered,  as  lateral  incisions  are  in  general 
attended  with  great  deformity.  It  is  possible,  and  sometimes  very  useful 
when  the  constriction  extends  to  a  considerable  distance,  to  strike  the  point 
of  the  bistoury  in  upon  the  director  through  the  integuments,  as  is  advised  by 


662  NEW   ELEMENTS    OF 

MM.  Heurtault  and  Tavernier,  and  not  as  is  usually  done,  make  the  puncture 
from  within  outwards.  Another  good  rule,  also  laid  down  bj  M.  Tavernier, 
with  a  view  to  avoid  any  error  in  calculating  the  relative  extent  of  the  incision 
into  the  organic  layers,  is  the  following;  the  director  once  introduced,  its 
point  is  made  to  project  a  little ;  the  surgeon  then  is  to  draw  back  the  skin 
until  the  rosy  border  of  the  mucous  layer  be  distinctly  seen.  The  points 
being  kept  in  this  position  by  the  operator  himself  or  an  assistant,  he  may  be 
sure  that  the  instrument  piercing  the  integuments  from  the  surface  to  the 
director,  or  from  the  director  to  the  surface,  and  brought  back  from  the  root 
of  the  prepuce  to  its  free  extremity,  will  make  as  neat  and  even  a  section  as  it 
is  possible  for  it  to  do. 

The  operation  being  completed,  the  cutaneous  replication  ascends  behind 
the  glans  penis.  The  lint  compress  is  laid  on  the  wound,  which  is  surrounded 
with  a  small  soft,  and  two  long  compresses,  or  a  Maltese  cross ;  to  conclude, 
the  bandage  is  carried  down  to  the  extremity  of  penis,  so  as  to  bring  it 
back  by  circular  turns  to  the  anterior  extremity  of  the  organ,  and  again  carry 
it  behind  where  it  is  to  be  fastened.  A  suspensory  previously  applied 
would  allow  this  little  arrangement  to  be  much  more  securely  effected,  and 
render  it  much  less  liable  to  derangement.  It  is  well  to  take  a  turn  or  two 
of  the  bandage  or  to  pass  a  cravat  around  the  loins;  the  whole  organ  may  be 
kept  turned  up  on  the  hypogastrium.  If  the  dressing  be  not  displaced,  it  need 
not  be  renewed  for  two  or  three  days ;  and  if  suppuration  takes  place  it  is 
really  so  simple  as  to  require  me  to  dwell  no  longer  upon  it.  That  the  wound 
may  remain  as  narrow  as  possible  in  the  antero- posterior  direction,  and  may 
not  be  tedious  in  healing,  there  is  some  advantage,  particularly  at  the  first 
dressing,  in  placing  the  folds  or  turns  of  the  bandage  on  the  body  of  the  penis, 
going  from  behind  forwards ;  and  also,  in  afterwards  using,  as  is  advised  by 
M.  Tavernier,  a  Maltese  cross  perforated  in  the  centre,  so  that  it  may  leave  the 
glans  uncovered  while  it  pushes  the  divided  prepuce  from  before  backwards. 
By  these  means  the  dressings  are  more  solid,  and  all  the  tissues  are  drawn  to- 
gether instead  of  tending  to  a  separation,  as  often  happens  when  this  precaution 
is  not  taken.  At  a  later  period  I  have  found  it  a  good  plan  to  draw  forward  the 
callous  rim  which  is  formed  for  a  good  while  by  the  edges  of  the  incision,  so 
as  to  compress  it  a  little  and  favor  its  absorption. 

§  1. — Paraphymosis, 

If  compresses  steeped  in  cold  or  iced  water,  which  have  the  property  of 
overcoining  strangulation  and  allowing  the  prepuce  to  be  drawn  over  the 
glans,  by  reducing  the  bulk  of  the  cavernous  bodies  and  diminishing  the 
flow  of  blood  into  them,  are  insufficient  or  cannot  be  employed,  and  unless 
the  inflammation  or  painful  state  of  the  parts  themselves  render  it  inexpedient, 
we  can  always  try  what  can  be  done  by  another  means  before  resorting  to 
the  operation  properly  so  called.  This  means  is  compression.  By  some  it  is 
executed  by  the  use  of  a  roller  bandage,  gradually  increasing  its  power  until 
the  reduction  of  the  glans  can  be  made ;  others  operate  with  their  fingers,  in 
such  a  manner  as  that  the  patient  is  for  the  most  part  immediately  cured  of 
the  affection. 

To  do  this,  the  surgeon  seizes  the  penis  with  the  index  and  middle  fingers 


OPERATIVE    SURGERY  663 

of  either  hand,  which  he  crosses  behind  the  morbid  ring  of  the  prepuce.  His 
two  thumbs  remaining  at  liberty,  are  to  press  upon  the  sides  of  the  glans  in 
such  a  way  as  to  act  in  concert  with  the  fingers,  but  in  opposite  directions, 
the  glans  being  pushed  strongly  back,  whilst  the  prepuce  is  drawn  forcibly 
forwards  as  it  were  to  cover  the  thumbs  which  are  crowding  within  it.  That 
the  fingers  may  not  slip  on  the  skin,  it  is  well  to  cover  each  with  a  piece  of 
thin  linen,  which  has  besides  the  advantage  of  rendering  the  operation  rather 
less  painful.  It  would  be  wrong  to  refuse  a  trial  to  this  remedy  on  the  sole 
ground  of  the  disease  having  lasted  twelve  or  eighteen  hours,  and  that  tlie 
parts  are  swelled  and  painful.  I  have  resorted  to  it  with  perfect  success 
twenty  hours  after  the  accident,  in  a  healthy  and  robust  young  man  twenty- 
five  years  of  age ;  and  after  the  lapse  of  three  days  in  another,  and  with  no 
more  convenience,  although  the  forepart  of  the  penis  was  extremely  sensitive 
and  that  several  chaps  existed  on  each  side  of  the  rim  of  the  prepuce. 

This  is  an  operation  likely  to  succeed  in  the  greater  number  of  cases  when 
it  is  well  performed,  but  of  which  the  mechanism  is  too  simple  to  require  its 
explanation  at  greater  length  to  a  person  intelligent  enough  to  do  it  as  it  should 
be  done. 

If  it  do  not,  however,  answer  the  object  of  the  surgeon,  we  must  resort  to 
the  use  of  cutting  instruments.  Whilst  an  assistant  holds  the  penis  at  both 
ends,  and  bends  it  moderately  upon  its  inferior  surface,  the  operator  slides 
a  narrow  bistoury  flatwise  between  the  dorsal  aspect  of  the  glans,  or  of  the 
corpora  cavernosa  and  its  coverings,  as  far  as  the  strangulation ;  turns  its 
edge  towards  the  skin  if  sure  of  having  penetrated  beneath  the  constriction, 
and  in  the  contrary  case  towards  the  penis ;  and  then  in  the  former  case  by 
depressing  the  wrist,  in  the  second  by  elevating  it  a  little,  he  cuts  it  immedi- 
ately, and  if  one  incision  does  not  appear  sufficient  makes  one  or  two  others  in 
a  similar  manner. 

Now,  instead  of  thus  ploughing  up  the  tissues  to  reach  the  stricture,  would 
it  not  be  better  to  incise  it  at  once  by  its  outer  surface  ?  I  see  nothing  to 
render  such  an  operation  impossible.  In  endeavoring  to  push  back  the  skin 
towards  the  pubis,  and  to  turn  out  the  morbid  rim  in  front,  the  bottom  of  the 
circle  which  causes  the  difficulty  is  generally  brought  into  view.  Nothing  is 
then  easier  than  to  carry  down  perpendicularly  upon  it  the  point  of  a  straight 
bistoury  held  like  a  writing  pen,  and  to  make  in  one  or  more  places  with 
the  instrument  little  incisions,  to  which  the  necessary  depth  may  be  given 
without  running  the  risk  of  erring  as  in  the  other  method.  I  give  the  preference 
to  this  method,  and  with  me  it  answers  so  well,  even  in  the  case  of  a  child  in 
whom  the  paraphymosis  was  of  three  days'  standing,  and  in  all  the  adults  in 
whom  I  could  not  relieve  by  the  fingers  and  thumbs,  that  I  can  scarcely 
conceive  of  a  case  in  which  the  former  method  need  be  indispensable. 

A  little  lint  spread  with  cerate,  lotions  of  marsh-mallows-water,  emollient 
topical  applications,  and  the  most  soothing  means,  are  all  that  is  called  for 
after  this  simple  operation,  which  can  only  be  rendered  serious  by  opening 
largely  into  the  corpora  cavernosa,  or  by  the  division  of  a  principal  artery  of 
the  penis  ;  even  then  such  occurrences  would  probably  prove  unimportant. 


664  NEW    ELEMENTS    01* 


§  3.  Stricture  of  the  Penis. 


.  Since  the  attention  of  the  profession  was  directed  by  Morand  to  this  sub- 
ject, all  practitioners  have  mentioned  individuals  who  from  depravity  or 
carelessness  have  mechanically  included  the  penis  in  bonds  or  rings,  from 
which  they  could  not  afterwards  withdraw  it.  Sometimes  it  is  a  ring  of  cop- 
per or  iron,  a  circle  of  gol(l,  silver,  or  iron,  a  metallic  ferrule ;  at  other  times 
a  piece  of  pack  thread,  a  riband,  or  even,  as  was  seen  by  M.  Dupuytren,  the 
socket  of  a  candlestick ;  again,  it  is  an  elliptical  steel  circle,  called  a  *'steel," 
which  such  imprudent  persons  pass  over  the  penis  so  as  even  sometimes  to 
include  the  testicles  themselves.  The  parts  speedily  react  upon  obstacles 
like  these,  which  are  soon  buried  in  a  fissure  of  greater  or  less  depth  ;  and 
which  by  exciting  inflammation  and  tumefaction,  are  promptly  followed  by 
perforation  of  the  urethra,  or  of  .the  fibrous  tunic  of  the  corpora  cavernosa, 
if  not  by  sphacelus  itself.  Ligatures  of  thread,  cord,  or  riband,  will  never 
seriously  embarrass  a  professional  man ;  the  point  of  a  bistoury,  or  a  pair  of 
very  sharp  scissors  being  always  able  to  overcome  the  difficulty,  and  the  same 
may  be  said  of  rings,  of  rushes,  osier  or  wood.  To  disengage  a  circle  of  ebony, 
ivory,  or  horn,  scissors  of  great  strength,  or  cutting  nippers,  are  necessary. 
The  file  and  the  saw  become  indispensable  in  the  division  of  metallic  sub- 
stances. A  cutting  diamond  in  such  a  case  would  be  invaluable  if  it  were  at 
hand.  Unless  it  were  of  extraordinary  thickness,  the  hardest  circle  would 
not  prx)bably  resist  a  couple  of  small  hand -vices  if  they  could  be  applied 
to  it. 

If  the  swelling  of  the  part  be  excessive,  the  congestion  is  to  be  lessened  by 
the  previous  employment  of  scarification  and  punctures.  The  sides  of  the 
fissures  are  then  to  be  separated  as  far  as  possible,  so  as  when  practicable  to 
admit  beneath  the  stricturing  body  a  flat  piece  of  linen  or  metal,  as  a  protec- 
tion to  the  parts  against  the  action  of  instruments.  The  saw  and  file  are  to 
be  used  across  rather  than  in  the  long  direction  of  the  penis,  and  the  use  of 
the  other  means  is  sufficiently  intelligible  without  entering  any  further  into 
useless  details. 

§  4.  Section  of  the  Frenum. 

The  frenum  of  the  penis,  like  that  of  the  tongue,  sometimes  projects  too  far 
forwards.  The  result  of  this,  in  certain  subjects,  is,  that  during  its  erection 
it  is  curved  downwards  to  such  a  degree  as  to  render  coition  painful,  and  emis- 
sion difficult.  The  remedy  for  this  inconvenience  is  so  easy  of  application, 
that  all  persons  almost  adopt  it.  In  the  first  place  the  abnormal  fold  fre- 
quently gives  way  of  itself  in  coition.  If  it  resists  these  efforts,  it  must  be 
divided  either  with  scissors,  or  a  bistoury.  The  glans  being  raised  up  by  the 
patient  or  an  assistant  the  surgeon  has  only  to  draw  down  the  prepuce,  and 
if  he  uses  scissors  cut  the  frenum  as  far  as  possible  from  before  backwards 
at  one  stroke.  If  a  bistoury  be  preferred  it  is  immaterial  whether  the  fre- 
num is  transfixed  at  its  base  and  divided  from  behind  forwards,  or  whether 
we  simply  cut  from  its  free  edge  backwards  towards  its  adhesions. 

In  every  case  it  is  better  to  separate  it  by  paring  the  glans,  so  that  no 


OPERATIVE    StJRGIiRY.  665 

protuberances  may  continue  on  this  part  after  the  recovery.  Its  destruction 
by  caustics,  such  as  the  nitras  argenti,  as  was  formerly  done  and  is  still 
among  some  surgeons,  could  only  be  advisable  in  a  patient  whose  fear  of  a 
cutting  instrument  was  excessive.  Although  dressing  of  any  kind  is  almost 
unnecessary,  if  the  individual  be  irritable  or  timid,  we  may  cover  the  little 
wound  with  a  piece  of  linen  spread  with  cerate  and  some  lint.  Care  must 
be  taken  not  to  allow  the  prepuce  to  remain  too  long  in  one  place,  if  it  con- 
tinues to  cover  the  glans;  for  thus  the  parts  might  become  readherent,  and 
the  object  of  the  operation  would  be  unattained. 

§  5.  Adhesions  of  the  Prepuce  to  the  Glans, 

The  inner  surface  of  the  prepuce  is  sometimes  closely  adherent  to  the 
glans,  to  a  greater  or  less  distance  from  the  orifice.  When  no  constriction 
accompanies  this  affection,  it  does  not  usually  bring  with  it  any  remarkable 
inconvenience ;  so  that  it  would  be  imprudent  to  seek  its  removal  by  an 
operation. 

If  it  however  impeded  coition,  of  which  examples  are  cited,  and  the  per- 
son was  willing  to  be  rid  of  it  at  any  risk,  the  following  plan  is  to  be  adopted 
for  curing  it. 

After  having  detached  the  prepuce  below  to  an  extent  sufficient  to  allow 
of  its  longitudinal  section,  the  surgeon  is  to  dissect  off  its  whole  circumfer- 
ence, little  by  little,  as  far  as  the  union  of  the  glans  with  the  body  of  the 
penis.  To  prevent  the  surface  from  again  coming  in  contact  and  adhering  as 
before,  the  skin  must  be  kept  drawn  down  towards  the  penis,  and  the  wound 
be  covered  with  a  perforated  piece  of  linen,  spread  with  ointment,  and  sus- 
tained by  lint,  a  compress,  and  a  bandage  :  in  short,  every  method  is  to  be  prac- 
tised by  which  the  two  bleeding  surfaces  may  separately  be  made  to  cicatrize. 
It  has  been  justly  observed  by  J.  L.  Petit,  that  the  separation  of  these  surfaces 
is  neither  easy  nor  unattended  with  pain.  It  would  perhaps  be  best,  when  they 
exist  on  the  whole  circumference  of  the  glans,  to  let  them  alone  unless  they 
are  complicated  with  phymosis.  On  the  other  hand,  when  only  a  simple 
frenum  exists,  or  that  only  a  portion  of  the  organ  is  confined  by  them,  the 
facility  of  their  destruction,  and  the  curvature  of  the  penis  during  erection 
which  results  from  them,  induced  us  to  separate  them.  It  has  been  ably 
shown  by  M.  Langier,  that  in  children  in  whom  phymosis  prevents  us  usually 
from  recognizing  their  existence,  or  at  least  discovering  from  their  situation, 
amputation  of  the  prepuce  or  circumcision  is  the  most  rational  measure  to  be 
instituted,  if  after  such  an  excision  the  greater  part  of  the  glans  can  remain 
uncovered. 

§  6.  Destruction  of  the  Prepuce 

Instead  of  being  of  too  great  a  length,  and  adhering  to  the  glans,  the 
prepuce  may  be  too  short,  or  have  met  with  a  loss  of  substance  more  or  less 
extensive.  Celsus  who  had  turned  his  attention  to  the  mode  of  remedying 
this  defect  in  conformation,  advises  a  circular  division  of  the  skin  at  some 
distance  from  the  glans  on  the  body  of  the  penis,  and  that  then  the  integu- 
ments be  drawn  forwards  and  fixed  by  sutures  beyond  the  free  extremity  of 
84 


666  NEW  ELEMENTS  OF 

the  organ.  We  now  know  to  a  certainty,  that  such  an  operation  is  useless, 
that  the  cicatrix  invariably  retracts  the  skin  by  degrees,  so  as  to  restore  the 
parts  to  their  original  condition ;  but  we  might  probably  succeed  better  by 
stripping  the  anterior  part  of  the  virile  member  of  its  integuments,  for  an 
inch  or  two,  so  as  to  be  able  to  bring  them  over  in  the  form  of  an  artificial 
sheath,  as  far  in  front  as  the  meatus  urinarius,  just  as  we  raise  up  on  the  face 
the  soft  parts  removed  from  the  neck  in  the  cheiloplastic  method  of  M.  Roux ; 
only  we  should  then  have  to  be  watchful,  lest  the  adhesions  of  the  new 
sheath  should  be  prolonged  on  the  surface  of  the  glans.  If  the  prepuce  had 
lost  but  a  small  portion  of  its  contour,  and  the  fissure  could  not  be  united  by 
the  hare-lip  operation,  we  should  then  have  to  dissect  the  two  edges  of  the 
division  more  or  less  off,  then  to  approximate  and  reunite  them  afterwards  by 
sutures,  after  having  irritated  the  edges.  As  .the  prepuce  is  as  susceptible  of 
being  mended  in  all  ways  that  can  be  adapted  to  nose  or  face,  it  is  evident 
that  strictly  speaking  the  posdeplastic  has  as  many  shades  of  application  as 
the  cheiloplastic. 

M.  Dieffenback  has  proved  that  Sabatier,  as  well  as  Petit,  was  wrong  in 
rejecting  as  useless  or  impossible  the  various  methods  of  restoration  appli- 
cable to  the  virile  member. 

§  7.  *dmputation  of  the  Penis, 

The  mobility  and  extreme  distensibility  of  the  envelopes  of  tne  penis  is  such, 
that  tumors,  of  the  prepuce  for  example,  gradually  push  back  the  glans  and 
corpora  cavernosa,  so  as  to  appear  to  occupy  the  body  of  the  member  itself, 
when  in  reality  its  appendages  alone  are  affected.  Hence  doubtless  arises 
the  error  of  many  older  writers,  who  believed  in  the  reproducibility  of  the 
penis,  and  who  thought  they  had  seen  it  spring  forth  again  after  amputation. 
In  fact  a  considerable  extent  of  parts  may  be  removed,  without  trenching  on 
the  meatus  urinarius.  The  tissues  which  had  been  turned  back  by  the  tumor, 
or  tumefaction,  then  lengthen  again,  and  soon  resume  their  primitive  dimen- 
sions, so  as  easily  to  impose  on  prejudiced  minds.  Cancer  is  not  the  only 
disease  capable  of  producing  a  similar  illusion ;  all  other  degenerations  possess 
this  property.  It  even  happens  sometimes  in  cases  of  acute  inflammation. 
In  1824,  there  came  a  robust  man,  about  forty  years  old,  to  the  Hospital  du 
Perfectionnement,  in  whom  the  penis,  highly  inflamed  as  high  as  the  pubis 
and  enormously  swelled,  sphacelated  to  within  two  inches  of  its  root,  in  twenty- 
four  hours.  Precautions  were  adopted  for  saving  what  remained  of  the  glans, 
or  corpora  cavernosa,  in  this  putrid  mass  ;  but  they  were  found  entire  behind 
the  sphacelus,  and  with  no  other  lesions  than  slight  excoriations  in  front. 

Amputation  of  the  penis  may  be  total  or  partial;  total  when  the 
cancer  occupies  its  whole  extent,  and  partial  in  a  contrary  case.  Such  cancers 
as  originate  in  the  sldn,  whether  on  the  prepuce  or  elsewhere,  are  a  very  long 
time  generally  in  reaching  the  fibrous  envelope  or  spongy  tissue  of  the  organ. 
The  extirpation  of  them  is  therefore  to  be  begun  in  such  away  as  to  respect 
the  principal  organ,  and  so  as  also  to  sacrifice  it  if  found  really  morbid  in  struc- 
ture. The  precept  of  removing  only  degenerated  tissues,  on  which  so  many 
old  authors  have  insisted,  and  to  which  Callisen  so  frequently  recurs  when 
speaking  of  the  operations  to  be  performed  on  the  genital  organs,  has  been  too 


OPERATIVE  SURGERY.  66^ 

often  forgotten ;  and  we  are  indebted  to  M.  Lisfranc,  for  the  eflforts  which  he 
has  made  in  our  time  to  recall  it  to  the  attention  of  surgeons.  Besides  the 
peculiarities  relating  to  the  envelopes  of  the  penis,  its  amputation  requires 
that  the  disposition  of  its  proper  constituents  be  not  lost  sight  of.  The  fibrous 
sheath  which  forms  its  envelope  or  shell,  and  the  spongy  tissue,  whose  cells  ail 
communicate  with  one  another,  dispose  it  to  lengthen  or  retract  immediately 
after  the  operation,  according  as  it  was  previously  doubled  back  or  drawn 
forward  by  the  cancerous  tumor.  The  cavernous  arteries,  enclosed  within  it, 
one  on  either  side,  having  but  little  adhesion,  project  from  the  surface  if  the 
wound  of  the  stump  retracts  considerably,  while  if  on  the  contrary  it  suffers 
elongation  they  will  appear  to  be  deeply  buried  in  its  areola.  The  urethra, 
at  its  under  surface  and  in  immediate  contact  with  the  skin,  has  this  pecu- 
liarity about  it ;  that  owing  to  the  junction  of  its  upper  and  free  to  its  under 
ide  flatwise,  it  is  hidden  on  the  circumference  of  the  wound,  immediately  after 
the  amputation. 

Tlie  Operation.— ^By  Ligature,  The  great  dread  of  hemorrhage  induced 
some  of  the  ancients  not  to  use  cutting  instruments  in  the  removal  of  the 
penis,  and  to  prefer  its  strangulation  by  ligature.  Ruysch  gives  an  example  of 
a  successful  application  of  this  method.  Heister,  Bertrandi,  and  some  other 
surgeons  of  the  last  century  did  not  disdain  the  employment  of  the  same  means. 

In  performing  it,  it  would  always  be  proper  first  to  introduce  a  sound  into 
the  bladder,  in  order  to  prevent  closure  of  the  urethra  by  the  ligature.  If  it 
is  feared  that  application  of  the  ligature  upon  the  skin  would  be  too  painful, 
there  is  no  objection  to  following  the  advice  of  Sabatier,  and  making  an 
incision  circularly  into  the  integuments,  and  before  putting  on  the  thread : 
but  it  is  precisely  this  very  incision,  as  painful  as  amputation  itself,  which 
makes  patients  afraid  of  excision  and  leads  them  to  prefer  strangulation. 

By  Jlmputation. — The  patient  must  lie  horizontally  on  the  edge  of  the 
right  side  of  the  bed.  An  assistant  takes  hold  of  the  root  of  the  organ,  and 
draws  tlie  skin  more  or  less  towards  the  pubis,  as  it  appears  that  the  disease 
has  drawn  it  forwards  to  a  greater  or  less  extent.  The  surgeon  then  seizes 
tiie  tumor  covered  by  a  cloth,  and  holds  it  firmly  in  his  left  hand.  With  his 
right  hand,  armed  with  a  small  scalpel  or  a  bistoury,  he  makes  one  perpen- 
dicular incision  from  above  downwards  or  from  below  upwards,  through  the 
body  of  the  penis,  a  little  beyond  the  limits  of  the  disease.  A  previous 
division  of  the  skin,  a  little  in  advance  of  the  spot  where  the  corpora  cavernosa 
are  to  be  cut  through,  would  scarce  lengthen  the  operation,  and  would 
always  allow  the  section  of  the  penis  to  be  even  with  that  in  the  retracted 
integuments. 

This  proceeding,  recommended  by  M.  Boyer  when  the  disease  extends  to 
the  scrotum,  seems  to  me  in  every  case  to  merit  the  preference.  There  are 
generally  six  or  seven  arteries  to  be  tied  ;  viz.  the  two  dorsal,  the  two  caver- 
nosus,  the  two  superficiales  perinei,  below  j  then  on  the  lower  median  line 
those  of  the  septum.  However,  the  principal  ones  are  the  two  dorsal  and 
two  cavernosa.  Should  tying  them  be  at  all  inconvenient,  the  laxity  of  the 
tissue  which  surrounds  the  first  would  render  their  insulation  and  torsion 
extremely  easy.  It  is  nearly  the  same  with  the  second ;  but  it  matters  not,  in 
such  a  wound  where  no  immediate  union  is  to  be  attempted,  whether  torsion  or 
ligature  be  adopted. 


668  NEW   ELEMENTS   OF 

Modification  of  M.  Barthelemy. — Before  proceeding  to  apply  the  dressings, 
a  catheter  must  be  passed  into  the  urethra.  Some  authors  having  asserted 
that  it  was  at  times  difficult  to  find  the  orifice  of  the  canal  again  at  the 
bottom  of  the  wound,  a  young  army  surgeon,  M.  Barthelemy,  conceived 
the  idea  of  introducing  the  catheter  previous  to  the  incision,  and  cutting  it  off 
as' well  as  the  penis,  so  that  it  might  always  be  found  in  its  natural  situation. 
This  plan  might  either  be  adopted  or  not,  indifferently,  but  that  it  is  liable  to 
be  attended  with  the  slipping  of  the  cut  extremity  of  the  catheter  into  the 
bladder,  besides  rendering  by  its  own  section  somewhat  less  easy  the  ampu- 
tation of  the  penis.  Moreover,  it  is  clear,  that  for  a  man  of  any  anatomical 
knowledge,  this  search  after  the  orifice  of  the  urethra  never  can  be  very 
embarrassins:.  If  the  skin  has  been  too  much  crowded  backwards  it  will 
spontaneously  return  and  cover  the  wound,  and  thus  offer,  possibly,  some 
inconvenience.  If  on  the  other  hand  it  has  not  been  sufficiently  pressed  back, 
it  will  be  seen  to  retract  towards  the  pubis,  and  leave  uncovered  the  fibrous 
envolope  of  the  corpora  cavernosa.  As  there  exists  no  remedy  against  this 
latter  inconvenience,  while  in  the  former  the  superfluous  integument  can 
always  be  cut  off,  it  is  better  perhaps  upon  the  whole  to  draw  the  integu- 
ments more  or  less  towards  the  pubis  in  an  amputation  of  the  penis. 

If  we  are  compelled  by  the  disease  to  operate  very  close  to  the  pelvis,  there 
is  still  no  reason  for  preferring  ligature  to  excision.  The  vessels  here  can 
present  no  great  difficulty,  and  the  actual  or  potential  cautery,  as  advised  by  so 
many  authors,  is  a  last  resource  fully  sufficient  to  put  a  stop  to  any  hemor- 
rhage which  might  occur. 

The  Dressing. — The  catheter  once  fixed  in  the  urethra,  all  that  is  necessary 
is  to  apply  a  perforated  Maltese  cross,  which  has  in  it  a  hole  to  allow  passage 
to  the  sound  over  the  wound.  X<int  compresses,  two  small  and  long  com- 
presses, a  narrow  bandage  which  keeps  them  on  the  remnant  of  the  penis  and 
then  goes  once  or  twice  round  the  pelvis,  form  the  whole  of  the  dressing, 
unless  we  prefer  as  after  the  operation  for  phymosis  to  use  a  suspensory  or 
T  bandage,  on  which  is  fastened  a  small  bandage  or  two  ends  crossed  over 
the  bleeding  surface.  The  only  object  of  the  catheter  in  this  case  being  to 
give  exit  to  the  urine  without  touching  the  wound  and  preventing  the  closure 
of  the  urethra,  an  objection  may  be  made  to  its  use,  by  stating  that  far  from 
being  injurious  the  flow  of  urine  over  the  suppurating  surface  is  often  very 
advantageous.  In  proof  of  this  it  is  alleged  that  urine  was  once  used  in 
facilitating  the  progress  of  healing  wounds.  It  has  appeared  to  some,  that  if 
expelled  by  the  bladder,  this  fluid  would  prove  sufficient  to  impede  the  closure 
of  the  urethra,  and  that  moreover  the  urethra  being  lined  with  a  mucous  mem- 
brane it  is  unreasonable  to  fear  its  obliteration.  I  saw  in  1823,  a  fact  which 
seems  to  give  strength  to  this  argument.  M.  Bongon  removed  the  penis  of 
an  old  man  for  cancer;  a  catheter  was  introduced,  and  the  dressing  applied 
secundum  artem.  But  the  man,  a  maniac  and  exceedingly  intractable, 
would  on  no  account  permit  the  least  apparatus  on  the  wound ;  and  on  the 
second  removed  it  all  with  the  catheter.  I  reapplied  them  several  times  but 
could  never  make  him  understand  that  they  were  to  be  kept  on  :  at  length  we 
gave  it  up,  but  not  without  anxiety  for  the  result.  However,  the  wound  healed 
very  regularly,  and  the  urethra  preserved  as  large  a  calibre  as  could  have 
been  wished.    The  catheter  then  is  not  indispensable.    As  its  presence  is  not 


OPERATIVE    SURGERY.  669 

without  its  inconvenience,  we  might,  even  if  we  did  not  wholly  dispense  with 
it,  employ  it  only  during  the  first  few  days,  so  as  to  prevent  a^y  imme- 
diate adhesion,  and  quite  towards  the  end  of  the  case  as  Le  Dran  recom- 
mends, to  prevent  secondary  stricture. 

I  cannot  close  this  subject  without  one  observation,  which  is,  that  simple 
though  it  be,  amputation  of  the  penis  is  nevertheless  often  followed  by  the 
most  disastrous  consequences.  Though  the  patients  who  are  the  subjects  of 
it  get  well  very  constantly  in  fifteen  or  twenty  to  thirty  days,  the  larger 
number  are  speedily  tormented  with  the  most  wretched  ideas,  and  fall  into 
melancholy  from  which  nothing  can  arouse  them.  Some,  to  avoid  it,  fly  to 
self-destruction,  while  others,  at  the  moment  when  it  is  least  expected,  sink 
beneath  the  pressure  of  the  moral  affliction  into  the  grave. 

SECTION  II. 

Sexual  Organs  of  the  Female,  * 

Abscess,  scirrhus,  lupus,  tumors,  and  cysts  of  every  species,  and  the 
varices  seen  on  the  labia  majora,  require  to  be  treated  and  operated  oa 
according  to  the  same  rules  as  when  on  any  other  part  of  the  body,  and 
here  required  no  special  mention.  Amputation  of  the  clitoris  and  removal  of 
the  nymphae,  are  so  seldom  called  for,  as  to  need  no  separate  description. 

^rt.  1. — Imperforation  of  the  Vulva. 

The  deficiency  of  an  aperture  in  the  vulva  is  sometimes  a  congenital 
defect ;  at  others  it  is  the  result  of  other  diseases  of  the  part ;  again,  it  is 
owing  to  the  existence  of  the  hymen,  which*,  instead  of  a  simple  valve,  is  a 
complete  disc ;  and  again  may  be  caused  by  adhesions  contracted  between  the 
different  parts  of  the  pudenda.  It  may  be  that  the  occlusion  of  the  vagina 
extends  more  or  less  into  the  pelvis,  or  even  to  the  cervix  uteri  itself.  In  the 
young  girl,  before  menstruation,  the  affection  in  question  can  in  no  wise  injure 
her  health ;  and,  but  for  the  catamenial  periods  it  would  be  no  otherwise  preju- 
dicial to  the  adult  woman  than  as  impediment  to  coition.  It  is  always  judi- 
cious, if  a  surgeon  is  called  early  to  the  case,  not  to  wait  until  the  age  of  puberty 
for  the  performance  of  the  operation;  for  if  the  operation  be  undertaken  to 
remedy  difficulties  caused  by  retention  of  the  menstrual  fluid,  its  consequences 
are  usually  more  serious  than  when  done  in  infancy.  If  the  vagina  be  closed 
by  a  membrane  only,  it  is  sufficient  to  pass  into  it  the  point  of  a  straight 
bistoury,  to  incise  it  freely  from  before  backwards,  then  across,  and  to  excise 
the  four  angles  thus  formed  for  its  destruction.  Afterwards  its  continuity  is 
to  be  preserved  to  a  sufficient  extent,  by  the  assistance  of  pledgets  of  lint  or 
sponges  of  a  teat  shape.  ^ 

If  previous  to  marriage  the  use  of  these  dilating  measures  were  to  be  dis- 
continued, there  would  be  incurred  the  risk  of  a  greater  or  less  retraction  or 
of  its  entire  reclosure ;  of  which  the  case  of  a  little  girl  six  years  old,  in  whom 
a  colleague  of  mine  only  effected  a  longitudinal  incision  of  the  hymen,  fur- 
nishes me  an  example.  It  is  perfectly  useless  first  to  puncture  with  a  trocar, 
and  then  to  employ  a  director  on  which  to  guide  the  bistoury  or  any  other 
particular  instrument.      Having  effected  its  perforation,  forceps   and  flat 


670  NEW   ELEMENTS    OF 

curved  scissors,  or  a  common  bistoury  even,  are  sufficient  always  for  removing 
the  portions  of  the  membrane.  It  is  not  common  to  be  called  on  to  perform 
this  operation  on  any  female  of  adult  age,  unless  she  have  symptoms  simulat- 
ing those  of  pregnancy,  such  as  enlarged  abdomen,  &c.  owing  to  the  retention 
within  of  the  menstrual  fluid.  If  the  hymen  alone  obstruct  the  passage,  it 
will  be  found  arched,  tense,  and  often  of  a  bluish  or  blackish  tint,  from  the 
presence  of  the  blood  behind  it  and  which  is  pressing  it  forwards.  In  that 
case  it  is  easier,  even,  to  open  than  in  the  preceding  one,  and  any  one  may  do 
it  v/ithout  danger.  Only  the  sudden  evacuation  of  so  vast  a  quantity  of  fluid, 
and  the  inability  of  the  uterus  and  other  distended  organs  to  retract  imme- 
diately on  themselves,  give  rise  afterwards  sometimes  to  visceral  inflamma- 
tion, and  fevers  of  a  bad  type.  Perhaps  it  is  better  to  use  no  pressure  or 
means  to  hasten  its  expulsion,  and  to  leave  it  to  the  natural  contractility  of  the 
organs  in  which  it  has  been  so  lodged.  Thus  no  vacuum  is  created  in  the 
cavities  into  which  we  have  opened.  It  is  not  possible  for  air  to  enter  in  and 
stagnate,  or  react  upon  the  morbific  fluid  or  on  the  parietes  of  the  cyst,  and  so 
produce  the  mischief  of  which  it  is  generally  accused.  Emollient,  detergent, 
or  slightly  resolvent,  or  even  antiseptic  injections  are  not  to  be  neglected  if 
their  use  be  indicated.  As  soon  as  fever,  heat,  and  pain  in  the  bottom  of  the 
abdomen  ensue,  the  patient  is  instantly  to  be  put  upon  the  severest  regimen, 
and  antiph^ogistically  treated  with  an  energy  proportioned  to  the  violence  of 
tjie  symptoms. 

The  operation  is  naturally  rendered  more  difficult  when  the  obliteration  ex- 
tends into  the  vagina  to  any  distance  from  the  external  orifice ;  first,  because 
it  is  impossible  to  say  how  far  the  portion  obliterated  extends,  unless  a  sort  of 
diaphragm,  a  transverse  perpendicular  septum  be  the  obstacle  to  be  destroyed ; 
secondly,  and  above  all,  we  have  to  employ  instruments  between  twoverv 
important  parts — the  rectum  and  the  bladder. 

Before  we  begin  then,  let  us  be  well  assured,  by  introducing  a  sound  into 
the  one,  and  one  or  two  fingers  into  the  other,  that  a  certain  thickness  of  tissues 
exists  between  the  two  canals,  that  the  uterus  is  in  its  normal  situation ;  lastly 
that  the  vagina  is  not  wholly  obliterated,  for  if  it  were  it  would  be  almost 
impossible,  and  consequently  rash,  to  attempt  its  artificial  re -establishment. 
Still  I  believe,  that  if  the  life  of  the  patient  was  threatened  by  the  menstrual 
accumulation,  and  that  there  existed  the  slightest  chance  of  reaching  the 
uterus,  by  cutting  away  between  the  rectum  and  bladder,  we  ought  to  dismiss 
every  fear,  and  shrink  not  before  the  difficulty  of  the  measure.  Suppose  it  to  be 
thought  advisable  to  resort  to  the  operation.  The  woman  is  to  be  placed  in 
the  position  as  in  operating  for  stone.  With  the  index  finger  of  the  left  hand 
in  the  rectum,  an  assistant  keeping  a  female  catheter  in  the  bladder,  the  point 
of  which  he  raises  towards  the  hypogastrium,  the  surgeon  passes  into  the  direc- 
tion of  the  vagina  either  a  long  narrow  bladed  bistoury  or  an  armed  trocar. 
The  cessation  of  resistance,  freedom  of  inclination  given  to  the  point  of  the 
instrument  in  any  direction,  are  evidences  that  it  has  entered  the  seat  of  the 
affection.  He  then  enlarges  the  wound  a  little  in  its  whole  length  by  with- 
drawing the  bistoury,  whose  cutting  edge  should  be  drawn  backward,  forwards, 
and  laterally,  if  he  be  sure  of  not  cutting  the  neighboring  organs. 

When  a  trocar  has  been  employed  and  the  canula  gives  exit  to  a  black  and 
viscid  liquid,  a  director  may  perhaps  be  indispensable  for  enlarging  sufficiently 


OPERATIVE    SURGERY.  671 

the  artificial  canal  we  have  made ;  after  which  the  introduction  of  the  finger 
will  show  if  the  division  is  large  enough,  or  in  what  direction  its  further 
extension  is  to  be  made.  Although  after  such  an  operation  the  vagina  generally 
remains  pervious,  prudence  requires  that  measures  be  taken  to  prevent  its 
closing.  A  tube,  either  of  metal  or  simply  of  gumelastic,  gradually  augmented 
in  size  to  a  certain  point  would  be  the  best  thing,  I  think,  for  accomplishing 
the  object,  although  pledgets  of  linen  or  lint,  removed  every  day  for  the  ad- 
ministration of  the  injections  might  equally  sufiice. 

Scientific  records  contain  so  many  cases  of  successful  performance  of  similar 
operations,  that  it  is  superfluous  here  to  recite  one  in  detail.  MM.  Ventura, 
Cabaret,  Delpech,  Desgranges,  Williams,  Toulmouche  of  Rennes,  &c.,  have 
within  a  few  years  completely  succeeded  in  several,  and  new  ones  are  every 
day  laid  before  the  public. 

It  must  not  however  be  forgotten,  than  in  a  case  recorded  by  Morgagni, 
the  woman  died  in  a  few  days ;  and  that  on  examination,  the  urinary  bladder 
was  largely  laid  open,  and  one  of  the  fallopian  tubes  burst  into  the  abdomen 
from  dilatation  by  blood ;  nor  that  M.  Dupuytren  has  frequently  seen  it  at- 
tended mth  fearful  accidents. 

Art,  2. — Puncture  of  the  Uterus. 

Closure  of  the  Os  Tincse. — As  in  the  vagina  there  may  never  have  been  any 
aperture  to  the  nedc  of  the  uterus,  or  it  may  have  become  closed  by  accident, 
it  is  equally  impossible  for  the  menses  to  be  expelled,  and  it  is  therefore  liable 
to  the  same  consequences.  The  first  thing  to  be  done  when  we  have  decided 
that  an  imperforate  uterus  really  exists  and  is  distended  by  a  fluid,  is  to 
seek,  by  means  of  the  finger,  for  the  neck  in  the  place  in  which  it  ought  to  be 
situated,  and  to  try,  if  it  be  discovered,  to  overcome  the  obstacle  if  possible 
by  the  introduction  of  an  ordinary  catheter.  Otherwise  its  perforation 
must  be  resolved  on,  which  has  now  been  done  a  great  many  times  with 
various  instruments.  Some  advise  the  puncture  to  be  made  with  a  trocar, 
others  that  it  be  made  in  preference  with  a  straight  bistoury  covered  to  a  few 
lines  of  its  point  with  a  strip  of  linen,  &c.  The  "  pharyngotome"  even  has 
its  admirers.  Dance  tells  us  that  Barre  employed  a  long  canula,  armed  with 
a  spear-shaped  point,  which  had  a  fissure  on  its  concavity ;  so  as  altogether  to 
bear  a  strong  resemblance  to  the  "  arrow  headed  sound"  of  Frere  Come.  On 
this  subject  every  one  is  at  liberty  to  please  his  own  taste  and  adopt  the  in- 
strument he  most  admires.  A  rather  long  bistoury,  concave,  and  protected 
by  lines,  carried  in  on  the  index-finger  of  the  left  hand,  will  answer  perfectly 
well  for  every  purpose,  while  every  indication  will  be  equally  fulfilled  by 
using  the  *'  sonde  a  dard,"  the  trocar,  or  the  "  pharyngotome."  Neverthe- 
less, I  believe  the  bistoury  and  trocar  to  be  the  preferable  instruments.  All 
that  is  necessary  is,  to  make  an  opening  into  the  uterus  large  enough  for  the 
fluid  to  escape  from  it,  and  not  to  venture  too  far  either  in  the  direction  of 
the  bladder  or  rectum.  As  in  the  operation  on  the  vagina,  we  must  here 
likewise  guard  against  the  return  of  the  disease,  and  do  all  in  our  power  to 
prevent  the  newly  established  orifice  from  closing  up  unless  the  natural  neck 
of  the  uterus  should  be  discovered.  We  must  attempt,  therefore,  to  convey 
into  the  uterus  the  end  of  a  gumelastic  catheter,  through  which  the  fluids 


672  NEW  ELEMENTS    OF 

may  flow  while  the  wound  is  kept  open.  In  the  operation  recently  performed 
with  success  bj  M.  Herves  de  Chegoin,  he  used  a  trocar,  the  canula  of  which 
permitted  him  to  carry  up  a  bougie,  which  in  its  turn  conveyed  the  end  of  a 
gumelasti'c  catheter,  destined  for  continuing  in  the  wound,  and  which  Was  at 
a  later  period  replaced  by  a  female  catheter.  This  is  the  wisest  plan,  and 
one  which  all  had  better  follow,  be  the  instrument  used  a  trocar,  bistoury, 
or  what  it  may. 

Retroversion. — Another  species  of  disease  may  also  require  puncture  of  the 
uterus ;  I  mean  retroversion  of  it  d^lring  pregnancy.  When  the  retroversion 
is  prolonged  beyond  the  third  or  fourth  month,  it  is  sometimes  impos- 
sible to  effect  the  replacing  of  the  organ,  owing  to  the  constant  increase 
of  volume  of  the  displaced  uterus.  The  only  remedy  then,  which  naturally 
presents  itself  to  the  mind  is  the  removal  of  what  it  contains.  As  that  of  the 
child  cannot  be  attempted,  we  have  but  to  remove  the  water  enclosed  in  the 
membranes  of  the  embryo.  This  very  plan,  originally  advised  by  Hunter 
in  cases  of  retroversion,  has  already  been  practised  many  times  with  suc- 
cess. Twenty  years  ago  a  case  was  related  by  M.  Jaurel  of  Rouen,  another 
was  witnessed  at  Lyons,  under  the  inspection  of  MM.  Viricel  and  Bouchet. 
A  third  has  been  more  recently  recorded  by  Mr.  Baynham,  so  that  it  is  not  as 
formidable  as  had  been  imagined,  and  is  a  means  of  relief  worth  keeping 
in  reserve. 

The  woman  being  placed  in  the  same  position  as  in  the  preceding  case,  and 
kept  there  by  assistants,  the  surgeon  examines  on  which  side  of  the  rectum 
or  vagina  the  uterus  is  most  distended.  One  rule  which  it  would  be  well,  I 
believe,  never  to  infringe,  is  to  begin  by  doing  every  thing  possible  to  intro- 
duce the  instrument  into  the  womb  through  the  opening  in  the  neck.  Unless 
absolutely  impossible,  puncture  by  the  vagina  seems  to  me  less  dangerous 
than  that  through  the  rectum,  inasmuch  as  we  are  not  inevitably  compelled 
to  perforate  the  peritoneum,  and  not  as  much  exposed  to  come  upon  the  pla- 
cental mass.  Mr.  Baynham,  however,  did  it  in  this  latter  method,  probably 
because  the  development  of  the  uterus  was  in  this  direction  much  more 
decided  than  in  that  of  the  vagina.  I  must  own  that  the  general  use  of  tro- 
cars leaves  no  fistulous  openings  either  in  the  gut  or  uterus,  and  that  the 
wound  closes  up  as  soon  almost  as  they  are  withdrawn.  In  Dr.  Baynham's 
case  only  two  ounces  of  fluid  escaped  by  the  canula,  which  was  nevertheless 
sufficient  to  permit  the  reduction  of  the  displacement.  Abortion  ensued  at 
the  end  of  some  days.  The  foetal  envelopes  were  yet  entire,  and  contained 
still  several  ounces  of  water;  the  placenta  had  been  pierced  as  well  as  the 
abdomen  of  the  child.  In  such  a  case  the  trocar  should  be  longer  than  for 
ordinary  paracentesis,  and  somewhat  curved.  That  contrived  by  Fleurant 
for  puncturing  the  bladder  through  the  rectum  would  do  very  well.  As  it  is 
possible  to  entangle  it  in  the  placenta,  or  that  the  cord  or  foetus  may  close  its 
orifice,  it  is  well  to  plunge  it  pretty  deep,  and  to  have  a  long  stylet  which  may 
be  passed  through  the  tube  fo  clear  its  upper  end,  and  permit  the  fluids  to 
flow  easily  through.  After  the  puncture,  we  must  strive  to  restore  the  womb 
to  its  natural  position.  But  that  abortion  is  an  almost  inevitable  conse- 
quence, the  attentions  afterwards  to  be  paid  would  merely  be  those  which 
enter  into  the  list  of  what  are  called  for  by  pregnancy. 


OPERATIVE    SURGERY.  673 

%^rt.  3, —^Prolapsus  of  the  Vagina, 

Instead  of  merely  reducing  the  protrusion  and  being  content  to  keep  it  up 
by  pessaries,  M.  DiefFenbach  conceived  the  idea  of  applying  to  the  pro- 
lapsus of  this  organ,  the  same  method  of  cure  which  had  long  before  been 
adopted  by  M.  Dupuytren  in  that  of  the  rectum.  He  first  effects  the  return 
of  the  part,  then  to  prevent  its  reprotrusion  he  excises  all  around  the  vulvular 
orifice,  the  loose  folds  on  the  inner  surface  of  the  labia  majora,  or  perineum. 
All  tliis  with  a  pair  of  good  scissors  and  forceps  is  done  without  any  difficulty. 
The  folds  thus  removed  ought  to  constitute  so  many  radii,  having  the  vagina  for 
their  centre,  so  as  that  their  extremity  may  extend  for  an  inch  or  half  an  inch 
into  it. 

The  dressing  consists  in  merely  washing  the  little  wounds  every  day  ;  or  if 
we  wish  to  obtain  a  smooth  cicatrice  and  cause  them  to  suppurate,  in  the 
introduction  of  a  pledget  of  lint  rather  bulky,  whose  base  will  easily  furnish 
a  little  bundle  for  each  incision. 

The  object  aimed  at  in  this  operation  is  to  contract  tlie  vagina  at  its 
entrance,  and  the  vulva,  by  giving  them  a  degree  of  firmness,  which  they  had 
long  before  ceased  to  possess.  Although  it  has  not  failed  to  succeed,  the  plan  of 
Messrs.  Heming  and  Marshall,  which  consists  in  the  excision  of  a  large  elliptical 
portion  of  the  mucous  membrane,  and  the  immediate  reunion  of  the  wound  by 
suture  would  evidently  not  answer  as  well.  We  shall  resume  the  explanation 
of  this  subject  when  we  reach  the  consideration  of  diseases  of  the  rectum. 
Should  the  prolapsus  of  the  vagina  be  of  very  old  date,  and  should  the  tissues 
have  undergone  degeneration,  or  such  change  as  to  render  its  reduction  totally 
impossible,  which  appears  to  have  been  the  case  in  the  instance  reported  by 
M.  Berard,  Jr.,  and  the  patient  at  the  same  time  determined  upon  being 
relieved  from  it,  we  have  clearly  no  other  resource  to  propose  than  excision. 
Yet  as  unhappily  it  is  difficult  in  these  circumstances  to  say  positively  that  tlje 
prolapsus  is  of  the  vagina  alone,  and  that  the  uterus  is  not  comprised  in  the 
tumor,  in  which  case  the  danger  attending  would  be  extremely  serious,  it  is  as 
Boyer  has  said,  one  which  should  never  hastily  be  decided  on.  It  should  be 
performed,  as  will  be  detailed  in  speaking  of  removing  the  uterus,  either  by  a 
cutting  instrument  or  by  ligature. 

Art,  4. — Reduction  of  Prolapsed  Uterus  and  Vagina, 

Whether  it  be  the  vagina  or  uterus  which  presents  at  the  vulva,  or  the 
uterus  shows  itself  in  the  neck,  or  reversed  on  itself  as  the  finger  of  a  glove  ; 
whether  it  be  prolapsed  a  third,  half,  or  all  its  length,  or  be  reversed  within 
the  pelvis,  this  operation,  reduction,  is  aKvays  to  be  employed ;  replacement 
always  to  be  practised ;  and  some  rules  are  necessary,  of  whose  importance 
the  surgeon  ought  not  to  be  unmindful.  These  displacements  are  accom- 
panied sometimes  with  symptoms  which  should  claim  for  a  moment  the 
attention  of  the  practitioner.  Some  must  be  encountered  before  the  reduc- 
tion can  be  proceeded  with,  others  can  scarcely  be  expected  to  disappear 
until  after  it  is  effected.  Among  the  first  are  fever,  inflammation,  and 
general  reaction;  among  the  second,  leucorrhoeal  discharges,  ulcers,  and 
excoriations.  Pain  in,  and  engorgement  of  the  tumid  organ,  are  no  further 
85 


674  NEW   ELEMENTS    OF 

obstacles,  than  as  offering  a  true  mechanical  impediment  to  the  restoration  of 
the  parts.  But  for  all  these  the  best  remedy,  the  best  soother,  nay  the  surest 
antiphlogistic  agent  is  reduction,  when  reduction  can  be  accomplished.  If 
the  vagina  protrude,  after  its  whole  surface  is  enclosed  in  linen  besmeared 
with  cerate,  it  is  to  be  gently  squeezed  between  the  fingers,  from  the  circum- 
ference to  the  centre,  befpre  it  is  pushed  from  below  upwards.  An  inverted 
uterus  requires  a  similar  application  of  a  piece  of  linen ;  but  it  might  be  well  to 
apply  the  tips  of  the  fingers  to  the  most  projecting  part  of  the  tumor,  so  as  to 
replace  it  more  surely,  and  absolutely  to  carry  it  up  above  the  superior  strait 
of  the  pelvis.  When  simple  prolapsus  uteri  only  is  present,  it  is  similarly  to 
be  wrapped  in  linen,  and  as  is  done  with  the  vagina,  we  must  strive  to  lessen 
the  base,  whilst  we  at  the  same  time  push  it  back  by  its  summit  in  the 
direction  of  the  axes  of  the  pelvis.  Suppose  there  is  retroversion.  It  is  some- 
times necessary  to  vary  the  patient's  position,  who  may  in  the  preceding  cases 
remain  in  the  horizontal  posture,  with  the  limbs  and  muscles  all  relaxed.  The 
first  thing  to  be  done,  to  right  the  uterus  thus  retroverted  in  the  pelvis, 
is  to  hook  with  the  index  and  middle  fingers  of  one  hand  the  os  tincse, 
usually  arrested  behind  or  above  the  pubis.  This  not  answering,  a  finger  or 
two  of  the  other  hand  are  passed  into  the  rectum,  to  push  up  and  forward  the 
fundus,  whilst  we  endeavor  to  draw  down  the  neck  at  the  same  time.  Failing 
in  these  resources,  we  are  advised  next  to  place  the  woman  on  her  elbows  and 
knees,  so  that  the  weight  of  the  abdominal  viscera  may  tend  to  force  the 
fundus  uteri  towards  the  umbilicus,  whilst  the  surgeon  is  trying  to  unloose  it 
at  the  same  time.  If  still  foiled,  we  must  imitate  Dusaussois,  who  by  the 
introduction  of  his  whole  hand  into  the  rectum  vanquished  difficulties  which 
until  then  had  been  invincible.  If  the  finger  had  not  hold  enough  upon  the  neck, 
it  would  be  proper,  as  is  recommended  by  M.  Bellangen,  to  introduce  into 
the  bladder  per  urethra  the  flat  sound  of  Segrot,  or  a  similarly  shaped 
catheter,  which  might  afterwards  be  used  as  a  hook  by  turning  its  concavity 
backwards. 

It  is  not  necessary  to  say  that  in  simple  displacement  of  the  uterus  within 
the  pelvis,  and  in  any  other  case  when  practicable,  we  must  begin  by  emptying 
the  bladder  by  the  catheter,  nor  that  it  is  sometimes  easy  to  embrace  the  parts 
to  be  returned  with  our  fingers,  sufficiently  firm  without  using  the  piece  of 
linen.  Repose,  a  horizontal  posture,  appropriate  injections,  venesection,  and 
a  general  antiphlogistic  regimen,  are  for  the  most  part  proper  after  these 
operations,  as  after  most  others,  to  moderate  the  irritation  which  must  have 
been  produced,  and  to  permit  the  tissues  to  resume  their  accustomed  functions. 

^rt,  5. — Pessaries, 

The  word  pessary,  which  once  comprehended  every  kind  of  material  what- 
ever which  was  introduced  into  the  vagina  to  support  the  uterus,  and  prevent 
it  from  becoming  displaced,  is  now  applied  only  to  certain  instruments 
of  definite  shape.  Hence  we  designate  by  different  epithets,  the  bladder 
introduced  by  Columella  into  the  vagina  of  cows,  a  practise  since  him 
imitated  by  some  surgeons  on  the  female,  in  the  same  manner;  the  folds  of 
linen  and  masses  of  tow,  of  which  Moschion  and  Absyrtes  speak. 

Pessary  of  the  Vagina, — Among  the  instruments  now  in  use  among  us 


1 


OPERATIVE    SURGERY.  675 

t;ome  whose  end  is  to  keep  up  reduced  hernia  of  the  intestines  which  have 
descended  behind  the  parietes  of  the  vagina,  or  to  prevent  the  descent  of  this 
part  itself.  Others  again  are  intended  to  obviate  descent  or  displacement  of 
the  matrix. 

The  former  are  of  two  kinds.  The  one  a  long  hollow  cylinder,  about  four 
inches  long,  called  **pessaire  en  bonden"  (bung  or  stopple  shaped),  and  of 
diameter  sufficient  to  fill  the  whole  organ.  The  others,  invented  by  M.  Jules 
Cloquet,  are  called  *'  elytroid  pessaries,"  and  differ  from  the  preceding  in 
being  a  little  flattened,  concave  on  their  front  part,  slightly  swelled  out  at 
each  extremity,  and  having  a  very  small  canal  or  passage  in  the  centre.  The 
name  which  the  Professor  has  given  them,  would  be  more  applicable  to  the 
stopple -shaped  pessary,  since  it  means  merely  "  of  a  sheath-like  form ;"  but  the 
name  is  of  little  consequence  provided  the  mechanism  be  well  understood. 

The  same  steps  are  to  be  taken  in  the  introduction  of  either  instrument. 
The  woman  lies  upon  her  back,  the  thighs  moderately  flexed,  and  the  legs  held 
a  part.  The  pessary  rubbed  with  cerate  is  carried  by  its  small  extremity  to 
,  the  orifice  of  the  vagina,  then  introduced  from  below  upwards,  and  from  before 
backwards,  into  the  cavity  of  this  organ. 

The  elytroid  pessary  being  larger  in  one  direction  than  in  the  other,  is  to 
be  presented  flatwise  to  the  large  diameter  of  the  vulva,  and  so  that  its  pos- 
terior angle  may  first  enter  the  vaginal  aperture,  and  serve  to  depress  the 
rectum  and  thickness  of  the  perineum  with  some  strength.  The  other  angle 
of  the  same  extremity  is  then  depressed  gradually,  slipping  beneath  the  arch 
of  the  pubis ;  after  which  no  further  difficulty  is  experienced  in  the  introduction 
of  the  instrument  into  the  vulvo-uterine  passage.  When  once  within  it,  it  is 
made  to  experience  a  rotatory  movement,  v/hich  brings  its  convexity  towards 
the  intestine  (rectum,)  its  concavity  forwards,  the  superior  extremity  beneath 
the  cervix  uteri,  and  the  inferior  extremity,  which  is  the  largest,  above  and 
crosswise  between  the  ossa  ischii.  The  "stopple-shaped"  pessary,  being 
merely  a  tube  with  very  thin  sides,  is  generally  introduced  more  easily  :  but 
as  it  is  straight  and  yeilding,  its  shape  is  soon  spoiled  by  the  organs,  and  it  is 
not  long  before  it  becomes  useless. 

Pessary  of  the  Uterus. — Pessaries  of  the  second  kind  have  experienced 
many  more  variations  in  form  and  materials  than  those  of  which  I  have  just 
spoken.  The  ancients  constmcted  them  from  an  oval  or  elliptical  plate  of 
wood  or  cork,  which  was  covered  with  a  coat  of  wax  of  unequal  thickness ; 
besides  which  they  were  of  gold,  silver,  copper,  lead,  and  even  tin,  of  every 
shape.  Those  called  **  ring-shaped"  (en  gimblette)  were  either  entirely  cir- 
cular or  slightly  curved  before  and  behind  in  the  form  of  a  figure  of  8,  or  else 
depressed  at  the  four  extremities  of  their'two  principal  diameters  together; 
or  simply  ellipsoid,  flat,  and  pe^-forated  in  the  centre.  In  England,  a  globe- 
shaped  pessary  is  employed,  sometimes  hollow,  sometimes  solid,  pierced  in 
the  centre  or  not,  and  the  same  method  is  adopted  in  America.  Cork  and 
wax  have  been  long  entirely  rejected  as  too  easily  altered  by  the  pressure  of 
the  parts,  and  not  sufficiently  supple.  The  same  fault  may  be  found  with 
ebony,  ivory,  gold,  silver,  singly  employed,  especially  as  we  possess  materials 
so  much  more  elastic,  lighter,  and  less  changeable.  They  are  now  made  almost 
altogether  of  elastic  gum ;  though  sometimes  it  is  supported  qn  linen,  horse  hair, 
felt,  woollen,  silk,  &c. 


k 


676  NEW   ELEMENTS   OF 

In  order  to  have  them  as  light  as  possible,  M.  Rondet,  who  employs  a  well 
tempered  steel  ring  covered  with  horse  hair,  and  real  caoutchouc,  has  con- 
trived others  of  the  same  substance,  the  circle  of  which  is  hollow  and  filled  with 
air.  As  bj  the  use  of  this  composition  pessaries  continue  elastic,  and  rather 
flexible,  causing  but  little  irritation  of  the  parts,  and  are  much  less  easily 
altered  in  shape  than  most  others,  they  justly  deserve  the  preference  which 
they  usually  receive.  Dr.  Physick  however  still  continues  to  use  gold  and 
silver  pessaries,  which  are  globular,  as  in  the  times  of  Clark  and  Denman, 
and  consist  of  two  capsules  soldered  together  at  their  base. 

Those  pessaries  which  are  rather  broader  transversly  than  from  before 
backwards,  are  in  the  whole  most  easy  of  introduction,  and  least  apt  to  inter- 
fere with  the  functions  of  the  bladder  and  rectum.  They  are  more  easily 
inserted  even  than  the  vaginal  pessaries.  All  that  is  to  be  done  is  to  carry 
them  into  this  passage  with  the  same  precautions  which  are  indicated  above. 
The  finger  placed  within  the  ring,  or  some  point  of  their  circumference, 
permits  us  to  give  them  always  a  suitable  situation ;  that  is,  to  effect  a  see-saw 
motion  which  brings  them  horizontally  within  the  pelvis,  one  edge  before,  the 
other  behind,  and  the  extremities  towards  the  ischii,  so  that  the  os  tincae 
may  rest  on  the  superior  concavity  which  extends  through  all  their  thickness. 
Women  who  have  lascerations  of  the  perineum,  or  in  whom  the  vulvular 
orifice  of  the  vagina  is  very  large,  derive  scarcely  any  benefit  at  all  from  the 
<*pessaire  en  gimblette"  or  from  the  ball-shaped,  which  they  can  seldom 
retain.  Surgeons  were  therefore  early  obliged  to  resort  to  other  more  perfect 
instruments  to  supersede  them.  The  species  described  by  Bauhin  as  "  en  bilbo- 
qufit"  (cup  and  ball),  are  made  of  a  ring  of  ivory  or  wood,  which  is  supported 
by  three  branches  ending  in  a  long  stem,  several  inches  in  length,  and  having 
three  or  four  holes  at  its  free  extremity.  The  cup  of  this  instrument,  intended 
for  the  reception  of  the  neck  of  the  uterus,  is  deep  enough  to  allow  an  easy 
escape,  between  the  three  branches  of  the  stem,  for  the  menses  and  other  fluids 
which  come  from  the  uterine  cavity.  The  ribands  which  go  from  the  lower 
apertures  of  the  stem  are  to  be  attached  to  a  girdle,  which  the  woman  is  not 
to  leave  off. 

Desormeaux  having  observed  that,  notwithstanding  the  grooves  between  the 
cup  of  the  pessary  and  its  root,  fluids  sometimes  accumulated  about  the  neck, 
and  these  acquired  irritating  properties,  contrived  to  convert  the  stem,  of  the 
instrument  into  a  true  canal,  and  to  give  the  cup  the  shape  of  a  very  small 
and  shallow  funnel ;  but  in  spite  of  his  precautions  the  fluids  still  collect 
sometimes  between  the  uterine  orifice  and  the  instrument  which  supports  it, 
so  that  in  fact  it  is  of  no  great  importance  to  prefer  this  pessary  to  the  old 
one.  If  as  some  practitioners,  Desormeaux  among  others,  insist,  we  did  but 
fix  the  olive-shap*>d  extremity  above  the  coccyx  within  the  vagina,  rather 
than  tie  it  with  ribands  to  a  bandage  around  the  body,  there  would  be  so  much 
risk  of  perforating  the  rectum  that  I  could  not  recommend  its  adoption ; 
even  though  the  instrument  should  be  fitted  with  the  peculiar  spring  within 
the  pivot  recommended  by  M.Recamier.  Some,  with  the  idea  of  guarding 
against  the  vacillation  and  unsteadiness  to  which  the  instrument  as  the  woman 
walks  is  perpetually  subjected,  have  advised  the  use  of  pessaries  which  have 
at  the  lower  end  a  plate  about  four  inches  long,  concave  above,  and  pierced 
with  a  large  hole  behind,  opposite  the  anus,  and  with  two  slits  in  front  so 


OPERATIVE  SURGERY.  677 

that  strings  attached  to  the  four  angles  of  this  plate  allowed  them  to  embrace 
the  whole  extent  of  the  perineum  closely  from  before  backwards,  and  to 
keep  the  pessary  nearly  immovable  in  the  direction  which  has  been  given 
to  it. 

Saviard,  discontented  with  the  pessaries  in  use  until  his  time,  invented  a 
little  apparatus  of  extreme  ingenuity,  for  supporting  the  uterus,  consisting  of 
a  curved  spring  fixed  by  one  extremity  on  the  hypogastrium,  whilst  the  other 
entere'd  the  vagina  to  compress  a  tampon  conveniently  adapted  to  it.  That 
proposed  by  M.  Villerme  is  upon  a  similar  principle.  Its  stem  represents  a 
large  arch,  the  concavity  of  which,  when  it  is  introduced,  ought  to  embrace 
the  anterior  half  of  the  pelvis.  It  is  a  sort  of  hook,  the  tail  of  which  fastened 
upon  the  hypogastrium  permits  the  head  in  the  vagina  to  sustain  or  support  the 
whole  gestative  organ.  M.  Deleau  has  just  brought  forward  another,  which 
holds  a  sort  of  middle  place  between  the'*  round"  and  "  cup  and  ball"  pessary. 
It  consists  of  an  elastic  spring  surrounded  with  gumelastic,  twisted  into  spiral 
curves  of  which  the  apex  or  first  ring  is  fastened,  and  the  b^sis  or  last  ring 
hangs  loose,  to  be  tightened  or  widened  according  to  need.  When  it  is  wished 
to  introduce  it,  the  circle  is  sufficiently  narrowed,  and  a  sort  of  piston  is 
fastened  to  its  head.  Left  in  the  vagina  point  uppermost,  its  elasticity 
readily  adapts  itself  to  the  dimensions  of  the  part,  without  any  risk  of  being 
displaced.  In  the  collection  of  theses  by  Haller,  Preuner  describes  one  similar 
in  almost  every  respect,  and  I  much  fear  that  its  advantages  are  more  apparent 
than  real.  Whatever  be  the  pessary  employed,  care  must  be  taken  to  with- 
draw and  clear  it  from  time  to  time.  Otherwise  it  might  become  covered  with 
calcareous  matter,  create  ulceration  of  the  vagina,  and  give  rise  to  serious 
consequences,  of  which  many  instances  are  recorded.  Women  soon  learn  to 
perform  this  little  operation  for  themselves,  and  to  have  no  need  of  any  one's 
assistance  to  replace  it  at  proper  seasons.  When  first  introduced  it  is  useful 
to  keep  the  patient  for  some  days  in  bed :  otherwise  she  would  be  exposed  to 
more  or  less  suffering  from  a  sense  of  weight  about  the  fundament,  which  is  apt 
to  excite  symptoms  of  irritation,  much  less  liable  to  happen  when  time  has  been 
given  to  the  parts  to  become  accustomed  to  the  foreign  body,  and  as  it  were  to 
mould  themselves  upon  it. 

One  question  here  presents  itself,  which  must  be  answered ;  are  pessaries 
really  advantageous  ?  no  doubt  they  do  give  a  great  deal  of  trouble  and  incon- 
venience, and  create  many  accidents.  Many  women  undoubtedly  cannot  en- 
dure them  at  all. 

The  pressure  they  cause  upon  the  bladder  and  rectum,  necessarily  is  an 
obstacle  to  the  function  of  these  organs.  The  neck  of  the  uterus  more  or  less 
irritated  by  such  a  body,  enters  and  is  strictured  within  the  aperture  of  the 
pessary  which  in  turn  is  too  apt  to  end  by  excoriating  and  perforating  the  walls 
of  the  vagina,  if  not  of  the  rectum,  or  bladder  of  urine.  If  instead  of  the  round 
pessary  the  cup  and  ball  instrument  be  preferred,  do  what  you  will  with 
it,  it  will  lean  more  in  one  direction  than  in  another,  and  will  at  length 
depress  the  os  tincse  as  well  as  the  vagina.  The  round  one  almost  always 
turns  over  backward  or  forward,  and  equally  ill  supports  the  neck  of  the 
uterus.  As  to  the  "  stopple-shaped"  pessary,  owing  to  the  thinness  arid 
almost  cutting  character  of  the  openings  at  each  extremity,  it  also  easily 
injures  the  parts  on  which  they  are  applied.    The  "  elytroid"  pessary  yet 


678  NEW  ELEMENTS  OF 

remains,  which  as  it  is  moulded  on  the  canal,  and  fills  it  with  some 
accuracy,  is  less  liable  to  be  displaced,  preserves  the  parts  in  a  natural 
position  with  greater  certainty,  requires  fewer  precautions  for  its  proper 
management,  and  hence  offers  fewer  objections  than  any  other.  But  as 
it  is  a  larger  mass  and  fills  the  whole  organ,  many  women  find  it  in 
this  respect  very  inconvenient.  Still  it  is  the  one  which  appears  to  me 
to  deserve  the  preference,  and  that  which  I  employ  when  I  cannot  dispense 
with  a  pessary  of  some  kind.  Since  these  instruments  are  so  far  from  being 
inoffensive  why  continue  to  use  them  ?  Certainly  in  many  cases  in  which  they 
are  directed  they  ought  to  be  proscribed  ;  for  example,  after  simple  prolapsus, 
after  the  reduction  of  a  retroversion,  the  introduction  of  oval  pledgets  of  lint, 
or  of  little  bags,  rendered  astringent  by  being  steeped  in  wine  in  which  rose- 
leaves,  oxy  crate,  (vinegar  and  water)  have  been  boiled ;  of  decoctions  of  kino ;  of 
solutions  of  alumen  sulph.  introduced  and  renewed  every  day  within  the 
vagina  for  a  long  time,  would  be  better  than  the  use  of  pessaries.  Fine 
pieces  of  sponge,  or  of  linen,  arranged  "and  sustained  as  is  done  by  women 
during  their  catemenial  periods,  would  also  supersede  them  very  advantage- 
ously, if  a  mechanical  means  were  absolutely  necessary  to  keep  up  the  uterus. 
Thirdly,  if  the  descent  of  the  organ  were  evidently  brought  about  by  the 
undue  size  of  the  vulva,  the  excision  of  its  surrounding  cutaneous  folds, 
though  painful,  would  deserve  I  think  the  preference,  as  likely  not  only  to 
produce  a  permanent  cure  but  also  to  permit  the  continuation  of  conjugal 
enjoyment. 

Art,  6. — Foreign  bodies. 

1.  In  the  Vagina. — Those  which  we  are  occasionally  called  on  to  remove 
from  this  part  of  the  body  are  usually  pessaries,  or  remains  of  pessaries  more 
or  less  changed  in  their  nature.  However,  other  substances  also  have  been 
observed.  M.  Dupuytren  detected  in  it  a  pomatum  pot,  the  bowl  of  which 
was  turned  downwards.  It  is  easy  to  fancy  the  variety  in  form  and  nature 
which  such  substances  as  are  introduced  into  the  part  by  accident  or  design 
on  the  part  of  the  woman  will  present,  and  the  character  of  the  affection  to  which 
they  give  origin.  Pessaries  which  had  been  lost  for  ten,  fifteen,  and  even 
twenty  and  forty  years,  have  been  known  to  become  encrusted  with  calcere- 
ous  matter,  corroded,  even  perforated  by  fungous  growths,  to  produce  pain,  in- 
flammation, and  the  most  fearful  train  of  symptoms.  In  a  woman  cured  by 
M.  J.  Cloquet,  the  changes  in  the  vagina  was  such  as  that  until  then  it  had 
been  considered  as  cancer.  Usually  they  ulcerate  and  perforate  either  the 
bladder  or  rectum,  and  sometimes  both  together.  A  woman  broke  the  stem  of 
a  •'  cup  and  ball  "  pessary  in  attempting  to  withdraw  it,  and  at  length  forgot  the 
ring  in  the  vagina.  After  a  lapse  of  many  years,  she  became  afilicted  with 
symptoms  which  induced  her  to  seek  the  extraction  of  the  foreign  body.  M. 
Dupuytren  then  ascertained  that  it  projected  both  into  the  rectum  and  bladder. 
Another  fact  still  more  curious  has  also  been  published  by  M.  Berard  of  which  I 
was  myself  a  witness.  The  patient,  an  aged  woman,  had  not  thought  of  her 
pessary  for  five  and  twenty  years  since  she  had  broken  the  stem.  By  the  ca- 
theter it  could  be  felt  naked  in  the  bladder,  and  very  distinctly  in  the  rectum 
with  the  finger.    The  vagina  below  was  nearly  obliterated  and  consisted  only 


OPERATIVE  SURGERY.  679 

of  a  cul-de-sac,  having  a  slight  opening  at  its  upper  part.  In  the  case  which 
was  communicated  by  M.  Larrouche  to  M.  Jules  Cloquet,  the  pessary 
(which  had  a  stem)  had  entered  the  rectum,  where  its  cup  had  become  the 
centre  of  a  stercoral  calculus,  while  the  extremity  of  the  stem  had  done  the 
same  in  the  bladder. 

The  operation  called  for  under  such  circumstances  must  be  as  various  as 
the  cases  in  which  they  are  required,  and  cannot  be  restricted  to  the  rules  of 
a  particular  description.  If  the  pessary  be  unadherent,  and  we  wish  only  to 
put  an  end  to  the  irritation  which  it  causes,  the  index  finger  passed  within  its 
circumference  or  on  its  edge  will  suffice  frequently  for  its  extraction.  If  it 
be  otherwise,  a  long  polypus  forceps  might  advantageously  take  the  place  of 
the  finger,  or  a  soft  blunt  hook,  carried  in  and  protected  by  the  index  finger 
of  the  left  hand,  may  be  tried.  When  it  enters  the  rectum  and  cannot  be  got 
out  by  the  vagina  it  is  to  be  drawn  forth  by  similar  means  through  the  anus. 
If  its  size  offers  an  obstacle  to  success  in  this  way,  its  division  into  pieces 
may  become  necessary.  If  it  be  of  wood,  ivory,  or  any  fragile  material,  this 
is  easily  enough  done  by  a  strong  and  solid  pair  of  pincers  or  forceps.  We 
cannot  say  so  much  for  metallic  pessaries.  Here  we  must  trust  to  the  feeble 
aid  of  a  file  or  small  saw  carried  up  the  rectum,  and  by  a  proper  canula  pre- 
vented from  injuring  it;  whil-t  with  forceps  the  foreign  body  is  to  be  kept  as 
motionless  as  possible.  M.  Dupuytren  succeeded  in  his  object  in  the  case 
just  related  by  means  of  a  saw.  In  the  patient  whose  case  I  witnessed  at  La 
Pitie,  M.  Lisfranc  began  by  making  an  incision  in  front  of  the  anus,  through 
a  portion  of  the  perineum,  in  order  to  make  himself  more  room.  He  then 
seized  the  pessary  without  any  very  great  difficulty,  and  promptly  withdrew 
it  with  the  assistance  of  forceps  held  in  the  right  hand,  while  the  middle  and 
index  fingers  of  the  left  hand  directed  their  motions  at  the  bottom  of  the  parts. 
The  position  of  the  woman,  and  the  precautions  necessary  before  and  after  the 
operation,  are  the  same  as  those  directed  in  the  other  proceedings  on  which  we 
have  dilated  in  the  preceding  sections.  If  a  glass,  a  vessel  either  of  wood  or 
earthenware,  be  the  cause  of  difficulty,  it  must,  when  every  effort  to  place  it 
in  a  favorable  direction  and  so  remove  it  entire  has  been  tried,  be  broken  in 
pieces  and  removed  piece-meal.  The  judgment  of  the  surgeon  must  more- 
over, make  up  for  the  silence  to  which  books  are  necessarily  reduced  on  such 
sutyects.  Unless  the  rectum  or  bladder  of  urine  have  been  opened,  the  results 
of  the  operation  are  very  simple.  It  is  likewise  remarkable  that  the  fistula  in 
them  are  not  long  in  closing  considerably,  and  even  end  by  healing  up  en- 
tirely. 

Art,  7. — Foreign  Bodies  in  the  Uterus, 

The  cavity  of  the  uterus  sometimes  contains  free  and  inorganic  masses, 
wnich  have  been  described  by  Louis,  under  the  name  of  calculi  of  the  uterus. 
These  calculi,  which  are  thought  by  MM.  Roux  and  Dupuytren  to  be  altered 
states  of  fibrous  tumors,  have  often  been  observed.  I  have  myself  seen  them 
both  in  the  cavity  of  the  organ  and  in  its  walls.  Whether  the  opinion  of ; 
MM.  Roux  and  Dupuytren  be  or  be  not  well  founded,  it  is  at  least  certain 
that  in  a  good  many  of  the  bodies  of  which  I  speak,  are  either  simple,  earthy 
concretions,  or  the  detritus  of  pregnancy.  One  which  I  had  an  opportunity  of « 


680  NEW   ELEMENTS   OF 

examining,  was  as  large  as  an  egg,  round  and  knobbed,  contained  in  many 
points  of  its  circumference  hairs,  and  some  portions  of  osseous  cutaneous 
tissues,  whilst  its  outer  surface  was  but  a  calcareous  crust.  Thej  have , 
awakened  naturally  the  anxiety  of  surgeons,  as  capable  of  leading  to  bad 
consequences.  Hippocrates  mentions  an  old  woman  who  had  taken  one  from 
the  vagina  of  a  servant,  ^tius  advises  that  they  should  be  made  to  pass  the 
neck  by  pushing  them  downwards,  with  two  fingers  in  the  rectum  and  the 
other  hand  placed  on  the  hypogastrium;  and  then  be  sought  for  with  forceps.. 
He  likewise  practised  dilatation  and  incision  of  the  cervix.  Louis  recommends 
that  cutting  scissors  be  introduced  into  the  os  tincae,  to  open  its  orifice  from 
within  outwards,  and  thus  favor  the  exit  of  the  calculus.  To  this  there  is  but 
one  objection ;  viz.  that  we  never  know  that  the  woman's  symptoms  indicate 
this  more  than  any  other  uterine  affection.  As  it  is  strictly  impossible  to  be 
certain  on  this  head,  no  one  at  this  day  would  dare  to  attempt  the  operation 
of  iEtius,  still  less  of  Louis,  unless  the  stone  were  more  or  less 'engaged  iji. 
the  cervix  uteri  and  could  then  be  distinctly  felt. 

Art,  8. — Polypi  of  tlie  Uterus. 

•No  method  of  treatment  has  been  proposed  for  the  cure  of  polypi  in  general, 
and  particularly  for  that  of  nasal  polypi,  which  has  not  been  applied  to  this 
disease  when  existing  in  the  uterus.  The  latter  species,  from  being  situated 
in  a  more  accessible  organ,  one  more  easily  explored,  and  more  readily  made 
to  change  its  situation,  have  not  excited  the  ingenuity  and  genius,  of  surgeons 
on  this  account  as  much  as  the  others.  Thus  cauterization,  of  which  Celsus 
seems  to  speak,  and  which  is  alluded  to  by  Verduc,  Volter,  &c. ;  scarification ; 
the  use  of  dessicative  remedies  contained  in  the  list  of  iEtius,  and  the  book 
ofMoschion  have  long  been  abandoned.  On  the  other  hand,  simply  tearing 
them  out,  or  this  combined  with  twisting  or  torsion,  is  applicable  only  in  a 
small  number  of  cases.  The  reason  why  it  appears  to  Sabatier  and  other 
modern  authors  that  the  treatment  of  this  disease  was  much  neglected  by  the 
ancients,  is,  that  it  was  known  in  medical  books  until  a  still  recent  period 
under  a  great  variety  of  different  names.  Philoteus,  for  instance,  evidently 
confounded  them  with  cancer,  and  Moschion  with  varix  of  the  uterus.  There 
can  be  no  doubt  on  the  subject,  when  the  mysterious  Aspasia  describes  them 
as  *' hemorrhoidal -tumors,"  which  spring  **  sometimes  from  the  neck,  some- 
times from  the  fundus  uteri,"  and  «*  seldom"  from  the  external  genital 
organs;  tumors  which  may  be  fearlessly  excised  when  white  and  hard, 
which  *'must  be  tied,"  when  they  are  easily  excited  to  hemorrhage,  and 
which  sometimes  resist  every  means  to  remove  them. 

I  understand  the  relative  value  of  the  various  methods  of  operating  for 
uterine  polypi ;  and  to  reconcile  the  conflicting  statements  of  writers  on  the 
subject,  a  few  words-  as  to  their  nature  and  origin  become  indispensable.  It 
is  indisputable  that  tumors  arise  in  the  uterus  perfectly  different  in  character 
from  one  another.  The  little  polypus,  noticed  by  Z.  Lusitanus,  the  removal 
of  which  was  attended  with  so  abundant  a  hemorrhage,  may  be  compared  to 
the  vascular  polypus,  so  tenacious  of  vitality,  seen  soften  in  the  nasal  fossa. 
M.  Berard  has  seen  in  the  neck  of  the  uterus,  soft,  and  nearly  wholly  mucous 
polypi,  much  resembling  those  of  the  nose.    I  have  thrice  seen  in  the  uteri  of 


OPERATIVE    SURGERV||jj  *  'W^if'      ^^^ 

women,  who  were  subjects  for  dissection  in  the  practical  scliool  of  anatomy, 
tubercles  of  various  size,  containing  small  vessels  which  were  continuous 
with  the  tissues  of  the  organ  and  yet  not  pedunculated.  MM.  Dance, 
Berard,  and  Cruveilhier,  have,  with  MM.  Mayer  and*Meisner,  seen  others 
which  appeared  to  be  the  result  of  true  partial  hypertrophy,  either  of  the  body 
or  cervix  of  the  uterus ;  that  is  to  say,  they  were  continuous  with  the  fibres 
of  the  viscus  without  any  line  of  separation,  and  their  structure  was  in  no 
respect  diflferent  from  that  of  the  viscus  itself.  In  1825  I  published  a  case 
of  this  kind,  and  preserved  the  pathological  specimen  in  alcohol. 

Others  again,  which  are  likewise  continuous  with  the  tissue  of  the  uterus, 
are  evidently  degenerations  or  morbid  alterations  of  its  structure.  They  are 
hard,  grey,  and  elastic ;  when  cut  into  their  aspect  is  that  of  a  lard-like  or 
semi-cartilagenous  substance,  homogeneous,  white,  wholly  destitute  of  ves- 
sels, and  in  which  it  is  impossible  to  detect  the  least  vestige  of  fibres.  I 
had  occasion,  in  the  beginning  of  this  year,  to  remove  one  which  possessed 
these  characters  in  a  striking  degree.  The  most  numerous  by  far,  are  those, 
nevertheless,  which  since  the  investigations  of  Bayle,  Roux,  and  Dupuytren, 
go  by  the  name  of  "  fibrous  bodies,"  and  are  primarily  developed  between 
the  tissues  in  the  thickness  of  the  uterus  itself.  I  am  induced  from  som^ 
observation,  to  think  that  they  often  result  from  an  effusion  of  blood,  a. 
fibrinous  concretion,  which  becoming  organized  by  degrees  continues  to  sus- 
tain its  vitality,  and  to  grow  by  imbibition  in  the  midst  of  the  surrounding 
parts  of  a  greyish  or  whitish  color,  like  the  preceding  species,  and  always 
appearing  to  be  composed  of  fibres  which  interlace  in  different  directions : 
they  contain  no  vessels,  and  are  covered  by  a  sheath  from  the  uterus,  thin  in 
proportion  to  the  magnitude  of  the  tumor,  and  which  becomes  more  distinct 
as  we  approach  their  peduncle. 

This  brief  detail  sufficiently  shows  that  hemorrhage  is  to  be  apprehended 
only  after  the  removal  of  uterine  polypi  of  the  first  varieties  ;  and  that  that  of 
the  tw^o  latter  species  can  never  occasion  it.  Now,  as  these  are  much  more 
frequently  occurring  it  follows,  cseteris  paribus,  that  excision  must  be  much 
less  dangerous  than  it  was  for  a  long  time,  and  by  some  is  still  thought  to  be. 

We  must  also  be  heedful  before  proceeding  to  an  operation,  that  we  have 
not  confounded  the  polypus  with  inversion  or  prolapsus  of  the  uterus  or  vagina, 
or  with  that  elongation  of  the  neck  from  hypertrophy  spoken  of  by  Lallement 
and  Bichat,  or  with  cancer,  &c.  It  is  enough  to  point  out  the  possibility  of 
these  mistakes  to  prevent  the  practitioner  from  falling  into  them ;  although 
they  have  often  been  made,  as  well  as  errors  of  the  opposite  kind.  There  is 
yet  another  which  I  never  saw  mentioned,  and  into  which  I  was  myself  very 
near  getting.  A  woman,  thirty-two  years  of  age,  came  under  my  care  at  the 
Hospital  St.  Antoine,  in  1828,  duri.ng  my  attendance  there.  She  had  from 
time  to  time  for  a  month  past  experienced  slight  losses  of  blood.  On  examina- 
tion I  discovered  a  mass  as  large  as  a  small  egg,  a  little  swelled,  of  firm  con- 
sistence, and  which  extended  by  a  very  distinct  peduncle  to  the  upper  part 
of  the  neck.  I  took  it  for  a  polypus.  The  patient  was  placed  in  a  bath,  and 
for  three  days  prepared  for  the  operation.  When  I  carried  my  finger  into  the 
parts  I  again  encountered  the  mass  I  had  before  felt,  but  as  I  tried  to  follow 
up  the  peduncle,  it  fell  into  the  vagina  and  I  removed  it.  It  was  a  fibrinous 
concretion,  a  mere  clot  of  hardened  blood  !  Polvpi  mav,  in  turn,  be  mistaken 
86 


t)82  ^  NEW  ELEMENTS  OF 

for  tumors  of  another  kind.  In  1823,  MM.  Richerand  and  Jules  Cloquet 
removed  one  as  large  as  a  child's  head,  which  they  took  from  the  vulva  of  a 
woman  where  it  had  hung  for  many  years,  and  supposed  they  had  removed 
the  uterus.  The  mass,  which  was  opened  in  the  presence  of  M.  Richerand, 
had  a  cavity  in  the  centre,  and  almost  every  other  character  of  the  uterus; 
and  it  was  supposed  to  be  an  unanswerable  demonstration  of  the  possibility 
of  removing  that  organ. 

The  patient  died.  When  examined,  the  uterus  was  entire  in  its  natural 
position ;  an  enormous  polypus  only  had  been  removed  ! 
.  A  woman  from  the  country,  who  came  to  the  Hospital  Perfectionnement, 
in  1824,  to  have  what  she  called  her  "  falling  down"  reduced,  had  in  the 
vulva  a  conical  tumor,  with  a  small  transverse  slit  across  its  summit,  which 
she  had  for  a  long  time  kept  up  by  a  pessary,  and  which  I  easily  returned  into 
the  vagina,  and  maintained  there  by  a  cup  and  ball  pessary.  After  her  return 
home  some  days,  she  was  attacked  with  abdominal  pain  and  returned  to  the 
hospital,  where  she  died  next  day  of  peritonitis.  The  tumor  which  I  had 
reduced  was  a  polypus,  fastened  to  the  fundus  uteri  by  a  peduncle  as  thick 
as  my  finger ! 

1st  Method. — Tearing  forth.  When  fibrous  polypi  have  effected  an  exit 
through  the  neck  of  the  uterus,  they  undergo  a  kind  of  strangulation,  which 
hs  sometimes  sufficient  to  effect  their  separation.  Two  examples  seen  by 
Mercadier  and  Louis,  have  been  reported  by  Levret.  Similar  ones  had  been 
related  by  Mauriceau,  Ruysch,  Hoffmann,  and  before  them  by  Rhodion  and 
M.  Donatus,  Vacoussin,  Gooch,  M.  Hue,  and  more  recently  by  M.  Herves  de 
Chegoin,  have  also  published  cases.  It  has  happened  to  me  to  se*e  one  yield 
abruptly  to  the  slight  efforts  I  made  to  bring  it  towards  the  vulva  to  excise  it. 
Latterly  Mr.  Griffith  has  announced  a  like  result  by  the  use  of  ergot.  Doubt- 
less this  falling  of  the  polypi  led  to  the  idea  of  the  plan  of  tearing  them  out  as 
practised  by  Dionis,  Juncker,  Heister,  and  since  formally  proposed  by  La- 
peyronie,  and  afterwards  by  Boudou.  These  authors  advise,  at  the  same  time, 
torsion  of  the  peduncle,  whether  as  a  guard  against  hemorrhage  or  to  break 
it  more  easily.  Torsion,  however,  added  to  mere  traction,  may  become  dan- 
gerous by  extending  into  the  tissues  of  the  uterus.  In  1753,  Hevin  sustained 
a  thesis  in  the  schools  of  surgery,  in  which  he  maintained  that  by  grasping  the 
origin  of  the  tumor  at  its  upper  part,  and  turning  it  in  itself  with  forceps,  this 
danger  would  no  longer  be  incurred. 

To  perform  this  operation  by  laceration,  we  are  to  seize  the  body  of  the 
polypus  with  the  forceps  invented  by  Musieux,  or  tlie  ordinary  kind,  or  even 
with  the  fingers  if  small,  or  else  with  straight  or  curved  forceps.  We  then 
exert  methodical  traction,  either  simple  or  combined  with  slight  rotary  move- 
ment, until  it  be  drawn  forth. 

It  is  only  at  this  precise  period  that  the  precautionary  advice  given  by 
Hevin  can  be  followed;  and  the  torsion,  really  such,  advised  by  Boudou  be 
practised  without  inconvenience,  in  cases  of  thick  foot  stalks  ;  otherwise  it 
can  have  no  good  end,  for  if  we  are  then  afraid  of  immediate  excision  nothing 
is  easier  than  to  apply  a  ligature  on  the  narrowest  spot  of  the  morbid  mass 
and  cut  below  it.  M.  Recamier,  who  thinks  that  these  bodies  can  be  des- 
troyed, not  only  by  extraction  but  by  a  kind  of  trituration  or  bruising,  has 
juiit  published  two  remarkable  cases  in  support  of  his  assertion.     In  one,  the 


OPERATIVE  SURGERY,  683 

polypus  as  large  as  the  great  toe,  projected  into  the  vagina  from  its  origin  in 
the  upper  part  of  the  cervix  uteri.  By  strong  pressure  with  the  index  finger 
of  the  right  hand,  he  contrived  to  divide  it,  reduce  it  to  a  pulp,  and  extract  it 
in  less  than  two  minutes.  In  the  other  case,  having  resisted  ligature  and 
extraction,  it  was  futilously  broken  up  by  hooked  forceps  and  the  fingers  into  a 
sort  of  flux,  the  filaments  of  which  slipped  ceaselessly  through  the  teeth  of 
the  instrument. 

Method  2d. — Ligature.  This  treatment  of  uterine  polypus  is  much  more 
ancient  than  Levret  has  supposed.  It  is  evident  that  ^tius,  Moschion,  and 
before  them  Philoteus,  were  acquainted  with  it,  and  that  it  was  frequently 
resorted  to  after  their  time.  It  is,  however,  but  just  to  Levret  to  confess, 
that  it  is  to  him  we  owe  its  adoption  into  the  practice  of  modern  times,  by 
showing  its  applicability  not  only  to  tumors  which  protrude  from  the  vulva, 
but  to  those  also  which  are  attached  highest  in  the  genital  cavity. 

To  eifect  it,  many  instruments  have  been  invented.  All  those  which  are 
employed  for  tying  nasal  polypi,  may  he  used  for  this  purpose.  The  two 
tubes  fastened  together  like  forceps,  the  principal  of  which  is  so  highly  praised 
by  Levret ;  those  constructed  by  Theden  on  nearly  the  same  principle  and 
plan ;  the  instrument  of  Lecat,  and  that  of  Herbiniaux,  are  now  abandoned. 
Neither  has  the  use  of  the  double  canula  of  the  first  of  these  authors  been 
retained  in  practice.  They  have  been  forgotten  since  the  separated  hollow 
tubes  constructed  by  Desault,  and  the  catheters  of  Niessen ;  and  every  thing 
leads  to  the  belief  that  the  alterations  proposed  by  Clark,  Laugier,  Locffler, 
CuUerier,  and  a  crowd  of  others  mentioned  in  the  Treatise  written  by  M. 
Meisner,  will  speedily  undergo  a  similar  fate. 

Method  of  Operating. — The  instruments  which  have  been  judged  advisable 
being  at  hand,  the  operation  is  conducted  in  the  following  way.  The  surgeon 
having  reconnoitered  the  position  of  the  polypus,  and  calculated  the  size  of 
its  peduncle,  arranges  the  ligature  which  he  means  to  employ.  This,  which 
in  the  time  of  Levret  was  of  fine  silver,  is  now  more  generally  made  of  silk 
or  thread  of  the  utmost  tenacity.  If  the  two  canula  of  Levret  are  selected, 
it  is  so  placed  as  to  make  a  handle  on  one  side,  and  to  be  fixed  on  the  other 
side  upon  a  ring  which  is  placed  outside  of  the  mouth  or  aperture  in  each.  One 
or  two  fingers  of  the  left  hand,  carried  as  high  up  as  possible,  convey  the 
whole  to  the  pedicle  of  the  polypus.  The  surgeon  then  takes  one  canula  in 
each  hand  ;  holds  firmly  fixed  in  one  spot  that  which  has  attached  to  its  base 
the  ligature,  with  the  other  encircles  the  base  of  the  peduncle  until  he  can 
cross  them ;  twists  them  ;  then  turns  them  together  on  their  axis  ;  withdraws 
them ;  then  includes  the  two  conjoined  extremities  of  the  ligature  in  another 
tube  called  a  "serre-noeud"  (knot-tightener),  which  allows  of  his  strangulating 
the  tissues  with  all  necessary  strength. 

The  instruments  of  M.  Desault,  differ  from  those  of  M.  Levret  in  having 
two  free  and  separate  '*  porte-noeuds"  like  those  of  David,  and  in  one  of 
them  a  sort  of  forceps  is  enclosed,  which  when  shut  ends  in  a  little  ring  at 
the  top.  One  half  of  the  ligature  is  first  passed  into  the  plain  canula,  and 
fixed  upon  the  ring  below ;  the  other  is  then  laid  hold  of  by  the  forceps,  which 
is  closed  and  drawn  back  into  its  sheath,  and  which  is  notched  at  its  inferior 
extremity  for  the  reception  of  the  end  of  the  second  thread.  This  apparatus 
is  carried,  like  the  former,  by  the  fingers  to  the  spot  which  offers  the  least 


L 


684  NEW  ELEMENTS  OF 

resistance.  When  he  arrives  at  th-e  peduncle,  the  operator  with  his  left  hand 
keeps  the  plain  canula  motionless,  with  the  right  seizes  that  armed  with  the 
forceps,  passes  over  with  it  the  whole  circumference  of  the  tumor,  and  brings 
it  back  to  the  level  of  the  other,  so  that  the  ligature  forms  a  complete  circle 
around  the  pedicle  to  be  strictured.  The  split  shank  pushed  into  the  canula, 
opens  by  its  own  spring,  loosens  the  string,  and  may  be  removed  without  its 
being  displaced.  The  extremities  of  the  ligature  being  then  united  so  as  to 
form  but  once  piece,  are  then  brought  through  an  opening  in  a  last  piece  of 
metal,  some  inches  long,  the  head  of  which  has  a  hole  in  it,  and  is  bent  at 
nearly  a  right  angle  on  the  body  of  the  instrument.  This  '^  serre-noeud" 
allows  the  elevation  of  the  constriction  to  any  degree  of  severity  which  may 
be  desired,  and  of  its  augmentation  or  diminution  as  may  be  seen  fit.  It  is 
finally  to  be  fixed,  after  having  been  surrounded  by  linen,  to  one  side  of  the 
vulva  by  a  small  riband. 

The  apparatus  of  M.  Neissen  consists  of  two  long  silver  canula,  curved, 
but  sufficiently  flexible  to  be  straightened  or  bent,  which  serve  to  convey  the 
ligature.  When  they  have  arrived  around  the  tumor  they  are  both  included 
.in  a  third  canula,  divided  by  a  middle  septum  into  two  tubes,  and  only  one 
or  two  inches  in  length.  This,  which  seems  but  a  fragment  of  the  double 
tubed  instrument  of  Levret,  is  carried  up  from  below  with  the  fingers  as  far 
as  possible,  and  still  higher  by  means  of  a  hooked  sound.  It  is  intended  to 
increase  the  strangulation  of  the  peduncle  of  the  tumor  more  and  more  by 
compelling  the  upper  extremities  of  the  two  first  canula  to  approach  one 
another  strongly,  without  departing  from  theii"  parallel  direction. 

At  first  sight  no  very  great  advantange  seems  to  arise  from  these  instru- 
ments over  those  employed  by  the  French  practitioners. ,  The  canula  of  the 
German  author,  being  no  more  than  those  of  Levret  a  little  increased  in 
length  and  curve,  perhaps  are  better  adapted  for  penetrating  a  great  depth; 
but  I  think  the  double  tube  intended  to  approximate  them  infinitely  less  cal- 
culated for  the  object  than  the  "  serre-nocud"  of  Desault.  If  this  latter  portion 
of  the  apparatus  be  thought  to  be  in  need  of  some  alteration,  the  fillet,  of 
which  M.  Mayor  has  made  so  happy  an  application  within  the  last  few  years, 
would  here,  better  than  in  the  nose,  deserve  a  justifiable  preference.  If,  in 
strangulating  the  polypus,  we  possessed  neither  the  mechanical  cylinder  of 
this  author,  nor  the  little  instrument  of  the  same  kiftd  invented  by  Levannier 
of  Cherbourg,  we  might  simply  attach  the  two  ends  of  the  ligature  to  a  piece 
of  linen,  or  other  solid  body,  and  tighten  them  on  that.  The  "  serre-noeud 
brise,"  which  Bichat  has  endeavored  to  substitute  for  the  forceps  canula  of 
Desault,  fulfilling  very  seldom  the  intention  of  its  inventor,  it  does  not  seem 
to  me  to  deserve  more  than  this  notice.  Nor  do  I  think  the  speculum  of  *M. 
Guillon,  modified  by  M.  P.  Dubois  so  as  to  hold  a  ligature,  of  such  a  nature 
as  to  supersede  the  very  simple  and  ingenious  contrivance  of  the  veteran 
surgeon  to  the  Hotel  Dieu. 

When  the  ligature  has  been  well  applied,  circulation  and  vitality  are 
quickly  interrupted  in  every  part  of  the  tumor  beneath  it.  Whilst  this  mass 
is  mortifying  and  being  decomposed  the  ligature  is  gradually  cutting  through 
its  peduncle.  It  is  easy  to  comprehend  how  this  will  be  accomplished  with 
greater  or  less  rapidity,  according  to  the  power  of  the  constriction  employed, 
and  to  the  density,  resistance,  and  bulk  of  the  tissues  which  it  encircles. 


i 


OPERATIVE    SURGERY.  685 

Did  the  dimensions  of  the  foot-stalk  not  exceed  an  inch  in  thickness,  a  single 
riband  drawn  tight  upon  it  would  suffice  to  cut  it  through  in  some  days. 
Beyond  this  thickness  it  has  been  thought  it  would  be  better  to  transj&x  it 
with  a  needle  and  double  ligature,  so  as  to  strangulate  each  half  separately. 
To  this  proceeding  two  objections  may  be  made :  1st,  polypi,  which  can  be 
drawn  down  into  the  vagina,  the  only  ones  capable  of  this  transfixion,  seldom 
have  root  enough  to  demand  such  a  precaution :  2d,  those  whose  foot-stalks 
are  more  voluminous,  as  to  allow  their  being  drawn  down  or  not,  are  all 
either  fibrous  bodies  which  ought  to  be  cut  off"  by  the  knife,  or  morbid  growths 
which  should  be  let  alone  altogether. 

Between  simple  ligature  or  excision  then  our  choice  should  lie.  Among 
the  instruments  for  applying  ligatures,  that  which  M.  Mayor  has  recently 
proposed  and  figured  in  his  treatise  on  "ligature  in  the  mass,"  seems  to  me 
especially  worthy  of  a  trial.  It  is  composed  of  two  elastic  stems  of  steel  or 
whalebone,  unless  there  were  time  to  procure  metallic  ones,  ending  superiorly 
by  crab-claws.  The  ligature  is  placed  in  them  just  as  in  the  instrument  of 
Desault,  and  is  to  be  carried  round  the  polypus  with  the  same  precautions. 
To  throw  it  off,  we  have  only  to  pull  rather  strongly  on  the  conducting  instru- 
ment, as  soon  as  the  knot-tightener  arrives  at  the  penduncle  to  be  incar- 
cerated. In  the  double  tube  of  Levret  the  two  portions  of  the  string  come 
together  too  near  the  polypus  to  render  their  passage  easy  when  we  wish  to 
increase  the  constriction.  It  is  so  indeed  with  all  "serrenoeuds,"  as  I  have  again 
recently  experienced.  M.  G.  Pelletan,  who  had  like  others  suffered  from  the 
inconvenience,  had  constructed  by  M.  Sirhenry  a  very  ingenious  little  apparatus 
to  do  it  away.  The  two  branches  of  his  knot-press  which  terminate  its  deep 
end,  separate  slightly  outwards,  like  a  fork,  for  some  lines  superiorly,  and  are 
applied  by  their  sinus  to  the  root  of  the  polypus,  and  scarcely  bend  the  liga- 
ture, while  they  in  some  measure  continue  its  circle.  A  spring,  a  kind  of  steel 
fillet,  curved  in  several  direction  to  increase  its  elasticity,  placed  at  the  free 
extremity  of  the  instrument,  receives  the  other  end  of  the  string  and  con- 
stantly increases  its  tightness.  This  elastic  part  can  be  adapted  to  any  other 
instrument,  and  among  others  that  of  M.  Mayor.  The  forking  out  of  the  knot- 
press  would  only  give  trouble  if  it  were  to  be  turned  on  its  axis  to  twist  the 
thread. 

Bemarks. — Before  we  strangulate  a  polypus  which  is  dependant  without,  it 
behooves  us  to  observe  that  its  peduncle  may  proceed  from  the  fundus  of  the 
inverted  uterus,  and  that  in  that  case  it  would  be  dangerous  to  place  the  liga- 
ture too  high  up  on  the  tumor.  Decomposition  of  a  polypus  within  the  sexual 
organs  often  gives  rise  to  accidents  which  we  would  fain  avoid.  The  disgust- 
ing smell  too  which  attends  it  is  so  extremely  nauseous  to  the  patient  and 
those  about  her.  When  the  polypus  is  large,  and  the  weather  warm,  it  really 
becomes  perfectly  insupportable.  The  putrifying  mass,  moreover,  may  irritate 
the  vulva  and  vagina,  and  if  it  be  reabsorbed  may  give  rise  to  constitutional 
infection,  and  a  fever  of  a  very  bad  type. 

If  the  tumor  cannot  be  drawn  out  we  must  resort,  to  overcome  these  inconve- 
niences, to  the  ordinary  methods  of  cleanliness,  simple  injections  of  mallow  tea, 
or  barley  water  sweetened  with  honey,  of  decoctions  of  kino,  or  better  still  of 
the  alkaline  chlorides  in  solution.  But  when  the  first  stalk  is  naturally  low 
down,  and  may  be  brought  lower  still  by  moderate  traction  with  but  little  pain. 


686  NEW  ELEMENTS  OF 

it  is  more  expeditious,  and  certainly  less  dangerous,  to  cut  off  the  whole  mass 
below  a  ligature  than  to  leave  it  to  come  off  of  itself.  It  is  not  worth  while 
to  discuss  the  question,  which  has  been  done  by  many  authors  of  imposing  re- 
putation, whether  when  the  ligature  is  applied  to  the  parts  before  our  eyes,  it 
is  better  to  practice  excision  immediately  than  to  wait  for  the  mortification 
produced  by  the  ligature.  By  the  former  method  the  patient  is  at  once 
relieved,  and  that  without  any  reasonable  apprehension  as  to  hemorrhage ;  by 
the  second  we  do  not  guard  against  this  unpleasant  occurrence,  and  as  it 
exposes  her  to  risk  of  the  consequences  without  corresponding  advantages  on 
this  head,  I  think  it  ought  to  be  abandoned  entirely.  Levret  maintained  that 
after  ligature  mortification  progressed  to  the  junction  of  the  polypus  and  ma- 
trix, notwithstanding  the  constriction  have  been  performed  below  this  point ; 
and  that  once  strangulated,  these  tumors  gradually  separate  always  in  the 
same  spot,  nearly  as  does  the  umbilical  cord  at  birth  whatever  be  the  spot 
where  the  string  had  been  placed.  To  M.  Boyer,  this  seems  a  dangerous 
doctrine.  In  fact  were  it  false  it  might  lead  to  vexatious  practical  results.  If 
it  be  adopted  it  would  matter  little  whether  the  string  be  placed  exactly  orj 
the  upper  part  of  the  pedicle,  or  somewhat  below  it.  As  it  is  usually  more  easy  to 
place  a  ligature  low  down  than  high  up,  as  likewise  some  may  dread  including 
some  part  of  the  uterus  tissue  in  it  by  elevating  it  much,  the  ligature 
would  often  be  so  placed  as  to  leave  a  part  of  the  polypus  still  within 
the  organ.  On  the  other  hand,  the  statement  of  M.  Boyer  is  correct, 
that  as  life  ceases  in  the  tumor  only  as  far  as  the  constricting  agent,  the 
ligature  ought  if  we  would  guard  against  a  return  of  the  disease,  to  be 
placed  as  high  up  as  possible  on  the  morbid  growth.  The  opinion  of  Levret  is 
based  upon  facts.  A  distinguished  surgeon  in  one  of  the  departments,  M. 
Genson  at  Lyons,  has  quite  recently  supported  it  by  a  statement  of  his  observa- 
tions. It  asserts  neither  any  thing  contrary  to  what  is  known  of  the  laws  of 
the  organism,  nor  which  cannot  be  said  of  the  separation  of  the  umbilical  cord. 
It  is  essential  that  this  point  be  well  understood — ^mucous  polypi,  and  those 
polypi  to  which  many  vessels  are  distributed,  and  which  are  evidently  con- 
tinuous with  the  tissues  of  the  uterus,  do  not  probably  make  in  favor  of  the 
theory  of  Levret,  which  seems  to  me  applicable  only  to  those  which  are  really 
foreign  bodies  within  the  cavity  of  the  organs,  and  to  those  polypi  which 
are  purely  lardaceous  or  fibrous,  and  destitute  of  any  appreciable  vascular 
supply. 

Sd.  Excision. — More  daring  than  were  surgeons  in  the  last  century,  the 
ancients  often  performed  exsection  of  genital  polypi.  Philoteus,  ^tius,  Mos- 
chion,  and  others,  evidently  described  this  method  when  they  advise  that  vari- 
cose excrescences,  and  hemorrhoidal  tumors  of  the  uterus  should  be  removed 
by  the  knife.  Aquapendente,  who  was  much  lauded,  used  for  its  accom- 
plishment forceps  with  a  scissors-shaped  extremity,  which  saved  him  the 
labor  of  first  drawing  out  the  polypus.  Although  here  and  there  some 
authors  have  called  attention  to  this  practice ;  though  Tulpius,  Waters,  and 
Fronton  quoted  by  Levret,  each  record  an  instance  in  its  favor,  it  has  not  yet 
triumphed  over  all  the  prejudice  which  theoretical  speculation  so  long  ago 
created  against  it.  M.  Boyer,  who  reports  that  he  has  once  successfully 
tried  it,  and  seems  not  far  from  giving  it  a  preference,  dares  not  however  to 
propose  it  formally  for  general  adoption.  It  is  condemned  as  being  more  likely 


OPERATIVE    SURGERY.  687 

than  any  other  to  give  rise  to  hemorrhage;  to  dangerous  wounds  of  tlie  rectum, 
bladder,  vagina,  and  even  of  the  uterus,  and  also  as  being  much  less  easy  than 
that  by  ligature.  The  wound  which  it  must  produce,  has  in  its  turn  frightened 
many  surgeons,  who  have  been  afraid  of  inflammation  in  the  gestative  organ, 
or  of  suppuration  and  an  ulcer  which  it  would  be  difficult  to  heal. 

All  the  research,  and  all  the  dissection  which  I  have  made,  along  with  those 
recently  performed  by  M.  Hervez  de  Chegoin,  have  convinced  me  that  all 
polypi  which  are  really  fibrous  bodies,  may  be  excised  from  the  uterus  without 
the  slightest  inconvenience.  They  never  adhere  to  the  organ  by  a  peduncle  of 
any  size,  nor  are  supplied  with  any  vessels.  The  layer  of  uterus  which  covers 
them  as  a  sort  of  hood  is  usually  very  thin,  and  constantly  reduced  to  a  mere 
shell  which  has  only  to  be  incised  to  allow  their  enucleation,  or  turning  out,  to 
be  easily  accomplished  with  the  fingers  or  the  handle  of  a  scalpel,  as  if  it  were 
a  leipoma  or  a  subcutaneous  cyst.  As  to  the  homogeneous,  hard,  and  greyish 
bodies,  like  the  preceding,  which  are  continuous  with  the  uterus,  the  section  of 
their  pedicle  can  never  bring  about  any  alarming  loss  of  blood,  if  I  can  judge 
by  those  which  I  have  seen  in  the  dead,  and  removed  from  the  living  body. 

Thirdly,  I  do  not  see  either  how  the  fibrous  masses  which  originate  in  partial 
hypertrophy  of  the  uterus  need  justify  the  least  fears  on  this  subject.  It  is 
rare  for  entire  excision  of  the  neck  of  the  uterus  to  be  attended  with 
abundant  hemorrhage,  and  it  is  not  easy  to  believe  than  removal  with  a  cutting 
instrument  of  the  little,  mucous,  soft  tumors  described  by  M.  Berard,  or  of  any 
other  polypus  production  capable  of  being  removed  by  ligature,  should  really 
be  rendered  dangerous  from  such  an  occurrence.  We  have  then,  lastly,  only 
the  reddish,  bleeding  fungi,  sometimes  painful  and  rarely  pedunculated,  of 
which  we  before  spoke,  which  can  be  unfit  for  the  operation  of  excision  :  but  to 
them  ligature  offers  no  better  a  resource  :  for  we  are  compelled  to  enrol  them 
in  the  list  of  those  distressing  affections  which  bafiie  our  art,  and  to  which  with 
the  greatest  propriety  the  term  "  noli  me  tangere"  may  be  applied.  For 
twenty  years  past  M.  Dupuytren  has  cut  away  every  uterine  polypus  which 
he  has  been  called  on  to  treat,  and  once  only  has  the  hemorrhage  appeared  to 
him  to  demand  any  particular  attention.  Numerous  facts  equally  conclusive 
have  been  cited  by  M.  Hervez  de  Chegoin.  Operations,  equally  successful, 
of  this  kind  have  been  related  by  M.  Villeneuve,  M.  Lejeune,  and  a  host  of 
other  surgeons.  In  Germany,  MM.  De  Siebold  and  Mayor  have  published  a 
treatise  to  prove  that  excision,  long  practised  by  them  in  the  Hospital  at  Vienna, 
has  been  attended  with  remarkable  success.  May  I  be  permitted  to  add,  that 
of  eight  operations  for  polypus  with  a  cutting  instrument,  performed  by  myself, 
not  one  has  been  followed  by  the  least  hemorrhage. 

The  Method  of  Operation. — The  instruments,  &:c.,  necessary  for  this  ope- 
ration, are  the  long  forceps  of  Museux,  a  common  bistoury  or  scalpel,  some  lint, 
and  some  astringent  preparation  in  case  of  need,  and  some  linen,  as  for  other 
bloody  operations.  If  the  tumor  be  very  large,  a  few  more  may  however 
become  necessary ;  such,  for  example,  as  forceps,  sharp  hooks,  or  what  I  have 
sometimes  used,  long,  strong  double  hooks  slightly  curved,  to  meet  the  shape 
of  the  parts.  In  ordinary  cases  the  right  hand  passes  the  forceps  closed  into 
the  vagina,  and  they  are  not  opened  except  to  seize  hold  of  the  tumor ;  while 
tlie  left  hand,  while  it  protects  the  parts,  directs  the  insertion  of  the  hooks. 
We  are  then  to  draw  down  the  morbid  mass,  bv  very  moderate  traction,  by 


& 


688  NEW    ELEMENTS    OF 

degrees ;  and  if  the  mobility  of  the  uterus  permits  us  to  get  the  pedicle  to  the 
vulva,  the  labia  are  to  be  separated  with  great  care  by  an  assistant,  and  the 
section  is  made  with  every  facility  by  means  of  some  cutting  instrument  or 
other.  When  on  the  contrary  the  poljpus  offers  much  resistance,  we  must 
not  permit  it  to  reascend,  but  with  the  point  of  a  straight  bistoury,  the  blade  of 
which  has  been  previously  wound  round  with  a  strip  of  bandage,  the  surgeon 
must  proceed  to  divide  it  at  its  narrowest  part,  always  following  the  knife  with 
the  fingers  of  the  left  hand,  which  continue  in  the  vagina.  I  had  occasion  to 
remove  from  a  young  lady,  living  in  the  street  of  the  "Petit  Carreau,"  a  polypus 
as  large  as  a  turkey  egg,  which  was  inserted  into  the  inner  surface  of  the  neck 
of  the  uterus,  and  which  after  it  was  once  engaged  in  the  vulva,  seemed  not 
willing  to  descend  any  lower.  Whilst  M.  Cottereau,  the  physician  to  the 
patient,  retained  it  in  the  pelvic  strait,  I  passed  up  my  left  index  and 
middle  lingers  towards  the  os  tinc» ;  then  slipped  a  covered  bistoury,  with  my 
right  hand  between  the  polypus  and  my  fingers,  to  the  top  of  the  vagina,  with 
which  I  easily  detached  the  tumor.  Not  a  drop  of  blood  escaped,  and  the 
the  lady,  after  the  third  day,  might  have  resumed  her  accustomed  occupations. 
An  almost  similar  case  has  just  occurred  in  my  department  at  La  Pitie. 

If  from  the  size  of  the  polypus  this  cannot  be  done,  we  must  use  a  bistoury 
curved  a  little  on  its  flat  side,  or  else  scissors  of  the  same  form.  In  those 
cases  where  it  would  seem  dangerous  to  make  traction  upon  the  uterus,  we 
should  find  an  invaluable  auxiliary  in  the  species  of  forceps  which  is  strongly 
curved  at  one  end,  somewhat  scolloped,  and  made  to  cut  like  the  forceps  of  J. 
Fabricius,  of  which  we  are  told  by  M.  Lauth,  that  M.  Lobstein  has  often 
made  use.  With  the  same  view,  M.  Mayor  contrived  a  long,  and  very  strong 
scissors,  curved  like  the  letter  S,  with  which  to  detach  the  tumor  whatever 
might  be  its  height.  The  same  end  may  however  be  accomplished  with  the 
equally  long  and  strong  scissors  which  are  employed  by  MM.  Boyer  and  Du- 
puytren,  and  which  have  only  a  simple  concavity  on  one  of  the  faces  of  their 
blade.  They  have  besides  an  additional  advantage,  that  of  detaching  gra- 
dually the  polypus  from  any  adhesions  which  it  may  have  contracted  with  tlie 
sides  of  the  vagina  before  it  is  drawn  down,  and  its  peduncle  divMed,  as  hap- 
pened in  a  case  seen  by  M.  Berard,  in  which  the  tumor  adhered  by  one  root 
to  the  vagina  and  by  the  other  to  the  uterus.  If  the  tumor  be  separated  from 
the  parietes  of  the  organ  from  which  it  springs  by  a  fissure  of  more  or  less 
depth  only,  instead  of  having  a  foot  stalk,  and  be  also  a  fibrous  body,  we  are 
not  to  suppose  it  indispensable  to  carry  the  cutting  instrument  into  the  deepest 
part  of  this  fissure.  If  we  can  cut  a  little  above  the  greatest  diameter  of  the 
polypus,  and  give  the  incision  a  certain  length,  so  as  to  divide  the  whole  layer 
of  tissue  which  surrounds  the'morbid  growth,  we  require  nothing  more  than 
the  fingers,  the  handle  of  the  instrument,  or  mere  traction,  to  detach  it,  as  a 
nut  is  separated  from  the  shell  which  surrounds  it. 

The  membranous  and  irregular  edge  which  result  from  the  enucleation,  either 
retract  and  cicatrize  or  return  on  themselves,  and  are  partially  destroyed  by 
suppuration.  Uterine  polypi  are  sometimes  so  large  as  entirely  to  fill  the 
vagina,  and  even  to  rise  up  into  the  hypogastrium  or  fossa  iliaca.  Baudelocque 
mentions  having  seen  one  of  which  the  lower  part  was  in  the  pelvis,  and  the 
other  projected  above  the  superior  strait.  He  succeeded  in  tying  the  lower 
part,  but  when  it  had  sloughed  away,  Louis  objected  to  searching  for  the  other 


*^^  OPERATIVE    SURGERY.  689 

half  with  forceps.     The  woman  died,  and  Baudeiocque  asserts  that  it  was 
possible  to  have  removed  it  as  well  as  the  other  portion  of  the  foreign  body. 
It  is  in  cases  like  this  that  this  author  advises  the  use  of  those  forceps  which 
Herbiniaux  had  used  before  him  with  complete  success.     All  the  advantages 
promised  by  Baudeiocque  has  since  been  realized  from  their  use  by  MM. 
Deneux,  Murat,  and  Hervez  de  Chegoin.  Now  that  we  have  very  clear  ideas  as 
to   the  nature  of  these  large  polypi   we  shall  attempt  their  removal  with 
more  boldness,  as  we  shall  not  feel  compelled  to  resort  any  longer  to  the 
ligature.     After  all,  the  forceps  is  not  the  only  instrument,  nor  is  it  always 
the  best  instrument  indicated  in  these  cases.  In  the  month  of  September,  1830, 
I  was  sent  for  to  Bergues  by  Doctor  Mazieres,  to  a  lady  who  had  been  brought 
almost  to  the  grave  by  an  enormous  fibrous  tumor  of  tiie  womb,  which  rose 
above  the  pubis,  and  entirely  filled  the  vagina.  Although  firm  and  very  elastic, 
it  could  be  so  depressed  as  that  the  blade  of  the  forceps  continually  slipped 
backwards  and  forwards.     1  preferred  seizing  its  summit  with  the  very  long 
forceps  of  Museux,  then  to  carry  up  above  its  thickest  part  two  strong  double 
liooks,  one  on  either  side,  and  to  fix  them  firmly  into  its  substance.     Thus 
seized   in   four    places  at  once,  methodical   traction   at   length  brought  it 
into  the  inferior  strait.     The  perineum,  which  I  was  obliged  to  cut  backwards, 
made  long  resistance;  but  at  length  my  index  finger  giving  me  notice  that  the 
pedicle  of  the  polypus  was  strongly  on  the  stretch,  I  slipped  up  on  it  a  straight 
bistoury  properly  protected,  and  an  incision  of  a  few  lines  allowed  the  elas- 
ticity of  the  parts  to  finish  the  operation.     It  was  a  fibrous  body,  the  size  of 
which  was  equal  to  that  of  a  child's  head.     No  bleeding  followed,  and  not- 
withstanding me  emaciation  and  exhaustion  to  which  the  patient  was  reduced, 
her  health,  as  M.Demazieres  wrote  me  a  month  afterwards,  was  perfectly  re- 
established.  . 

There  are  cases  nevertheless  in  which  such,  is  the  situation  of  the  tumor 
that  nothing  seems  capable  of  bringing  it  down.  A  woman,  thirty-six  years  old, 
was  brought  into  my  department  of  the  Hospital  St.  Antoine,  by  M.  Kapeler, 
after  a  long  residence  in  the  medical  side.  In  her  the  tumor  filled  nearly  the 
whole  pelvis,  and  formed  a  considerable  projection  below  tlie  strait.  It  was 
agreed  between  Kapeler  and  Marjolin  and  myself,  that  its  extirpation  should  be 
attempted  by  the  natural  passages.  I  seized  it  thrice  with  a  common  forceps, 
and  thrice  I  failed  to  effect  its  descent.  I  then,  fearing  I  might  unnecessarily 
increase  her  sufferings,  thought  it  best  to  leave  her  to  the  natural  consequences 
of  her  disease.  In  a  few  months  she  died.  In  the  autopsy  we  found  a  fibrous 
bpdy  destitute  of  a  pedicle,  extensively  putred,  originating  in  the  thickness  of 
the  right  wall  of  the  cervix,  from  which  it  was  otherwise  easy  to  separate  it 
after  cutting  through  the  enveloping  layer  of  natural  tissue.  Another  tumor,  as 
large  as  the  two  fists  only,  in  contact  on  one  side  with  the  former  one,  occupied 
the  right  side  of  the  uterus,  and  like  it  was  covered  by  a  thin  reflexion  of  the 
organ.  These  two  masses,  the  base  of  which  was  as  large  almost  as  their  greatest 
diameter,  and  were  larger  above  than  below  the  strait,  could  not  have 
been  seized  firmly  enough  by  forceps  to  have  been  drawn  down  and  removed ; 
but  the  dissection  convinced  us  that  their  enucleation  had  certainly  been 
possible,  notwithstanding  the  extent  of  the  adhesions,  if  by  any  means  we 
could  have  brought  then)  to  the  inferior  strait,  or  have  carried  the  bistoury  to 
any  point  of  their  circumference.  As  this  kind  of  polypus  does  not  tear 
87  ^^ 


690      ,  NEW  ELEMENTS  OF 

very  easily,  it  would  not  be  iinadvantageous  perhaps,  when  we  have  succeeded 
in  bringing  them  out  at  the  vulva,  to  pass  through  them  by  means  of  a  long 
curved  needle,  having  a  handle  and  pierced  near  its  point,  a  strong  waxed 
silk  riband  of  which  a  loop  might  be  made,  and  thus  permit  us  to  pull  on  them 
without  so  much  interfering  with  the  other  instruments. 

If  the  tumor  is  of  a  doubtful  nature  ;  if  it  be  possible  to  draw  it  down  by 
seizing  it  with  forceps  so  as  to  allow  the  finger  to  pass  over  the  peduncle  ; 
if,  as  cases  are  quoted  by  Levret  and  Eschenbac,  we  feel  arteries  beating  in 
this  peduncle ;  and  if,  notwithstanding  our  dissertation  on  this  subject  fur- 
ther back,  we  still  dread  the  prospect  of  hemorrhage,  there  is  nothing  to 
hinder  the  previous  application  of  a  ligature  high  up,  as  Mayor  advises,  before 
we  practise  the  excision. 

In  conclusion,  let  me  observe,  that  neither  ligature,  tearing  away,  or  exci- 
sion is  to  be  attempted  where  the  tumor  is  still  wholly  enclosed  within  the 
uterus,  nor  when  we  are  satisfied  that  it  is  not  the  only  one,  and  that  others 
exist  in  the  thickness  of  the  organ  beyond  the  reach  of  surgical  means.  All 
that  the  patient  requires  after  the  excision  is  injections,  at  first  emollient, 
then  detergent,  and  finally  astringent.  If  contrary  to  all  expectation  hemor- 
rhage does  ensue,  I  think  that  astringent  injections,  rolls  of  lint  soaked  in 
oxycrate,  eau  de  Rabel,  solution  of  alum,  or  else  besprinkled  with  colophany 
or  some  styptic  powder,  would  quickly  put  a  stop  to  it.  The  tampon,  if  all 
were  vainly  tried,  should  not  as  a  last  resource  be  omitted. 

Art,  9. — Cancer  of  the  Neck  of  the  Uterus. 

The  amputation  of  the  neck  of  the  uterus,  is  a  triumph  of  modern  surgery. 
Osiander  was  the  first  person  who  positively  proposed  it  towards  the  end 
of  the  last  century,  and  who  performed  it  in  1801.  Tulpius,  to  whom  it  is 
attributed  by  M.  Tarral,  seems  to  me  undeserving  of  the  honor.  The  sarco- 
matous tumors  of  which  he  speaks  were  evidently  polypi,  which  is  moreover 
proved  by  the  figure  of  that  which  was  removed  from  Ids  patient  Gertruda 
Turrita.  It  is  nowhere  to  be  found,  that  he  ever  thought  of  exsection  of  the 
fundus  of  the  uterus.  Lazzari,  who  claims  it  for  Monteggia,  and  Baude- 
locque,  who  assigns  it  to  Lauvariol,  have,  I  think,  both  fallen  into  an  error; 
and  I  cannot  assure  myself  that  it  was  performed  by  Andre  de  la  Croix  and 
Lapeyronie,  as  is  contended  by  M.  Tarral.  All  that  can  be  said  is,  that 
Wrisberg  recommended  it  in  1787,  and  that  it  was  certainly  done  by  many 
persons  through  accident  before  it  was  ever  designedly  put  into  practice. 
No  sooner  were  the  cases  of  Osiander  known  in  France,  than  M.  Dupuytren 
hastened  to  put  into  practice  the  ideas  of  the  Goettingen  surgeon,  and  to  test 
them  by  many  experiments.  M.  Recamier  was  not  long  in  following  in  the 
same  path,  so  that  in  1815  excision  of  the  cervix  of  the  uterus  with  us  was 
quite  a  common  operation.  It  was  reserved  for  M.  Lisfranc  yet  further  to 
extend  its  usefulness,  and  to  demonstrate  to  the  most  incredulous  the  very 
little  danger  that  attended  it.  It  has  now  been  done  so  often  by  so  many 
different  people,  that  it  is  perfectly  needless  to  enumerate  the  examples  and 
to  reply  to  the  objections  made  by  MM.  Wenzel  and  Zang,  who  have  for- 
mally denourxed  it.  The  difficult  point  is  to  ascertain  precisely  when  it  is 
indicated.     The  elongation  from  simple  hypertrophia  of  the  neck  of  the 


OPERATIVE   SURGERY.  691 

uterus,  does  not  require  it ;  for  it  is  rather  an  infirmity  than  disease.  It  is 
equally  uncalled  for  by  excoriations,  ulcers,  and  syphilitic  vegetations,  which 
are  not  incurable  in  their  nature.  The  same  thing  may  likewise  be  said  with 
respect  to  induration ;  to  those  rugosities,  unattended  with  pain,  or  with  or 
without  chronic  swelling,  which  are  so  often  seen  in  women  from  thirty  to 
forty  years  of  age.  It  is  only  in  well  characterized,  real,  cancerous  degene- 
ration, that  we  may  be  allowed  to  perform  it.  But  here  is  precisely  the 
knotty  point  in  the  case;  for  so  long  as  cancer  is  unulcerated,  and  presents 
only  a  more  or  less  tumid  mass  high  up  in  the  vagina,  its  diagnosis  is 
extremely  difficult.  In  the  first  place  it  requires  great  familiarity  with  the 
Iiardness  and  consistence  natural  to  the  neck,  the  variety  of  size,  projection, 
density,  and  of  form  which  it  presents,  according  to  the  age  and  different 
conditions  in  which  the  patient  may  be  seen,  so  as  not  to  apprehend  the  pre- 
sence sometimes  of  a  disease  of  which  no  vestige  really  exists.  How,  indeed, 
can  we  be  sure  that  we  mistake  not  as  to  the  nature  of  an  organic  lesion,  in  a 
part  so  deep,  amid  a  texture  so  dense,  and  amid  elements  as  variable?  Nor 
is  this  all ;  were  the  existence  of  cancer  to  be  incontestably  established,  it 
still  becomes  necessary  to  affix  limits  to  its  spread.  It  is  rare  that  all  doubts 
are  entirely  dissipated  on  the  case  until  a  very  advanced  period ;  and  then  it 
is  almost  impossible,  to  guarantee  that  the  cervix  uteri  alone  is  effected,  and 
that  the  body  of  the  organ  is  not  more  or  less  attacked.  The  surgeon  is  then 
always  in  fear  of,  1st,  removing  an  organ  which  is  not  diseased,  and  of  course 
performing  Unnecessarily  a  painful  and  dangerous  operation,  or  else,  2dly,  of 
removing  a  portion  of  a  disease  only,  the  remainder  of  which  will  infallibly 
result  in  the  death  of  the  patient.  It  is  a  natural  consequence  of  these  re- 
marks, that  the  indication  for  the  performance  of  amputation  of  the  summit  of 
the  uterus  must  be  very  rare ;  and  that  one  need  not  be  astonished  if  very 
well  informed  surgeons  are  yet  in  doubt  as  to  its  being  ever  a  suitable  one. 
Since  we  could  ask  ourselves  the  question,  what  advantage  arises  from  extir- 
pation of  this  disease  when  it  exists  in  the  breast?  it  would  be  difficult  to  have 
hindered  its  being  asked  when  the  affection  was  seated  in  the  uterus.  So 
long  as  extirpation  is  admitted  to  be  a  remedy  for  external  cancer,  no  one  can 
with  reason  deny  its  utility  in  cancerous  diseases  of  the  genital  organs,  when 
done  under  certain  conditions.  It  is  even  consoling  to  remark,  that  in  the 
latter  parts,  the  disease  remains  longer  a  local  one,  and  is  in  reality  less 
likely  to  reappear  in  other  places,  than  when  it  exists  in  any  other  part. 
I  cannot  myself,  then,  think  this  operation  ought  to  be  absolutely  abolished 
from  practice.  It  is  better  to  try  it  than  to  abandon  the  patient  to  certain 
deatli,  if  the  spread  of  it  is  such  as  to  give  any  hopes  of  its  total  extirpation. 
Two  very  different  species  of  cancerous  degenerations  affect  the  cervix  uteri. 
Sometimes  the  disease  progresses  by  ulceration  either  of  the  edges  of  the 
neck,  or  of  its  cavity  towards  the  thickness  of  its  parietes;  and  the  ulcers, 
which  are  sometimes  covered  with  fungous  vegetations,  not  unfrequently 
penetrate  into  the  very  interior  of  the  uterus,  almost  as  does  the  gnawing 
cancer,  the  710K  me  tangere  of  the  face  and  mouth.  Sometimes  on  the  other 
hand,  a  cerebriforme  or  scirrhous  mass  appears  in  the  very  thickness  of  the 
organ,  on  or  neir  its  free  extremity,  or  at  any  other  point  of  its  extent. 

Cauterizing. — Caustics  can  be  applied  only  to  the  ulcerated  form  of  cancer ; 
for  the  tumors  can  be  conquered  only  by  extirpation,  properly  so  called.     I 


692  NEW    ELEMENTS   OF 

think,  that  as  one  is  not  sure,  when  the  disease  has  not  gone  far  nor  deep, 
whether  it  be  of  a  cancerous  rather  than  of  any  other  character,  we  should  first 
make  use  of  the  argenti.  nitras.  In  a  more  advanced  stage  of  the  affection, 
and  when  its  malignity  can  no  longer  be  doubted,  we  may  choose  between  the 
muriate  of  antimony,  caustic  potassa,  and  nitrate  of  mercury;  or  even  if  we 
are  so  disposed,  try  the  effect  of  the  actual  cautery.  But  as  our  object  is  not 
alone  to  destroy  the  tissues  but  to  change  the  action  on  the  morbid  surface, 
and  the  acid  nitrate  of  mercury  is  of  incontestible  value  in  a  host  of  other 
affections  of  a  like  nature,  I  think  that  an  advantage  would  ensue  from  its 
general  adoption. 

The  Operation. — After  the  woman  is  placed  and  supported  on  the  edge  of 
a  bed,  and  the  parts  diseased  are  brought  into  view  by  a  speculum  uteri,  the 
surgeon  wipes  and  dries  the  ulcer  by  carrying  up  to  it  on  a  long  pair  of  for- 
ceps, small  sponges  or  little  rolls  of  lint.  He  then  lays  a  little  coarse  lint 
between  the  circumference  of  the  cervix,  and  the  inner  face,  of  the  speculunij 
in  order  to  prevent  the  caustic  from  spreading  to  the  healthy  parts,  and  passes 
up  the  '*  cautery  stone"  (composed  of  potassa,  &c.),  or  else  the  nitrate  of  silver 
in  a  conical  shape,  held  in  a  very  long  porte-crayon,  or  one  supported  on  an 
another  instrument  to  the  bottom  of  the  ulcerated  excavation.  If  he  prefers 
the  acid  nitrate  of  mercury,  he  steeps  in  it  a  roll  of  lint  or  fine  linen,  and 
carries  it  in  like  manner  up  to  the  parts.  Before  the  speculum  is  withdrawn 
repeated  injections  of  warm  water  are  to  be  thrown  in,  with  a  view  to  prevent 
the  action  of  the  caustic  from  extending  to  other  than  the  diseased  spot.  The 
woman  is  then  put  into  a  bath,  and  afterwards  subjected  to  the  regimen 
advised  after  the  severer  operations. 

If  the  case  were  one  of  simple  excoriation  only,  or  of  slight  ulcerations,  this 
washing  of  the  parts  by  injection  would  be  almost  unnecessary,  and  the  other 
precautionary  measures  scarcely  needful.  The  operation  is  to  be  repeated 
oftener  or  more  seldom,  according  to  the  effects  which  result  from  it,  o^wavy 
four,  six,  or  eight  days;  and  it  is  only  to  be  ultimately  discontinued  when  the 
granulated,  scarlet  appearance  of  the  part  seems  to  indicate  the  cicatrization 
of  the  ulcers.  When  it  has  not  been  thought  prudent  to  resort  to  caustics,  or 
when  they  have  been  tried  with  little  or  no  benefit,  and  that  otherwise  we 
are  certain  the  whole  of  the  disease  can  be  removed,  there  can  no  longer  be 
any  hesitation  in  deciding  upon  its  exsection. 

Anatomical  Remarks. — In  order  fearlessly  to  amputate  the  cervix  uteri, 
certain  anatomical  details  should  be  known.  The  vagina,  which  surrounds 
this  part,  is  thin  ;  in  contact  at  one  part  with  the  bladder,  at  another  with  the 
rectum,  and  continuous  by  its  whole  upper  extremity  with  the  proper  tissues 
of  the  uterus  itself.  In  a  natural  state,  this  free  and  depending  portion  of 
the  organ  of  gestation  is  neither  three,  six,  or  eight  lines  in  length,  whatever 
may  be  said  about  it;  but  sometimes  one  and  sometimes  another  of  these 
dimensions,  and  that  without  being  in  any  way  diseased.  The  lips  of  the 
OS  tinc3e,  which  in  women  who  have  borne  no  children  are  closed,  but  in  those 
who  have  had  families  are  naturally  separated  and  frequently  soft  within, 
knobbed,  and  as  it  were  fungous  even  in  some  cases,  and  in  others  more  or 
less  tumid,  are  moreover  when  in  a  state  of  perfect  healthiness  sometimes 
greyish,  sometimes  purplish,  sometimes  more  or  less  red  in  color.  In  mar- 
ried NVwirien  the  anterior  labium,  which  usualiv  is  more  salient  and  thicker 


OPERATIVE    SURGERY.  693 

than  the  posterior,  is  sometimes  seen  differently  characterized.  The  vagina 
may  be  detached  from  this  anterior  lip  for  more  than  half  an  inch  without 
risk  of  opening  the  peritoneal  cul-de-sac  which  divides  it  from  the  bladder, 
save  that  as  the  urinary  bladder  adheres  to  its  anterior  surface  very  closely, 
there  is  a  possibility  that  this  part  may  be  reached  by  the  instrument.  Pos- 
teriorly, the  peritoneum  does  not  merely  cover  the  corresponding  surface  of 
the  uterus.  It  passes  down  upon  the  vagina  to  form  the  recto-genital  excava- 
tion ;  so  that  the  bistoury  on  this  side  would  have  only  to  penetrate  the  thick- 
ness of  a  few- lines  to  puncture  it. 

It  was  probably  an  oversight  of  M.  Mury,  who  says  in  his  thesis  that  there 
is  a  distance  of  eight  lines  forward  and  ten  backward  between  the  summit  of 
labia  of  the  cervix  and  the  serous  membrane  of  the  abdomen.  The  two  peri- 
toneal reflexions  which  fasten  the  matrix  in  the  pelvis  contain  only  a  few 
vessels,  twigs  of  nerves,  and  some  cellular  tissue.  In  a  great  many  women, 
being  very  lax,  they  permit  us  to  make  very  strong  traction  on  this  organ 
without  any  danger,  and  with  scarcely  any  severe  pain.  Finally  the  structure 
of  the  cervix  uteri,  being  in  a  great  measure  destitute  of  venous  or  arterial 
trunks,  the  bleeding  which  follows  its  exsection  is  very  seldom  alarming. 

The  imputation. — The  method  of  performing  excision  of  the  uterus,  did 
not  at  once  attain  that  degree  of  perfection  which  we  see  it  has  reached  in 
our  day.  Osiander  began  by  passing  two  silk  ribands,  with  the  assistance  of 
a  curved  needle,  through  the  diseased  organ,  which  he  drew  and  held  firmly 
down  by  the  two  loops,  so  as  not  to  cut  it  until  it  came  more  or  less  near  the 
vulva.  The  introduction  of  two  fingers  into  the  rectum,  permitted  him  to 
cut  it  above  when  he  could  not  bring  it  down ;  but  the  invention  of  his  hyste.ro- 
/ame  induced  him  to  relinquish  his  riband  tractors,  which  he  had  not  used  for 
a  long  while  before  his  death.  M.  Dupuytren,  and  most  surgeons  after 
him,  have  used,  instead  of  the  ribands  of  the  surgeon  of  Goettingen,  a 
Museux's  forceps  of  great  length,  with  hooks  slightly  curved,  and  which 
easily  embraces  the  diseased  part.  As  this  instrument  easily  tears  through 
the  tissues  it  is  sometimes  advisable  to  insert  two.  M.  Colombat  has  con- 
structed one  with  four  branches.  Others  contrived  instruments  which  were 
to  be  introduced  through  the  os  uteri  into  its  cavity,  and  there  opening 
assume  a  hooked  form,  and  drag  it  strongly  downward.  The  most  ingenious 
one  on  this  principle  is  that  of  M.  Guillon.  Another  much  more  complicated 
was  proposed  by  M.  Hatin,  and  M.  Recamier  has  since  invented '  others. 
Osiander  neglected  the  use  of  a  speculum.  Witli  us,  on  the  contrary,  it  is 
almost  constantly  put  in  requisition ;  and  many  persons  have  been  concerned 
ill  bringing  it  to  perfection.  That  first  proposed  by  M.  Recamier  was  a 
simple  tin  cone.  To  it  M.  Dupuytren  added  a  handle,  which  rendered  it 
much  more  convenient  in  its  application.  The  ancients  possessed  one,  which 
is  engraved  in  the  works  of  Pare,  Joubert,  Manget,  and  Scultetus,  composed 
of  two  valves,  susceptible  of  being  approximated  or  parted  at  pleasure. 
Following  this  principle,  that  of  Mdme  Boivin  is  made  in  tv/o  half  cylinders, 
and  has  at  its  large  end  a  handle  ending  in  two  rings  or  circles  like  a  pair  of 
forceps.  This  is  introduced  closed  into  the  vagina,  and  by  pulling  in  different 
directions  the  two  halves  of  the  handle  it  is  made  to  open  a  pair  of  scissors, 
and  to  enlarge  the  canal  to  be  explored  as  much  as  is  requisite.  M.  Lisfranc 
has  constructed  one  different  from  this^  only  in  having:  its  summit  a  little  fiat- 


k 


694  N£W    ELEMENTS    Ot 

tened,  elongated,  of  greater  thickness,  and  the  handle  destitute  of  rings. 
For  the  purpose  of  keeping  it  open  at  the  suitable  width,  M.  Guillon  has 
added  to  it  a  stem,  a  kind  of  slide,  which  detached  by  the  finger  allows  it  to 
close  instantly.  The  same  practitioner,  to  avoid  pinching  the  tissues,  which 
they  are  very  liable  to  when  the  ordinary  speculum  is  used,  adds  to  his,  when 
introduced,  a  third  piece.  This  plate  is  made  to  slide  from  the  base  to  the 
point  of  the  two  principal  halves  of  the  instrument,  along  a  groove  which  there 
is  on  the  inner  surface  of  the  free  edge  of  each. 

Not  satisfied  with  a  double  branch  speculum,  the  triple  speculum,  of  which 
drawings  also  exist  in  the  ancient  works  of  which  I  have  spoken,  has  been 
revived.  But  as  it  is  especially  necessary  to  dilate  the  upper  part  of  the 
vagina,  MM.  Bertze  and  Colombat  have  endeavored  to  produce  a  specu- 
lum, of  which  the  base,  when  the  instrument  was  closed,  was  to  be  at  the 
handle,  but  at  the  opposite  extremity  when  open.  That  of  Bertze  is  com- 
posed of  two  tubes,  enclosed  one  within  the  other.  The  inner  tube  which  is 
divided  at  its  upper  part  into  several  elastic  branches,  is  so  disposed  that 
these  branches  separate  by  their  own  resiliency  when  they  are  set  loose,  by 
drawing  towards  you  the  tube  which  serves  as  their  sheath.  Eight  pieces 
constitute  that  of  M.  Colombat,  which  together  form  a  hollow  cone  whose 
point  may  be  narrowed  or  opened  at  pleasure  when  introduced  by  means  of 
return  screws  placed  at  the  two  extremities  of  one  of  the  great  diameters  of  the 
base.  The  instrument  when  open  represents  a  sort  of  grating,  which  easily  al- 
lows of  our  seeino;  the  neck  of  the  uterus  and  interior  of  thevao;ina  at  the  same 
time.  Of  all  these  varieties  of  the  speculum,  the  perfected  one  of  Mdme.  Boivin 
appears  to  me  the  best.  The  only  reproach  which  I  can  make  it,  is  the  in- 
convenience of  admitting  the  entrance  of  the  mucous  membrane  between  the 
edges,  and  allowing  it  to  be  pinched  by  them  when  the  instrument  is  closed. 
But  this  objection,  which  the  proposed  modifications  have  as  yet  very  imper- 
fectly remedied,  applies  with  much  greater  force  to  the  three  branch  speculum 
of  M.Hatin,  to  that  of  M.  Colombat,  and  even  that  of  M.  Bertze,  which  may 
moreover  injure  the  organs  with  their  points,  and  do  not  reflect  the  light  with 
equal  distinctness.  With  regard  to  this  latter  consideration,  the  primitive,  or 
cylindrical  speculum,  is  still  the  best,  not  excepting  even  the  cribriform,  or 
perforated  speculum  of  M.  Ricque. 

Many  kinds  of  cutting  instruments  have  also  been  tried.  M.  Dupuytren 
has  often  used  with  advantage  a  sort  of  curette  or  trowel,  slightly  concave ; 
which  cuts  only  at  its  upper  extremity,  which  is  convex,  and  of  a  semilunar 
shape.  By  a  circular  motion  this  instrument  cuts  the  cervix  uteri  at  the  bottom 
of  the  speculum  very  well,  and  might  in  fact  penetrate  within  the  Uterus,  as 
if  to  hollow  out  the  organ  conically,  and  remove  all  the  morbid  tissues. 
M.  Hatin  employs  a  forceps  terminating  in  two  cutting  extremities,  like  the 
spoon-shaped  instrument  of  Fabricius  ab  Aquapendente,  or  the  forceps  of  M. 
Lobstein,  to  the  stem  of  his  principal  instrument. 

Again ;  the  apparatus  of  Colombat  is  so  constructed  that  his  crotched 
forceps  carries  with  it  a  stem;  at  the  end  of  which  is  a  little  blade  placed 
crosswise,  which  by  a  particular  contrivance  may  be  depressed  or  raised,  and 
which  cuts  very  neatly  when  made  to  turn  upon  its  stem  all  around  the  cervix 
above  the  hooks. 

Nothin?-  has  been  invented,  even   to  the   ligature   recommended  by  M. 


OPERATIVE    SURGERY.  695 

Lazzari,  which  has  not  had  its  partizans,  and  which  may  not,  in  fact  be  put 
in  practice.  M.  Mayor  thinks,  and  not  without  a  show  of  reason,  that  by 
carrying  a  silk  riband  up  above  the  disease,  by  means  of  the  instruments  he 
has  for  conductors,  it  would  be  very  easy  afterwards  to  strangulate  it  with 
his  fillet  for  effecting  constriction. 

The  truth  is  that  these  shades  of  difference  reduce  themselves  to  two 
methods ;  one,  that  which  attempts  the  descent  of  the  neck  as  much  as  possible 
before  it  is  cut;  and  the  other,  that  which  prefers  cutting  in  its  natural 
situation.  The  latter,  at  first  sight,  would  seem  the  preferable  one,  insomuch 
as  it  precludes  all  kind  of  pulling  and  laceration.  But  it  is  nevertheless, 
much  the  least  advisable  of  the  two  first,  because  it  does  not  admit  of  an 
equally  exact  appreciation  of  the  state  of  parts,  and  of  getting  equally  near 
to  the  uterus  itself;  and  then,  because  it  is  in  fact,  much  less  easy  of  execu- 
tion. It  deserves  a  preference,  only  in  those  cases  in  which  the  uterus  is  so 
firmly  immovable,  as  that  the  ablest  combination  of  tractive  efforts  cannot 
bring  it  into  the  inferior  strait,  which  must  be  a  very  rare  event,  for  to  cut  off 
the  OS  tincai  with  any  chance  of  success,  the  disease  must  be  complicated  with 
no  other  affection  and  with  no  alteration  in  the  uterus  or  its  appendages.  The 
fillets  of  Osiander  since  the  improvements  made  in  the  crotchet  forceps  can  no 
longer  be  retained  in  use  in  the  first  method.  To  me  the  speculum,  which- 
ever it  may  be,  seems  much  more  embarrassing  than  useful.  Directing  their 
introduction  with  the  fingers  of  the  left  hand,  it  can  never  be  very  difficult 
to  place  the  forceps  around  the  neck,  and  no  one  can  doubt  the  greater  facility 
of  manipulation  in  a  free  vagina.  If  it  becomes  necessary  to  multiply  them 
to  prevent  any  tearing  whatever  of  the  parts,  it  is  certainly  better  to  imitate 
MM.  Dupuytren  and  Lisfranc,  and  place  a  second  pair  of  forceps  above,  or 
in  an  opposite  direction  to  the  former.  I  have  always  found  the  straight 
bistoury,  wrapped  round  with  its  little  bandage  to  a  short  distance  from  its 
point,  more  convenient  than  any  other,  as  it  may  be  carried  so  far  up  into  the 
vagina.  I  have  only  to  add  that  instruments  of  traction  which  unfold  in  the 
Interior  of  the  organs,  are  dangerous  for  the  most  part,  and  should  be  formally 
proscribed.  It  is  difficult  to  do  without  a  speculum,  when  the  cervix  has  to 
be  excised  in  its  natural  situation  ;  and  the  "  speculum  brise,"  owing  to  the 
want  of  space  and  freedom  of  motion,  is  in  this  case  the  only  one  which  can 
answer  tlie  expectation  of  the  surgeon.  Then  also  the  scissors  slightly  curved, 
the  cutting  ring,  the  curette  of  M.  Dupuytren,  or  the  bistoury  concave  on  its 
flat  side  near  the  point,  would  come  into  use. 

The  Method  of  Operating. — The  speculum  being  selected,  one  or  more  for- 
ceps of  Museux,  the  bistoury  which  one  prefers,  the  scissors  or  curette,  some 
lint,  compresses,  and  a  T  bandage  are  all  the  things  that  are  wanted.  The 
position  of  the  patient  is  the  same  as  in  applying  the  caustic.  One  assistant 
holds  her  head  and  arms,  two  others  take  charge  of  the  lower  limbs,  a  fourth 
hands  the  instruments  as  they  are  successively  needed.  The  surgeon  seated 
in  front  of  the  vulva,  begins,  if  he  has  resolved  upon  using  it,  by  introducing 
the  speculum ;  after  he  has  besmeared  it  with  cerate  he  slides  it  gently  in  the 
axis  of  the  pelvis,  pressing  principally  on  the  posterior  commissure  of  the  pu- 
dendum, and  so  passes  it  up  to  the  seat  of  disease ;  then  as  the  cervix  presents 
more  or  less  perfectly  at  its  extremity  it  is  to  be  turned  forwards,  back- 
wards, or  sideways ;  whereas,  if  it  be  the  speculum   ''  brise"  it  is  to  be 


696  NEW  ELEMENTS  OF 

opened  so  as  to  spread  asunder  the  wliole  vagina,  and  expose  the  whole  extent 
of.  disease.  If  we  suppose  that  he  wishes  to  leave  it  in  that  particular  situation 
to  apply  his  forceps,  he  gives  it  in  charge  to  an  assistant,  until  he  has  properly 
disposed  of  them.  He  then  withdraws  it,  and  the  speculun  *'brise/'  here  offers 
a  very  great  advantage  in  allowing  of  the  easy  disengagement  of  the  forceps 
above.  If  he  neglects  to  employ  a  speculum,  two  fingers  of  the  left  hand  are  first 
to  be  carried  up  into  the  vagina;  whereafter  having  examined  the  form  and 
extent  of  the  disease,  they  are  to  remain.  The  closed  forceps  is  then  passed 
up  on  their  palmar  surface,  which  is  opened  when  it  reaches  the  cervix,  and 
applied  as  high  up  as  possible,  so  high  at  least  as  that  the  hooks  may  be  fas- 
tened into  a  healthy  part  of  the  uterus.  With  this  forceps,  which  is  to  be  im- 
planted rather  by  pushing  than  pulling,  he  makes  gentle  traction,  and  endeavors 
to  bring  the  part  down  into  the  vulva.  It  is  better  in  making  these  tractive 
efforts,  to  employ  only  the  right  hand  rather  than  both,  acting  always  in  the 
direction  of  the  pelvis,  and  to  use  the  fingers  of  the  left  hand  to  protect  the 
hooks  of  the  instrument,  which  should  never  be  abandoned.  If  he  perceives 
the  forceps  to  slacken  their  hold,  or  that  the  points  are  about  to  tear  what 
they  embraced,  he  immediately  gives  the  first  pair  to  an  assistant  to  hold, 
and  inserts  a  second  into  the  opposite  diameter  of  the  cervix. 

When  the  parts  appear  outwardly,  he  has  the  two  sides  of  the  vulva  parted 
carefully,  gives  the  instrument  or  instruments  of  traction  to  some  one,  calls 
for  his  bistoury,  carries  it  in  the  first  place  to  the  right  side,  and  always  above 
the  disease,  brings  it  forward ;  then  over  to  the  left  side  :  or  he  might  perform 
the  section  of  parts  from  behind  forward,  and  from  left  to  right.  If  the 
affection  seems  not  entirely  circumscribed  he  should  proceed  to  detach  the 
adhesions  of  the  vagina  one  by  one,  so  as  to  remove  not  only  the  os  tineas,  the 
upper  part  of  the  neck,  but  also  to  hollow  out  conically  the  inferior  part  of  the 
uterus  itself  if  it  appears  to  him  to  be  necessary.  As  soon  as  the  section  is 
finished  the  fundus  uteri  rises  and  resumes  its  natural  situation.  If  some 
portions  of  diseased  tissue  or  cancerous  tubercles  have  escaped  the  knife,  we 
must  reintroduce  the  speculum,  seize  them  with  forceps,  and  without  hesita- 
tion cut  them  away  or  destroy  them  by  caustic.  When,  as  happens  in  an 
immense  majority  of  cases,  there  follows  no  bleeding,  no  dressings  are  required. 
Injections  of  tepid  water,  or  of  cold  water  as  is  advised  by  some,  for  a  few 
days  is  all  that  is  done.  I  can  see  however  no  objection  to  slipping  up  to  the 
bleeding  surface  a  shift-shaped  piece  of  fine  linen,  to  be  softly  stuffed  with 
balls  of  lint,  if  blood  should  flow  too  abundantly,  and  the  state  of  the  patient 
such  as  to  make  us  lose  nothing.  This  shift  would  render  plugging  very  easy, 
and  would  expose  to  no  danger  which  was  not  easily  remediable  at  the 
moment. 

Thus  far  I  have  performed  twice  only  excision  of  the  cervix  uteri;  in 
neither  case  did  I  require  any  thing  besides  Museux's  forceps  and  a  straight 
bistoury.  In  the  first  female  I  removed  the  whole  neck.  The  operation  was 
quickly  over,  easy,  and  gave  but  little  pain.  Some  blood  flowed,  which  simple 
means  soon  arrested ;  yet  she  died  nevertheless  on  the  third  day  afterwards. 
On  opening  the  body,  neither  peritonitis  nor  any  other  appreciable  lesion  was 
discernible.  The  remainder  of  the  uterus  was  healthy,  iDut  a  small  cerebri- 
form  mass  existed  on  the  right  side  behind  the  vagina.     An  aperture  of  two 


OPERATIVE    SURGERY.  697 

lines  in  width  occupied  this  side  of  the  vulvo-uterine  canal,  and  communi- 
cated with  tlie  genito-rectal  excavation.  We  could  not  determine  whedier  it 
was  effected  during  the  operation,  or  in  the  autopsic  dissection.  It  was  quite 
certain,  however,  that  no  fluid  had  been  effused  from  it. 

In  mj  second  case,  having  experienced  some  difficulty  in  bringing  down 
the  cancer  to  the  orifice  below,  I  carried  up  the  straight  covered  bistoury 
without  any  great  trouble,  to  a  depth  of  two  inches  into  the  vagina  and  above 
the  limits  of  the  disease,  and  directing  its  progress  on  the  palmar  surface  of 
tlie  fingers  of  my  left  hand,  thus  completed  the  operation.  This  patient  who 
at  first  appeared  to  be  doing  well,  died  at  the  end  of  six  weeks.  She  had 
several  cerebriform  tumors  existing  on  the  right  lumbar  region  and  deep  in  the 
right  broad  ligament  of  the  uterus.  A  patient  on  whom  M.  Blandin  operated 
died  of  uterine  phlebitis.  One  of  those  whom  M.  Lisfranc  lost,  perished 
from  peritonitis ;  others  are  carried  off  by  a  state  of  nervous  depression,  of  the 
severity  of  which  it  is  impossible  to  assign  any  explanation.  Thus  far,  no  one 
has  fallen  a  victim  solely  to  the  loss  of  blood.  MM.  Rust  and  Grsefe  of  Ber- 
lin, MM.  Roux  and  Dupuytren,  who  have  seen  several  die  owing  to  the  imme- 
diate sequelae  of  this  operation,  have  never  attributed  the  fatal  issue  to  this 
occurrence.  Exsection  of  the  cervix  of  the  uterus,  then,  though  easy  and 
often  unimportant,  is  nevertheless  sometimes  extremely  dangerous  and 
speedily  fatal.  Nay,  from  the  view  taken  of  it  in  the  beginning  of  this 
article,  it  should  seem  that  success  could  follow  it  but  seldom.  ButOsiander 
for  all  this  perforiped  it  eight  and  twenty  times ;  M.  Dupuytren  fifteen  or 
twenty  times ;  and  Lisfranc  forty  or  fifty  times,  with  not  more  than  one  case 
fatal  in  six  or  seven.  Women  on  whom  it  had  been  performed  have 
repeatedly  become  pregnant,  and  have  been  delivered  without  accident.  M, 
Dupuytren  even  relates  a  case  in  which  he  repeated  the  operation  for  a  return, 
of  the  disease,  which  recovered  also  the  second  time.  Lastly^  it  is  said,  that 
cures  thus  effected  are  in  most  cases  radical  ones. 

I  shall  not  enter  on  a  consideration  of  the  question,  whether  since  it  has 
been  practised,  excision  of  the  cervix  uteri  has  not  been  performed  very  often 
when  no  cancer  existed  in  it,  as  some  persons  have  asserted  ;  but  shall  con- 
fine my  remarks  to  stating  that  M.  Dupuytren,  who,  as  it  were  naturalized 
the  operation  in  France,  now  seldom  resorts  to  it;  that  M.  Lisfranc,  in 
whose  hands  it  has  been  so  successful,  does  it  much  more  seldom  than  for- 
merly ;  and  that,  according  to  M.  Heisse,  Osiander  himself  had  ceased  to 
perform  it  at  all  for  sometime  before  his  death. 

The  two  instances  recorded  by  M.  Stoltz  of  Strasbourg  are  certainly  not 
more  calculated  to  exalt  our  idea  of  its  utility. 

Art,  10. — Extirpation  of  the  Uterus, 

Historical. — Removal  of  the  uterus  has  so  long  been  looked  upon  as  an  im- 
possibility, that  it  has  been  doubted,  even  in  our  times,  whether  it  had  ever 
really  been  done.  A  difierent  opinion  has  prevailed  among  some  authors, 
however,  in  almost  every  age.  Soranus,  to  prove  the  unimportance  of  this 
organ  to  the  woman,  states  that  it  may  be  removed  without  fatal  conse- 
quences ;  '*  as,"  he  adds,  '^  is  testified  to  in  the  works  of  Themison ;"  and  he 
even  goes  so  far  as  to  enforce  the  operation  as  a  precept ;  for  he  advises  that 
88 


698  NEW  ELEMENTS   OF 

when  it  putrijies  it  is  immediately  to  be  extiq)ated,  without  any  reserve,  and 
positively  asserted  that  its  entire  removal  has  sometimes  been  done  with  suc- 
cess. In  Bauhin's  additions  to  the  work  of  Rous?et  may  be  found  nineteen 
cases  which  evince  the  boldness  of  the  physician  of  Ephesus ;  while  Schenck 
of  GrafFemberg  relates  a  still  greater  number." 

All  these  accounts,  however,  as  there  are  amongst  them  so  many  which  are 
wanting  in  authentic  proof  or  sufficiency  of  detail,  have  been  rejected  as  in- 
conclusive ;  and  with  greater  propriety  as  many  were  performed  by  midwives, 
many  by  quacks,  and  again  many  by  very  ignorant  surgeons;  and  that 
besides,  it  is  so  easy  to  be  deceived  by  inversions  of  the  vagina,  polypous  or 
sarcomatous  tumors,  that  unless  the  facts  had  been  established  by  autopsic 
examination,  the  mind  must  continue  to  entertain  doubts  as  to  their  truth. 
Rousset  in  his  book  gives  moreover  so  many  evidences  of  a  want  of  fidelity, 
and  Bauhin  and  Schenck  seem  to  have  been  so  credulous,  that  one  is  naturally 
led  to  doubt  their  testimony.  Who  can  believe  that  extirpation  of  the  uterus 
was  performed  on  the  woman  spoken  of  by  Plempius,  who  notwithstanding 
afterwards  became  pregnant  ?  In  the  other,  who  according  to  Plater  retained 
her  sense  of  venereal  enjoyment,  and  continued  to  menstruate  ?  In  the  third 
quoted  by  Schenck,  from  Carpus,  in  that  mentioned  by  Morgagni,  from  Wei- 
deman,  all  of  whom  presented  the  same  phenomena  ?  Is  the  testimony  of 
Vieussens  a  much  more  credible  authority,  at  all  events  more  conclusive,  who  in 
giving  an  account  of  an  examination  of  a  female  in  whom  the  matrix  had  been 
removed  fifteen  years  before,  admits  that  a  portion  of  the  organ  was  left  at 
the  fundus  of  the  pelvis.'^  And  the  case  of  Pierrette  Boucher,  who  had  been 
operated  on  three  years  previous,  and  whom  Rousset  caused  to  be  disenterred 
three  days  after  her  death,  and  opened  before  a  physician  and' a  midwife  not 
named,  may  not  this  be  an  account  of  pure  invention  got  up  for  the  occasion  r 
Yet  it  cannot  be  disputed  now-a-days,  that  removal  of  the  uterus  has 
several  times  been  performed,  and  that  in  some  cases  the  patients  have  sur- 
vived it. 

Not  to  speak  of  those  cases  cited  by  Moschion,  Avensoar,  Rhazes,  Mercu- 
rialis,  Woega,  Fernel,  and  others,  we  meet  with  one  in  the  works  of  Pare 
which  cannot  be  considered  as  doubtful.  The  operation  took  place  on  the 
King's  day,  1575,  and  the  patient  lived  three  months  afterwards,  and  died  of 
some  other  affection.  On  the  examination  of  the  body,  Pare  demonstrated  the 
absence  of  uterus,  and  he  remarks  as  a  circumstance  deserving  of  notice,  that 
nature  had  confined  herself  to  building  (batir)  a  mere  hardness  at  the  fundus 
of  the  pelvis,  in  room  of  the  extirpated  organ.  Under  this  view  of  the  sub- 
ject, the  principal  facts  known  as  to  the  early  history  of  this  proceeding, 
may  be  arranged  under  two  principal  categories.  In  the  first,  prolapsus  of 
greater  or  less  standing  of  the  organ  existed ;  the  second  relates  to  it  in  a  state 
of  inversion.  Among  the  former,  we  place  the  account  given  by  H.  Saxonia, 
of  a  Venitian  servant  woman,  who  tore  away  the  prolapsed  utems  with  her 
own  hands ;  the  cases  by  Paul  of  Leipzig ;  by  Cohausen,  Tencel,  Goulard, 
and  also  tliose  which  have  since  been  made  known  by  Laumonier,  in  1784, 
Clark,  Vanheer,  A  Hunter,  in  1797;  by  M.  A.  Petit,  Hosack,  Galot  de  Proj 
vius,  in  1809. 

Should  all  these  relations  not  be  adopted  as  facts,  and  it  appears  evidei 
that  Liaumonier,  and  Bardol  amongst  others,  removed  merely  a  polypus,  and  n< 


OPERATIVE  SURGERY.  699 

the  entire  uterus,  the  same  thing  cannot  possibly  be  said,  as  to  M.  Galot,  who 
conveyed  the  specimen  to  the  Society  of  the  Faculty  of  Medicine  at  Paris ; 
nor  as  to  M.  Marschall  of  Strasbourg,  to  whom  an  opportunity  was  afforded 
ten  years  afterwards,  on  the  death  of  the  woman,  to  prove  by  the  dead  body 
the  removal  of  the  gestative  organ. 

In  18£2  this  operation  was  successfully  performed  by  M.  Langenbeck. 
The  cases  published  by  M.  Fodere  in  1825;  those  of  MM.  Recamier  and 
Marjolin,  contained  in  the  Revue  Medicale  of  1826,  as  well  as  that  just  an- 
nounced by  M.  Delpech,  admit  no  longer  of  any  hesitation  on  the  subject; 
and  it  is  clearly  proved  that  the  prolapsed  uterus  has  frequently  been  re- 
moved from  the  living  subject  unattended  by  a  fatal  issue. 

Under  the  second  series  of  the  categories,  which  like  the  first  contains  its 
doubtful  facts,  and  others  more  or  less  certainly  true,  may  be  included  the 
case  related  by  Ulm,  who  states  that  a  midwife  in  pulling  at  the  cord, 
having  inverted  the  uterus  excised  it  at  one  stroke  of  a  razor;  the  other  by 
Bernard,  nearly  alike,  except  that  the  woman  recovered ;  a  third  of  the  sam.e 
kind  related  by  Wrisberg;  that  by  Viardel ;  a  fifth  which  occurred  in  Lower 
Poiton  and  published  by  Caille ;  that  recorded  by  Anselin,  of  Amicus,  ia 
which  he  himself  removed  the  inverted  organ.  To  it  likewise  belong  the 
cases  of  R.  Baxter,  Mullaer,  Jean  Muller,  and  of  Sorbait;  those  related  by 
Figuet  of  Lyons,  by  Faivre  of  Vesoul ;  as  well  as  that  in  which  it  is  said 
that  Desault  excised  a  portion  of  an  inverted  uterus  in  the  removal  of  a 
polypus.  Without  including  in  the  account  the  cases  of  Gattinaria,  of 
Berenger  de  Carpi,  and  Fonteyn,  mentioned  by  M.  Dezeimeris,  there  must 
still  be  added  to  this  list  those  by  Messrs.  Charles  Johnson,  in  1822,  Newn- 
ham  and  Windsor,  (1809,)  Rheineck,  Davis,  Chevalier,  Weber,  Dj-.  Gooch, 
Cordeiro,  &c.  It  is  owing  to  the  distinction  not  having  always  been  made 
between  removal  of  a  uterus  previously  prolapsed  out  of  the  pelvis  and  that 
of  one  in  which  no  displacement  from  its  natural  seat  had  occurred,  that  all 
the  doubts  and  vagueness  about  this  latter  operation  have  existed,  even  to  the 
period  in  which  we  live.  Without  such  a  distinction,  it  is  in  fact  impossible 
to  understand  the  subject;  for  the  two  circumstances  are  far  from  identical. 

1st,  Of  the  Displaced  Uferus.'—When  every  attempt  at  reduction  has  been 
made  in  vain,  and  the  disease  threatens  to  destroy  life,  the  operation  before 
us  becomes  indicated;  but  it  is  at  the  same  time  to  be  remembered  that  pro- 
lapse merely  of  the  uterus  is  rarely  fatal;  that  it  may  be  a  mere  infirmity; 
that  it  often  allows  of  pregnancy  within  it,  as  is  proved  by  the  case  reported 
by  Marigues  of  Versailles,  and  that  of  M.  Chevruel;  that  usually  the  general 
health  is  but  little  impaired ;  and  that  in  order  for  a  surgeon  to  decide  on  this 
step,  some  degeneration  or  morbid  condition  in  itself  dangerous  must  be 
superadded  to  the  descent  of  the  organ.  It  is  usually  so  easy  to  reduce 
its  inversion  after  delivery  of  the  foetus,  that  it  is  only  an  exception  to  the 
rule  that  it  can  require  the  performance  of  so  dangerous  an  operation. 

If  however  the  woman  should  have  been  ill  treated ;  if  brutal  and  ignorant 
manipulation  have  induced  gangrene,  or  disorganization  of  the  uterus,  to  a 
degree  which  precludes  all  hope  of  its  reduction  or  preservation,  exsection 
presents  a  resource  of  which  we  should  do  wrong  not  to  avail  ourselves.  It 
ought  to  be  a  rule  never  to  separate  from  the  body  a  uterus  which  has 
descended  out  of  the  pelvis,  without  some  very  clear  and  urgent  necessity. 


700  NEW   ELEMENTS   OF 

Admitting,  as  proved,  the  occasional  successful  result  of  its  removal,  it  is  but 
just  to  confess  the  dangers  which  attend  it;  and  not  to  forget  that  the  woman 
spoken  of  by  Blasius,  Farbricius,  Hildanus,  and  Ulmus,  operated  by  their 
midwives,  all  died;  that  the  patient  of  MM.  Recamier  and  Marjolin 
survived  only  two  months  ;  that  an  unhappy  woman  received  at  La  Charite, 
in  July  1824,  whose  uterus  had  been  tied  eight  days  before  by  mistake,  died 
also  in  a  few  weeks  after;  and  lastly,  that  if  the  facts  related  by  MM.  De 
la  Barre  and  Baudelocque,  in  which  a  spontaneous  disappearance  of  an 
inversio  uteri  occurred  at  the  end  of  several  weeks  in  one  woman,  and  after 
lasting  seven  years  in  the  other  person,  be  correct,  amputation  of  it  in  such 
cases  can  be  seldom  indispensable. 

Method  of  Operation. — Those  who  have  performed  this  operation  of  abla- 
tion of  the  uterus  through  ignorance  or  rashness,  have  done  it  in  a  manner 
that  deserves  no  discussion.  No  one  now  would  think  of  tearing  \i  away, 
or  excising  it  with  a  razor  or  kitchen  knife,  without  any  previous  precaution ; 
or  of  hot  coals  or  other  caustics  which  have  been  employed  by  some  women 
on  themselves,  by  quacks,  matrons,  and  the  older  authors.  The  rational 
methods,  from  which  we  may  be  permitted  to  select,  are  strangulation,  with 
or  without  immediate  amputation;  pure  or  simple  excision ;  and  extirpation, 
with  a  dissection  of  the  peritoneum. 

Ligature  is  extremely  easy,  for  beneath  our  eyes  we  have  the  pedicle 
around  which  it  is  to  be  placed.  But  then  the  pedicle  is  rather  large,  and  the 
pain  caused  by  its  constriction  has  at  times  been  so  excessive  as  to  threaten 
the  life  of  the  patient ;  so  much  so,  that  in  M.  Marschall's  case,  among  others, 
it  was  necessary  to  cut  the  thread  very  soon;  and  resolve  upon  excision  at 
once,  which  was  entirely  successful. 

By  using  a  ligature,  moreover,  we  run  the  risk  of  including  the  urethra,  as 
was  seen  by  Ruysch,  or  a  kunckle  of  intestine,  as  did  a  quack  mentioned  by 
Klein,  or  the  bladder,  &c.  Mr.  Windsor,  with  a  view  of  performing  a  more 
speedy  section  and  of  giving  less  acute  pain,  pierced  the  root  of  the  tumor,  as 
Faivre  had  done  before  him,  with  a  double  riband,  so  as  separately  to  encircle 
both  halves.  The  observation  of  Clark,  Neunham,  and  Recamier,  proves  that 
an  ordinary  ligature  is  not  always  dangerous. 

By  excision  the  patient  is  more  quickly  relieved.     As  the  ligature  can  be 
of  no  use  but  to  prevent  hemorrhage,  one  does  not  see  the  advantage  there 
would  be  in  trusting  to  it  alone  the  destruction  of  the  uterus.     If  strangulation 
then  be  adopted,  either  simple  or  by  dividing  the  root  of  the  body  to  be  cut 
away  into  several  portions,  to  me  it  seems  advisable  to  cut  away  immedi- 
ately afterwards  the  parts  which  are  beneath  it.     This  was  done   by  Baxter, 
Bernard,  and   a  host  of  others.     To  avoid  wounding  an  intestine,  or  the 
apparatus  for  the  excretion  of  urine,  it  is  sufficient  to  impress  a  few  gentle  ^ 
shakes  on  the  pelvis,  by  having  it  raised  on  the  bed  above  the  other  parts  of  S 
the  body.     Besides  this,  the  pain  which  ensues  from  pinching  an  intestine,^' 
the  only  accident  which  can  happen  of  this  kind,  and  which  cannot  be  always 
avoided,  will   quickly  indicate  its  occurrence,  and  can  be  easily  remedied 
without  delay;  while  the  bladder  and  urethra  would  always  be  out  of  the  way, 
of  danger,  unless  the  riband  were  carried  very  high  up  indeed,  which  wasj 
done  by  a  quack  whom  Ruysch  mentions.     The  multiple  ligature,  which  has 
undoubtedly  the  same  advantage  here  as  in  epiploic  hernia,  gives  less  pain, 


OPERATIVE    SURGERY.  701 

because  it  causes  less  traction  and  folding  in  on  the  root  of  the  organ,  cuts 
the  parts  more  quickly,  and  is  less  disposed  to  slip  or  slacken,  when  excision 
is  conjoined  to  its  application,  than  a  common  ligature  is. 

It  appears  to  me  that  excision  of  a  prolapsed  uterus  of  long  standing  ought 
not  less  generally  to  be  preferred  to  ligature.  The  only  risk  attending  it  is 
of  hemorrhage.  Now  the  vessels  which  the  peduncle  of  the  tumor  contains 
are  not  large  enough  to  make  this  dread  a  very  serious  one.  Moreover 
what  is  to  prevent  us  from  using  the  ligature  to  it,  if  it  should  appear  ne- 
cessary, or  else  employ  topical  astringents,  tampons,  or  the  potential  cautery. 
Excision,  as  it  is  more  prompt  and  less  painful,  offers  a  great  advantage  over 
strangulation,  and  ought  to  ensure  a  greater  ratio  of  successful  results.  It 
was  that  which  was  practised  on  the  patients  of  whom  Pare,  Bernhard,  &c., 
relate  the  cases.  I  do  not  see  the  benefit  of  imitating  M.  Langenbeck's 
proceeding.  The  female  on  whom  he  operated,  had  an  incomplete  prolapsus 
with  scirrhous  degeneration,  like  those  of  MM.  Ruysch,  Hosack,  Wolf, 
Fodere,  and  Recamier.  This  surgeon  thought  it  necessary  to  dissect  oft' 
cautiously  from  the  exterior  to  the  interior  the  whole  of  the  uterine  reflexion 
of  the  peritoneum,  so  that  after  removal  of  the  organ  this  membrane  was 
found  to  be  uninjured.  It  is  true  that  his  patient  got  perfectly  well,  and  is 
living  to  this  day.  The  passage  of  air  into  the  abdomen  through  the  vagina* 
which  is  thought  possible  even  after  recovery  by  Rousset,  who  has  cited  a 
case,  and  by  Siebold,  who  attributes  to  it  the  death  of  one  of  his  patients,  is 
thus  surely  prevented.  Let  it  be  observed,  that  all  this  latter  apprehension 
is  mere  assertion,  easy  to  refute :  and  that  if  M.  Langenbeck's  plan  is  to  be 
followed  it  will  become  one  of  the  longest  and  most  difficult  operations  in 
surgery. 

Qd.  The  Uterus  not  Displaced. — A  question  which  naturally  follows  the 
preceding  observMlons,  is  that  which  relates  to  removal  of  the  entire  uterus 
from  its  natural  situation.  If  Lazzari  is  to  be  credited,  this  operation  has 
been  thrice  performed  near  the  beginning  of  this  century  by  Monteggia. 
Siebold  asserts  that  it  was  once  done  by  the  elder  Osiander,  and  with  success. 
It  is  at  least  certain,  apparently,  that  it  was  really  practised,  April  ISth, 
1812,  by  M.  Paletta — but  on  his  part  undesignedly.  He  meant  to  remove 
nothing  but  the  cervix  which  had  become  cancerous,  and  only  discovered 
that  the  entire  uterus  had  been  exsected,  upon  examining  it  after  the  opera- 
tion. To  Doctor  Sauter,  of  Constance,  then  the  merit  is  due  of  having  first 
conceived  "the  project  of  this  operation;  and  of  having  executed  it  after  a 
rational  method  and  upon  fixed  principles.  It  may  now  be  asked,  whether  if 
exsection  of  the  uterus  be  really  practicable,  it  is  useful;  and  in  what 
manner  it  may  become  dangerous.  A  few  words  on  each  of  the  cases  we  are 
acquainted  with  will  enable  the  reader  to  decide  these  points  for  himself. 

M.  Sauter's  patient  died  four  months  after  the  operation,  which  was  on  the 
22d  January,  1822;  and,  says  the  author,  of  a  paralysis  of  the  lung;  the 
bladder  had  been  injured.  On  the  5th  of  February,  1824,  M.  Hoelscher 
followed  the  surgeon  at  Constance.  In  twenty-four  hours  the  patient  died  ; 
and  the  body  showed  symptoms  of  peritonitis.  The  woman  on  whom  Siebold 
operated,  April  19th,  1824,  lived  sixty-five  hours  only,  and  she  died  of  peri- 
tonitis. In  the  patient  on  whom  M.  Langenbeck  operated  January  1 1  th,  1825, 
and  who  died  in  thirty-six  hours,  traces  of  peritonitis  were  also  visible.     Sie- 


702  NEW  ELEMENTS   OF 

bold  performed  the  same  operation  on  a  second  woman,  on  the  25th  July, 
1825.  She  was  dead  on  the  following  day,  and  with  the  same  phlogosis  as  the 
others,  besides  evincing,  when  opened,  many  organic  lesions  which  ought  to 
have  been  known  beforehand.  On  the  5th  August  of  the  same  year,  M. 
Langenbeck  had  recourse  for  the  second  time  to  extirpation  of  the  matrix, 
and  the  woman  who  died  in  fifty  hours  after,  offered,  as  did  the  others, 
incQntestible  evidence  of  peritoneal  inflammation.  Of  four  patients  on  whom 
Br.  Blundell  operated,  three  died — one  after  thirty-nine  hours,  another  in 
nine  hours,  and  the  third  very  quickly ;  but  the  precise  lesions  which  were  found 
on  examination  of  the  bodies  are  not  known.  The  first  of  the  four  who  had 
been  supposed  cured,  died,  at  Guy's  Hospital  a  year  afterwards  of  a  return  of 
the  cancer,  Mr.  Banner's  patient,  on  whom  he  operated  on  the  2d  Septem- 
ber, 1828,  died  on  the  fourth  day  of  peritonitis.  Mr.  Lizars  of  Edinburgh, 
wishing  to  follow  in  the  steps  of  his  two  fellow-countrymen,  performed  the 
same  operation  on  the  2d  of  October,  and  the  patient  died  within  the  twenty- 
fi)ur  hours.  M.  Langenbeck,  a  third  time  repeated  it  in  1829;  the  patient 
survived  only  a  fortnight.  On  the  26th  July,  1829,  M.  Recamier,  first  per- 
formed it  in  France.  He  appeared  to  have  better  success  than  any  preceding 
surgeon,  yet  like  Dr.  Blundell  he  had  the  misfortune  to  lose  his  patient  at 
the  end  of  a  year's  time ;  unfortunately  no  autopsia  could  be  made.  I  have 
only  learned  that  she  sunk  under  chronic  diarrhoea  and  a  long  continuance  of 
febrile  irritation. 

In  September,  1829,  M.  Roux  performed  the  operation  in  his  presence ; 
the  patient  in  his  case  dying  on  the  evening  of  the  next  day.  The  professor 
a  few  days  afterwards  again  practised  excision  of  the  uterus,  but  under  very 
unfavorable  circumstances.  The  operation  was  long  and  painful ;  abundant 
hemorrhage  ensued,  and  death  resulted  at  the  expiration  of  twenty-five  hours. 

M.  Recamier  did  it  again  on  the  ISth  January,  1830.  Here  also  consid- 
erable bleeding  occurred,  and  the  woman  lived  only  thirty- three  hours.  M. 
Dubled,  operated  on  a  case  on  the  20th  June,  1830,  which  survived  only  twenty- 
two  hours,  and  died  of  symptoms  of  debility,  of  which  the  examination  of 
the  corpse  furnished  no  explanation.  M.  Delpech,  who  in  his  turn  thought 
fit  to  attempt  its  performance,  was  not  more  successful  than  others;  his 
patient  died  on  the  3d  day,  but  not  he  assures  us  of  peritonitis.  The  En- 
glish Journals,  give  a  last  case,  that  of  Mr.  Evans,  and  which  seems  to  have 
been  successful ;  but  I  have  not  accurate  details  enough  about  it  to  speak  of 
it  more  fully. 

We  see  by  this  enumeration,  rejecting  the  doubtful  cases  of  Monteggia 
and  Osiander,  and  including  that  of  M.  Paletta,  whose  patient  perished  on 
the  3d  day  of  highly  acute  peritonitis,  twenty-one  performances  of  the  abla- 
tion of  the  uterus,  perfectly  authentic  and  incontestible,  all  done  within 
twenty  years,  and  not  one  permanent  cure  eft'ected  out  of  the  whole  number ! 
Is  there  a  more  appalling  statement  to  be  met  with  in  the  records  of  surgery  ? 
And  is  not  this  melancholy  result  sufficient  to  banish  this  operation  from 
practice  for  ever  ? 

For  all  this,  the  disease  which  it  is  performed  to  remove  is  so  common,  so 
invariably  fatal,  and  leads  to  the  grave  through  so  much  pain  and  anguish, 
that  this  last  hope  will  not  be  abandoned  without  regret  which  seems  occa- 
fiionaUy  to  have  been  opposed  to  it  with  some  success;  some  persons  will 


OPERATIVE    SURGERY,  703 

again  probably  venture  upon  its  repetition,  and  the  preceding  facts  will  not 
appear  to  all  such  as  to  warrant  its  final  and  complete  proscription.  Amid 
the  dangei-s  to  which  it  exposes  the  patient,  that  of  peritoneal  inflammation  is 
of  chief  importance.  But  yet  in  every  case  this  result  has  not  followed. 
The  patients  of  MM.  Sauter  and  Recamier  and  of  Dr.  Blundell,  who 
survived  its  performance,  were  not  affected  by  it,  nor  did  the  bodies  of  all 
who  died  evince  its  uniform  presence.  To  this  it  can  be  replied,  that  with 
regard  to  those  who  died  the  most  speedily,  say  in  less  than  twenty-four  hours, 
peritonitis  could  not  have  yet  developed  itself,  although  even  it  were  a  neces- 
sary consequence  of  the  operation.  On  the  other  hand,  if  it  be  considered, 
that  traumatic  peritonitis  may  often  be  averted,  and  that  medical  art  is  not 
without  the  means  of  subduing  it  when  it  is  developed,  it  does  not  follow  that 
on  this  account  ablation  of  the  uterus  must  be  driven  from  practice. 

Hemorrhage  is  another  occurrence  of  great  moment,  and  often  serious ; 
many  have  been  attacked  with  it,  as  may  be  seen  in  the  cases  operated  on  by 
M.  Roux  and  Recamier,  and  as  has  happened  also  in  Germany  and  in  Eng- 
land. Still  in  the  majority  it  did  not  occur,  and  we  may  be  permitted  to 
express  the  hope  that  the  perfection  which  operative  medicine  is  attaining 
will  some  day  or  other  enable  us  to  avoid  it  with  consideiable  certainty. 
Some  it  is  said  have  sunk  beneath  the  exhaustion  of  suffering  and  distress. 
Be  it  so  ;  to  this  at  least,  in  part,  a  remedy  will,  we  may  hope,  hereafter  be 
provided  from  the  nature  and  position  of  parts  to  be  removed.  It  is  yet  a 
question  to  be  solved,  why  women  who  have  survived  the  first  and  violent 
tempest  and  the  immediate  consequences  of  the  operation,  have  continued  to 
languish,  and  have  died  at  last  ?  For  this  event,  neither  peritonitis,  hemor- 
rhage, nor  suffering  can  be  held  responsible.  To  those  who  think  that  the  death 
of  these  females  was  owing  to  the  privation  of  uterus  simply,  the  case  men- 
tioned by  Vieussens,  which  survived  fifteen  years,  that  of  M.  Marschall, 
whose  patient  died  at  the  expiration  of  ten  years,  and  that  of  M.  Langenbeck 
who  is  yet  living,  from  all  of  whom  the  prolapsed  uterus  had  been  removed, 
will  be  a  sufficient  answer 

Whatever  it  may  be,  we  see  what  chance  is  offered  of  recovery  from  extir- 
pating a  cancerous  uterus  when  performed  under  those  circumstances  in 
which  only  it  is  admissible  to  attempt  it.  If  we  seek  to  reduce  these  con- 
ditions to  great  preciseness  we  shall  find  it  no  easy  matter,  and  shall  discover 
how  very  rare  their  combination  in  one  person  must  be.  So  long  as  cancer 
has  not  attacked  the  whole  organ,  pure  and  simple  excision,  which  admits  of 
our  ascending  very  high  up,  ought  to  suffice,  and  should  alone  be  essayed.  It 
was  by  means  of  excision,  that  Bellini  extirpated  the  lower  half  of  the  uterus, 
in  1828,  with  complete  success.  It  was  excision  also  which  M.  Dubled  pro- 
posed as  a  substitute  for  ablation  or  extirpation  in  his  work  which  was  pre- 
sented to  the  Academy.  But  when,  on  the  contrary,  the  disease  possesses  the 
whole  uterus,  how  can  we  be  certain  that  it  has  attacked  no  other  organ  also. 
It  is  very  true  that  by  introducing  the  finger  alternately  into  the  vagina  and  into 
the  rectum,  whilst  the  other  hand  is  applied  to  the  hypogastric  region,  we  may 
often  acquire  motives  for  suspecting  the  existence,  or  of  believing  on  the  non-ex- 
istence of  material  alteration  in  the  pelvis,  in  the  region  of  the  ovaries  and  their 
tubes ;  in  a  word,  of  the  uterus  and  its  appendages  ;  but  the  most  experienced 
pracl^tioner  even  then  can  learn  but  greater  or  less  probabilities,  and  never 


r04  NEW  ELEMENTS  OF 

attain  to  any 'certainty  of  opinion.  Shall  we  then  with  all  this  uncertainty  de-r 
cid^  upon  the  performance  of  this  fearful  operation  ?  To  render  those  proceed- 
ings with  which  we  are  acquainted  proposable,  even  when  the  uterus  alone  is 
supposed  to  be  affected,  the  organ  must  at  least  preserve  its  natural  mobility, 
and  be  free  from  unnatural  adhesions.  Now  whilst  it  is  found  under  these  cir- 
cumstances, it  is  not  in  all  probability  throughout  diseased  ;  and  if  so  theadea 
of  its  excision  ought  to  present  itself  to  the  mind.  How,  lastly,  are  we  to 
decide  in  an  early  stage  of  disorganization,  by  merely  feeling  with  our  fin- 
gers through  the  parietes  of  the  abdomen,  rectum,  and  vagina,  that  the  body 
of  the  uterus  is  really  cancerous,  or  that  it  is  a  little  smaller,  or  a  little  larger 
than  usual  in  a  normal  state  ?  Two  principal  methods,  the  one  called  hypo- 
gastric, the  other  sub-pubic,  have  been  projected  for  extirpating  the  uterus. 
If  Musitanus  is  to  be  credited,  extirpation  of  the  matrix  through  the  hypogas- 
trium  is  far  from  being  as  novel  as  is  generally  believed.  In  fact,  this  author 
says,  according  to  Wier,  that  a  girl  of  exceedingly  salacious  disposition  was  thus 
n-jperated  on  by  her  father,  who  made  an  incision  into  the  lower  part  of  the 
abdomen,  and  through  this  sought  for  the  uterus  and  removed  it  on  the  spot. 
It  is  however  probable,  that  the  peasant  of  whom  Musitanus  speaks  did  no 
more  than  remove  the  ovaria,  which  is  done  to  the  females  of  domestic 
animals,  but  without  touching  the  womb  itself.  The  same  remark  applies  to 
passages  in  J^^tius,  Schurigius,  add  others  ;  wherein  it  is  stated  that  surgeons 
liave  ventured  to  open  the  abdomen  of  certain  women  and  to  take  out  the 
gestative  organ.  Be  this  as  it  may,  the  hypogastric  method  was  described  and 
proposed,  in  1814,  by  M.  Gutberlat,  who  upon  the  subject  enters  into  the  most 
circumstantial  details.  He  makes  use  of  a  sort  of  ring  fixed  upon  a  long 
hanflle,  which  is  carried  into  the  vagina,  and  by  embracing  the  os  tincae,  serves 
U)  fix  tlie  organ  in  the  abdomen.  He  then  makes  an  incision  of  sufficient 
length,  in  the  extent  of  the  linea  alba,  above  the  bladder,  which  allows  of  the 
introduction  of  his  left  hand  into  the  abdomen,  and  then  with  scissors  carried 
in  by  the  right  hand  he  is  enabled  to  detach  the  broad  ligaments  and  upper 
extremity  of  the  vagina,  and  extract  the  uterus  entire.  It  does  not  appear 
that  the  author  ever  practised  his  method  upon  the  living  subject.  Judging 
from  what  occurs  in  the  dead  body,  the  ring,  &c.  of  which  he  speaks  can 
answer  only  when  there  is  no  enlargement  of  the  neck  ;  and  it  would  be 
moreover  a  very  hazardous  means  of  protection  to  the  bladder,  and  not  to  be 
relied  on.  The  separation  of  the  uterus  is  really  very  easy  in  this  way.  I 
aelieve  that  M.  Langenbeck  was  the  first  person  who  ventured  to  perform  it 
during  life.  But  with  as  light  variation  from  Dr.  Gutberlat'S  method,  he 
advises,  that  before  meddling  with  the  uterus  we  assure  ourselves  by  the 
finger  and  eye  of  the  condition  of  the  tubes  and  ovaries,  that  they  may  equally 
be  removed  if  they  participate  in  the  disease.  And  he  likewise  thought  it 
better  to  open  the  peritoneum  from  the  vagina,  as  a  greater  security  against 
Injuring  the  bladder.  Many  of  the  modifications  of  this  able  surgeon,  are 
however  unfortunately  more  apt  to  complicate  than  perfect  the  hypogastric 
method  as  recommended  by  Gutberlat.  This  method  has  also  been  put  to 
the  test  of  experiment  in  France  by  M.  Delpech,  who  prefers  previously  to 
detach  the  uterus  forwards  by  the  vagina,  and  that  to  get  at  it  across  the 
hypogastrium  a  semilunar  incision  be  made  in  the  side  of  the  median  line, 
;he  convexity  of  which  is  to  look  outwards,  so  as  to  have  a  large  flap,  which 


OPERATIVE    SURGERY.  70$ 

being  turned  back  on  its  right  edge,  gives  room  to  the  surgeon  to  manipulate 
freely  at  the  fundus  of  the  pelvis.  If  it  should  be  ever  proved,  that  large  open- 
ings may  be  made  into  the  parietes  of  the  abdomen  without  danger,  the  hypo- 
gastric method,  more  or  less  perfected,  would  ultimately  make  extirpation  of 
the  matrix  easy  enough  to  do.  But  it  is  not  the  way  to  make  it  of  general  preva- 
lence to  combiHe  the  sub-pubic  operation  with  it,  any  more  than  the  incision 
into  the  perineum,  as  proposed  by  Frere  Come,  to  bring  about  the  adoption  of 
the  sub-pubic  operation  for  stone.  One  operation  is  quite  sufficient  without 
combining  the  two.  Of  the  twenty-one  cases  known  in  which  removal  of  the 
uterus  was  practised,  nineteen  were  performed  by  penetrating  from  below  up- 
wards. M.  Sauter,  who  could  not  bring  down  the  organ  as  was  done  by  Osian- 
der,  divided  the  vagina  ascendingly  by  small  incisions  on  the  anterior  surface 
of  the  cervix  uteri,  succeeded  in  anteverting  the  organ,  separated  the  broad 
ligaments  successively,  and  finished  by  gradually  isolating  it  from  the  rectum, 
Hoelscher  and  Siebold  operated  in  almost  the  same  manner.  Once  however  the 
latter  was  obliged  to  cut  the  vagina  laterally,  to  facilitate  the  introductions  and 
motions  of  his  fingers  within.  He  also  thought  it  advisable  to  take  the  precau- 
tion of  introducing  a  catheter  into  the  bladder,  so  as  to  protect  it  or  direct  the 
motions  of  tlie  bistoury  while  he  separated  the  vagina  from  the  forepart  of  the 
uterus.  M.Langenbeck  began  by  making  an  incision  of  the  perineum  from  before 
backwards  ;  then  divided  the  vagina  backwards,  forwards,  and  upon  its  sides ; 
lastly  seized  the  uterus  by  its  fundus,  and  completed  its  detachment  by  cau- 
tious dissection.  Dr.  Blundell,  by  detaching  the  vagina  backwards,  enters 
at  once  into  the  recto  uterine  fossa  of  the  peritoneum,  he  then  seizes  the  fun- 
dus of  the  uterus  with  a  hook,  retroverts  it,  divides  the  broad  ligaments,  and 
finishes  by  its  separation  from  the  bladder.  Mr.  Banner  preferred  turning  the 
organ  over  on  its  side,  after  having  detached  it  behind,  in  front,  and  off  of  one 
of  its  broad  ligaments,  rather  than  effect  its  overturn  on  one  of  its  surfaces. 
His  operation  ended  in  the  section  of  the  remaining  ligament.  The  incision 
into  the  perineum  made  byLangenbeck,  was  by  Mr.  Lizars  carried  quite  into 
the  rectum  ;  he  then  divided  the  vagina  on  both  surfaces  of  the  diseased  organs 
before  reversing  it. 

In  France,  MM.  Recamier  and  Roux  have  always  followed  the  procedure 
of  M.  Sauter,  modified  in  two  particulars.  M.  Recamier  recommends  the  use 
of  tractors,  such  as  were  previously  mentioned,  if  they  can  be  introduced :  or 
if  this  is  not  possible,  the  carrying  up  into  the  uterus  of  one  brarch  of  a  double 
hook  forceps,  the  other  branch  of  which  should  have  three  points,  and  be  ap- 
plied as  high  as  possible  on  the  exterior  face  of  the  neck.  If  this  cannot  be 
done,  he  then  advises  the  use  of  the  instruments  of  Museux,  either  simple  or 
jointed  like  the  forceps,  bent  of  Z  shape,  or  only  at  a  right  angle,  as  proposed 
by  M.  Tanchou,  at  the  outer  third  of  their  handle,  so  that  they  may  not  too 
much  conceal  parts  during  the  remainder  of  the  operation.  With  one  or 
other  of  these  instruments  the  cancer  is  to  be  drawn  down  as  far  as  possible, 
A  straight  bistoury,  guarded  by  the  right  hand,  serves  to  detach  the  vagina  from 
below  upwards  from  the  forepart  of  the  uterus,  then  to  effect  the  separation 
of  the  matrix  itself  until  we  arrive  nearly  to  the  peritoneum,  which  is  after- 
wards to  be  opened  with  a  pharyngotome,  a  convex  and  probe-pointed  bis- 
toury, or  some  cutting  instrument.  The  same  bistoury,  the  probe  pointed 
one,  or  better  still  a  curved  bistoury,  still  guarded  by  the  finger  and  passed 
89 


706  NEW    ELEMENTS   OF 

in  at  the  peritoneal  opening,  and  carried  alternately  from  left  to  right,  is  suffi- 
cient to  detach  entirely  the  anterior  surface  of  the  organ  from  the  bas-fond  of 
the  bladder,  and  to  lay  bare  the  origin  of  the  broad  ligaments.  The  index 
finger,  passed  up  above  the  fallopian  tube  easily  glides  upon  the  posterior  sur- 
face of  the  peritoneal  reflexion,  and  permits  its  being  cut  from  above  down- 
wards, in  all  the  thickness  of  the  fold  to  its  inferior  third;  and  allows  the  rest 
to  be  included  in  a  strong  ligature.  Having  done  the  same  thing  on  the  oppo- 
site side,  M.  Recamier  finishes  the  section  of  the  broad  ligaments,  turns  over 
the  uterus  forwards,  and  detaches  it  from  above  downwards  from  the  rectum. 

The  ligatures  employed  by  M.  Recamier,  are  applied  upon  the  inferior 
halves  of  the  peritoneal  pinions  only,  because,  according  to  this  surgeon,  the 
principal  vascular  branches  are  here  situated.  He  is  even  of  opinion,  more 
over,  that  it  would  be  possible,  with  a  finger  in  the  rectum  and  another  in  the 
vagina,  to  discover  the  uterine  artery  by  its  pulsations,  and  contrived  to  tie  it 
in  the  lower  part  of  the  ligament  in  which  it  lies.  This  would  constitute  a 
separate  operation,  and  should  be  done  three  or  four  days  before  the  principal 
one  is  performed.  This  modification  is  equally  thought  very  easy  of  execu- 
tion by  M.  Gendrin ;  he  considers  it  as  very  essential,  and  accordingly  strongly 
advocates  its  adoption.  This  gentleman  also  advises  successive  isolation  of 
the  uterus  in  all  its  circumference,  and  that  at  the  close  of  the  operation,  it  be 
turned  on  its  own  axis,  and  not  reversed  or  turned  over.  Instead  of  placing  his 
ligature  below  the  insertion  of  the  tubes  as  is  done  by  M.  Recamier,  M.  Taral 
on  the  contrary  begins  by  surrounding  with  it  the  whole  of  the  broad  liga- 
ment, using  for  this  purpose  a  curved  needle,  like  that  of  Deschamps,  and  the 
left  index  finger  and  thumb,  to  carry  it  round.  M.  Taral,  likewise,  advocates 
the  introduction  of  a- catheter  or  sound  into  the  bladder,  so  as  to  use  it,  at 
the  instance  of  Siebold,  as  a  guide  to  the  vesica  during  the  dissection  of 
the  vagina  off  the  anterior  surface  of  the  uterus.  Injury  to  the  bladder  may 
be  much  oftener  avoided,  he  says,  by  raising  up  its  fundus  before  the  cutting 
instrument  with  the  index  and  middle  fingers,  whilst  separating  the  tissues 
in  that  direction,  even  until  the  peritoneum  itself  be  opened  into,  than  by 
tearing  the  cellular  layer  rather  than  cutting  it. 

M.  Dubled,  lastly,  is  of  opinion,  that  after  having  got  the  uterus  down  as 
low  as  possible,  and  destroyed  its  adhesions  from  one  broad  ligament  to  the 
other,  first  before  and  then  backwards,  a  ligature  should  be  passed  below  the 
roots  of  the  tubes  across  the  lateral  ligaments,  so  as  to  embrace  their  two 
lower  thirds,  and  to  allow  of  their  being  cut  between  the  string  and  gestative 
organ,  and  that  then  it  would  be  easy  to  amputate  the  uterus  as  far  as  its 
fundus  or  upper  edge,  so  as  to  leave  the  tubes,  ovaries,  and  round  ligament, 
in  situ,  and  also  without  necessarily  opening  the  peritoneal  cavity.  But  it  is 
evident  that  this  method  has  nothing  to  do  with  complete  extirpation  of  the 
uterus :  and  that  it  is  no  other  than  a  perfected  state  of  its  excision  as  per- 
formed by  M.  Bellini. 

It  would  be  difficult  to  say  which  of  these  methods,  so  various,  is  the  best 
adapted  for  the  purpose  ;  and  more  particularly  as  none  have  been  followed  as 
yet  with  complete  success;  and  that  those  which  appeared  to  be  followed  by 
cures  were  done  by  different  methods.  M.  Sauter's  patient  in  whom  the 
uterus  was  turned  over  forwards,  lived  four  months;  that  of  Dr.  Blundell, 
who  lived  for  a  year,  was  operated  on  by  the  posterior  reversion.  The  patient  of 


OPERATIVE   SURGERY.  707 

M.  Recamier,  who  remained  cured,  was  operated  on  after  this  gentleman's 
peculiar  method. 

The  perfecting  of  this  operation,  as  proposed  by  MM.  Gendrin  and  Taral, 
having  as  yet  been  practised  on  dead  bodies  only,  I  shall  not  here  discuss 
its  advantages,  or  the  objections  against  it.  Moreover,  as  it  will,  if  ever  again 
performed,  be  long  reflected  upon  before  it  is  undertaken,  and  as  it  is  probable 
that  each  one  will  feel  at  liberty  to  adopt  some  modification  of  these  modifi- 
cations, I  should  fear  to  trespass  upon  the  time  of  my  reader,  did  I  dwell 
longer  upon  those  I  have  thus  briefly  described. 

Art.  11. —  Vesico-vaginal  Fistula, 

Vesico-vaginal  fistula,  notwithstanding  the  frequency  of  its  occurrence, 
the  difficulty  to  which  it  gives  rise,  and  the  disgust  which  it  creates,  has 
hitherto  been  subjected  to  few  surgical  procedures  for  its  removal.  Either 
as  the  result  of  difficult  labors,  of  ill  conducted  obstetrical  manoeuvres,  of 
gangrenou-s  perforation,  of  contusion  or  other  traumatic  lesions,  it  is  an 
affection  from  which  a  spontaneous  recovery  is  impossible ;  nor  does  the  want 
of  success  which  has  hitherto  attended  the  attempts  that  have  been  made  to 
relieve  it,  justify  the  almost  complete  silence  with  which  it  is  passed  over  by 
standard  authors.  There  are  several  sorts  of  treatment  which  may  be  applied 
to  it. 

1st.  Suture. — Suture,  which  naturally  first  presents  itself  to  the  imagi- 
nation, is  of  such  difficult  performance,  that  few  surgeons  have  attempted 
it,  and  in  the  works  which  have  issued  from  the  Parisian  school  it  is  scarcely 
alluded  to.  To  attempt  to  stimulate  the  edges  of  a  wound  which  one  knows 
not  how  to  lay  hold  of;  to  bring  it  together  by  thread  and  needles,  when  there 
seemed  to  be  nothing  to  fasten ;  to  act  upon  a  movable  septum,  out  of  sight 
between  two  reservoirs,  on  which  scarce  any  hold  can  be  taken  ;  has  always 
appeared  capable  only  of  inflicting  unnecessary  pain  on  the  suft'erer,  and  has 
accordingly  generally  been  refrained  from.  Roonhuysen,  who  is  said  by  M. 
Chelius,  to  have  first  advised  it,  did  not  put  it  in  practice.  If  I  have  under- 
stood rightly,  it  was  his  nephew  who  spoke  to  him  about  it,  and  who  thinks 
that  after  having  quickened  the  life  of  the  edges  of  the  ulcer,  it  might  be 
possible  to  transfix  and  approximate  them  by  a  quill  sharpened  to  a  point. 
The  success  said  to  have  been  obtained  by  the  use  of  sutures  by  Walter,  Fatio, 
Schroeger,  and  others,  is  not  invested  with  proof  so  positive  as  to  produce  an 
entire  conviction  of  its  truth.  But  we  can  no  longer  entertain  any  doubts 
of  its  efficacy.  The  repeated  observations  made  by  M.  Noegele,  in  1812,  give 
reason  to  anticipate  success  in  many  cases.  Following  the  footsteps  of 
the  professor  of  Heidelburg,  M.  Ehrmann  proved  its  value  on  a  patient 
confided  to  him  by  M.  Flamant;  and  the  essay  published  by  M.  Deyber 
informs  us  that  he  was  himself,  in  conjunction  with  the  latter  gentleman, 
equally  fortunate  in  the  case  of  a  woman  whom  they  treated  at  Strasburg. 
The  fistula,  which  in  the  first  of  these  cases  was  very  broad,  in  the  other  very 
narrow,  was  a  long  while  in  cicatrizing  after  the  stitches  came  away,  and 
attended  with  much  suppuration ;  so  that  the  case  did  not  result  from  immediate 
contact  in  the  parts.  In  1828,  it  was  done  with  a  like  happy  result  by  M. 
Malagodi,  of  Bologna:  while  the  unfortunate  attempts  made  by  M.  Roux  at 


708  NEW  fiLtlMENTS  OP 

La  Charite,  in  1 829,  make  neither  for  nor  against  it,  since  the  symptoms 
which  preceded  the  death  of  his  patient,  were  not  at  all  such  as  are  naturally 
attributable  to  the  introduction  of  the  suture. 

Method  of  Procedure, — The  following  is  the  manner  in  M'hich  M.  Malagodi 
operated.  He  placed  his  patient  and  caused  her  to  be  held  as  in  the  operation 
for  stone  J  carried  the  index  linger  with  a  leather  stall  into  the  vagina,  and 
through  the  fistula  into  the  bladder;  used  it  as  a  hook  to  draw  out  one  of  the 
lips  of  the  bladder  a  little  towards  the  vulva,  and  cut  its  callous  portions 
with  a  straight  bistoury;  did  the  same  to  the  other,  side  of  the  fistula  by 
changing  hands,  and  then  began  to  insert  the  stitch.  For  this  second  stage 
of  the  operation  M.  Malagodi  again  laid  hold  of  one  edge  of  the  wound  as 
before  with  the  left  index-finger ; — conveyed  a  small  crooked  needle  to  near 
its  posterior  extremity  at  a  distance  of  two  lines  without ;  brought  it  again  by 
a  circular  sweep  from  the  bladder  into  the  vagina  so  as  to  make  it  cross  the 
vesico-vaginal  septuniy  and  afterwards  disengaged  it.  Another  needle  fixed 
to  the  other  end  of  the  string  was  also  carried  through  the  fistula,  and 
brought  out  from  the  bladder  to  the  vagina  to  be  withdrawn  as  the  first  had 
been.  The  surgeon  applied  a  second  and  third  stitch  in  the  same  manner, 
tied  each  separately  so  as  to  obtain  an  exact  coaptation,  and  concluded  by 
cutting  them  very  accurately  close  to  the  knot  with  scissors.  A  catheter 
was  kept  in  the  bladder,  and  the  patient  confined  to  her  bed.  The  first  and 
second  day  the  urine  passed  entirely  by  the  catheter ;  on  the  third  a  few  drops 
were  seen  to  have  escaped  by  the  vagina.  The  two  posterior  stitches  had 
perfectly  succeeded.  That  nearest  to  the  urethra  had  torn  through  the  tis^ 
sues.  It  was  not  thought  necessary  to  begin  the  operation  anew.  Repeated 
applications  of  the  nitrate  of  silver  at  different  times  completed  the  cure  at 
the  end  of  a  few  weeks.  M.Roux  thought  the  twisted  preferable  to  the  plain 
suture.  In  order  to  stimulate  the  edges  of  the  fistula  he  employed  pincers  or 
forceps  ending  in  a  semi-eliptical  flat  surface  or  plate,  very  much  like  the 
disk  of  a  pair  of  tongs,  one  of  the  halves  of  which  had  been  removed.  When 
once  the  lips  of  the  wound  were  seized  by  this  instrument,  M.  Roux  easily 
cut  it  away  with  a  straight  bistoury,  and  could  have  done  it  equally  well  with 
a  pair  of  long  scissors.  The  stitch  was  first  passed  from  the  vagina  through 
the  left  edge  of  the  wound  into  the  bladder  by  means  of  a  curved  needle  and 
the  instrument  usual  for  conveying  it.  This  needle  was  then  drawn  out  from 
the  bladder  into  the  vagina  through  the  other  side  of  the  fistulous  opening; 
then  withdrawn,  carrying  with  it  into  the  two  lips  of  the  Wound  a  little  me- 
tallic pin  fastened  to  the  end  of  the  string.  Three  others  were  afterwards 
inserted  with  similar  precautions,  after  which  a  loop  of  one  suture,  carried 
over  the  first,  and  crossed  over  each  of  the  fixed  pins  successively  turn  by 
turn  as  is  done  in  the  operation  for  harelip,  brought  about  an  approximation 
of  the  ctit  surfiices,  and  completed  the  twisted  suture.  Symptoms  of  inter- 
mittent fever,  and  subsequently  of  functional  derangement  of  the  brain,  and 
inflammation  of  the  peritoneum  and  pleura  began  in  a  few  days  to  manifest 
themselves,  and  increased  to  such  a  degree  as  on  the  12th  to  destroy  the 
patient.  On  opening  her  body  the  fistulous  opening  was  found  very  much 
enlarged,  between  the  edges  of  which  not  the  slightest  union  had  been  effected 
at  any  part.  But,  as  M.  Roux  very  judiciously  observed,  since  an  inter- 
vening acute  phlegmasia  almost  always  arrests  the  progress  of  cicatrization  in 


1 


OPERATIVE    SURGERY.  709 

wounds,  and  even  causes  it  to  retrograde  when  once  began,  it  would  be  unfair 
to  conclude  from  the  failure  in  this  that  the  twisted  suture  was  not  adapted 
to  any  case  of  vesico-vaginal  fistula.  The  method  followed  by  M.  Schroeger, 
though  less  ingenious,  had  notwithstanding  a  more  fortunate  issue.  Still  it 
cannot  be  said  to  have  been  crowned  with  complete  success;  suture  was 
thrice  practised,  and  the  words  of  tlie  author  himself  are  proof  that  the  patient 
did  not  get  entirely  well  even  after  the  third  time.  *'  I  convinced  myself," 
says  he,  "  that  the  wound  was  all  healed  but  about  the  space  of  one  line— 
of  which  it  had  been  difficult  to  pare  off  the  edges.  The  patient  was  much 
relieved,  and  I  was  in  hopes  of  being  able  to  conduct  her  case  to  a  perfect 
cure  on  a  fourth  application  of  the  sutures;  when  indispensable  business 
compelled  her  to  leave  Erlangen." 

M.  Duges's  patient  was  rather  injured  than  benefited  by  the  suture.  A 
young  girl,  who  was  in  my  department  at  La  Pitie  for  a  long  while,  submitted 
to  the  operation,  which  was  performed  by  M.  Robouham ;  but  according  to 
what  I  was  told  by  M.  Mondiere,  who  was  a  witness  to  it,  unattended  with 
any  marked  benefit.  It  would  be  useless  in  me  therefore  to  detail  the  steps 
of  their  respective  proceedings.  Unless  the  fistula  is  extremely  wide  it  is 
not  possible  to  hook  in  the  index-finger  on  one  edge  as  was  done  by  the  sur- 
geon at  Bologna,  nor  to  seize  it  with  the  tong-shaped  forceps  used  by  M. 
Houx.  A  longitudinal  division  alone  would  answer  for  the  insertion  of  a 
suture  after  the  manner  of  these  two  surgeons.  Now  it  is  well  known  that 
vesico-vaginal  fistulas  are  for  the  most  part  transverse  or  semilunar  slits,  with 
an  anterior  concavity  between  the  urethra  and  the  entrance  of  the  ureters  into 
the  bladder.  But  for  the  too  great  complexity  of  M.  Noegele's  apparatus  it 
would  assuredly  offer  a  much  better  chance  of  success  than  the  preceding 
ones,  although  little  better  suited  than  they  to  any  but  longitudinal  openings. 
We  must  have  some  more  simple  contrivance  before  suture  can  be  generally 
adopted.  M.  Schroeger  had  reason  to  congratulate  himself  on  so  nearly 
curing  his  patient,  and  on  obtaining  so  happy  a  result  from  his  three  trials, 
considering  that  he  only  inflamed  the  posterior  half  of  the  fistula,  and  that 
he  passed  in  his  stitches  a  line  or  two  from  the  cut  edges.  Experiments 
which  I  have  made  on  the  dead  body  lead  me  to  believe  that  we  might  succeed 
better  in  the  following  way.  I  place  the  patient  on  a  bed  or  table  properly 
covered,  and  of  a  convenient  height.  A  mattress  rolled  up  is  placed  under 
the  abdomen,  upon  which  the  woman  lies,  by  which  the  thighs  may  be  flexed 
whilst  in  this  position.  An  assistant  keeps  the  vagina  open  by  means  of  a 
wide  tube  (gouttiere)  of  metal  or  thin  wood.  With  one  cut  of  straight 
scissors  I  enlarge  the  fistula  backwards  for  a  line  or  two,  do  the  same  to  its 
anterior  angle  with  a  straight  bistoury,  so  as  successively  to  lay  hold  of  each 
lip  with  a  good  staphyloraphe  forceps,  and  cut  away  its  edge  either  with  straight 
scissors  or  scissors  a  little  curved  on  their  flat  surface.  The  sutures  are  then 
put  in  three  or  four  lines  without  the  stimulated  edges.  The  forceps  answer 
instead  of  the  finger  and  thumb  to  hold  the  parts  while  it  is  being  transfixed 
with  small  needles  in  the  way  that  is  done  by  MM.  Roux  and  Malagodi. 
Everv  thread  is  knotted  with  the  fingers  at  the  bottom  of  the  vagina.  If  the 
orifice  be  a  transverse  one,  a  bistoury  curved  on  its  flat  side  near  its  point, 
and  very  sharp,  carried  into  the  vagina  will  answer  for  detracting  a  selvege 


i 


710  NEW   ELEMENTS   OF 

or  border  off  of  its  deep  edge  kept  turned  over  in  another  direction,  or  drawn 
down  by  the  assistance  of  a  hook  and  good  forceps. 

Procedure  of  M.  Lewziski, — Convinced  of  the  difficulties  I  have  pointed 
out,  several  surgeons  have  turned  their  attention  to  another  method  of  treat- 
ment. It  was  natural  that  as  a  first  principle,  the  mind  should  be  pleased 
with  the  idea  of  bringing  back  the  posterior  edge  of  the  fistula  towards  the 
urethra,  while  the  anterior  edge  was  to  be  turned  backwards  at  the  same 
time.  In  a  thesis  defended  in  1802  before  the  faculty  at  Paris,  M.J.J. 
Lewziski  endeavored  to  establish  the  practice.  The  instrument  which  he 
recommends  is  a  flat  sound  slightly  curved,  pierced  with  two  holes  at  its 
point  for  the  passage  of  a  needle  also  curved.  A  stem  or  spring  enclosed  in 
this  canula  is  employed  to  push  out  the  needle  into  the  vagina  through  the 
posterior  lip  of  the  fistula  when  the  instrument  is  once  passed  into  the  bladder. 
When  drawn  out  at  the  vulva,  the  needle  drags  along  with  it  a  thread  of 
which  a  loop  or  stitch  is  made.  After  several  are  placed  in  the  same  manner, 
they  are  all  closed  in  a  knot-tightener  to  close  the  vesico -vaginal  aperture.  ' 

Sounds,  Finces  Erignes,  or  Crotchet  Forceps:^ — In  1826,  M.  LallemaM 
published  a  case  of  long  standing  vesico-vaginal  fistula,  cured  by  means  of  an 
instrument  somewhat  analagous  to  that  of  M.  Lewziski.  The  apparatus  of 
the  professor  of  Montpelier  is,  in  fact,  composed  of  1  st,  a  large  canula  about 
four  inches  long ;  2d,  a  double  hook  which  is  made  to  move  by  a  stem  within 
the  principal  instrument,  so  as  to  be  pushed  out  and  drawn  easily  back  again 
into  its  sheath ;  3d,  of  a  circular  plate  attached  to  the  other  end  of  the  canula 
or  sound,  which  in  case  of  need  would  prevent  it  from  penetrating  too  deeply 
into  tlie  urethra;  4th,  of  a  tv/isted  spring  [en  Z)o?/(/m),  designed  to  draw 
forward  the  little  hooks  when  once  engaged  in  the  posterior  lip  of  the  fistula. 
Its  application  is  similar  to  that  which  I  described  in  speaking  of  the  contri- 
vance of  M.  Lewziski.  The  sound  being  passed  into  the  bladder,  allows  the 
hooks  to  be  pushed  even  into  the  vagina  through  the  vesico-vaginal  septum, 
which  it  is  the  business  of  the  left  index  finger  to  sustain.  By  the  turn  of  a 
screv/  they  remain  fixed  in  this  position.  A  ball  of  lint  or  of  fine  linen  is 
then  placed,  so  as  to  protect  the  tissues,  between  the  forepart  of  the  urethra 
and  the  outer  plate  of  the  sound  ;  lastly,  the  spring  is  loosed,  which  thence 
forward  acts  simultaneously  by  pulling  on  the  posterior  lip  of  the  wound 
through  the  medium  of  the  hooks,  and  by  crowding  back  the  inferior  wall  of 
the  urethra  by  means  of  the  circular  plate,  or  of  the  lint  which  serves  as  a 
fujcrum  for  it.  By  means  of  mechanism,  which  it  would  require  too  much 
time  to  describe,  the  trigger  of  the  spring  may  be  graduated  so  as  to  produce 
a  moderate  pressure  only,  but  which,  however,  is  sufficient  to  bring  the  two 
etiges  of  the  opening  in  contact.  For  three  days  M.  Lallemand  was  flattered 
with  hopes  of  complete  success.  On  the  fourth,  a  few  drops  of  urine  having 
escaped  per  vaginam,  it  became  necessary  to  remove  the  instrument,  on  the 
inferior  surface  of  which,  four  lines  in  advance  of  the  hooks,  a  small  blackish 

*  The  translator  not  being-  acquainted  with  any  Eng-lish  word,  which  expresses  this 
species  of  forceps,  beg-s  leave  to  subjoin  the  meaning  of  the  word  erigne,  that  the  nature 
of  the  instrument  may  be  better  understood.  It  is  a  curved  hook,  used  by  surgeons  to 
remove  parts  difficult  to  be  taken  hold  of,  and  to  facilitate  their  extirpation.  They  are 
either  single  or  double  ;  and  are  made  with  the  hooks  at  one  or  both  extremities.  Per- 
haps the  word  crote/iei  forceps  will  convey  the  idea.  The  word  sonde^  in  French  signifies 
equally  a  catheter,  a  probe,  and  a  sound. — Translator. 


OPERATIVE    SURGERT.  Tit 

brown  spot  was  observable.  The  fistula,  however,  appeared  to  be  considerably 
diminished  in  extent.  A  new  application  of  the  crotchet  sound  was  attempted ; 
and  this  time  the  adhesion  appeared  complete.  However,  some  imprudence 
which  was  committed  in  about  ten  days  again  gave  rise  to  a  flow  of  urine 
through  the  vagina.  A  very  small  separation  only  had  occurred,  and  the 
surgeon  thought  it  possible  to  complete  by  caustic  the  cure  which  his  in- 
strument had  so  far  advanced.  He  was  written  to  sometime  afterwards,  that 
nothing  passed  any  longer  through  the  fistula,  and  that  the  recovery  seemed 
to  be  complete.  Still,  as  M.  Lallemand  does  not  assert  that  the  cicatrization 
of  the  fistula  in  this  case  was  perfect,  the  result  is  left  somewhat  doubtful. 
Some  persons  who  think  themselves  well  informed  about  it,  are  positive  that 
the  patient  relapsed  into  her  former  condition,  and  that  she  came  to  Paris  to 
consult  other  medical  practitioners  on  her  case.  Besides,  as  the  operation 
began  and  ended  with  the  application  of  the  nitras.  argenti.  and  as  this  article 
alone  has  in  many  cases  lately  been  incontestably  successful,  the  statement  is 
really  very  far  from  being  as  conclusive  as  at  first  sight  it  might  be  supposed. 
An  attempt  of  the  same  kind  was  made  with  this  instrument  during  the  year 
1829,  at  the  hospital  Beaujon.  In  it,  likewise,  the  hopes  of  success  which  once 
were  entertained  were  not  realized  ;  and  ere  long  the  patient  was  as  much 
afflicted  as  she  had  been  before.  The  inventor  himself  seems  to  have  been' 
equally  frustrated  in  two  attempts  which  he  has  since  made. 

The  instrument  invented  by  M.  Dupuytren,  and  which  he  once  used  with 
success,  is  a  kind  of  large  canula  or  female  sound,  which  has  on  its  sides  two 
little  operculi,  or  guards  (onglets),  which  open  like  wings,  or  shut  entirely, 
according  as  a  central  stem,  shaped  like  a  spring,  is  drawn  out  or  pushed  in, 
which  controls  their  motions.  It  is  introduced  closed  into  the  bladder.  The 
operculi  once  separated  and  fixed,  it  is  drawn  towards  the  operator  as  if  he 
was  about  to  remove  the  whole ;  by  preventing  it  from  entering  the  urethra, 
the  guards  cause  it  to  carry  forward  along  with  it  the  posterior  lip  of  the 
fistula,  while  some  lint  or  linen,  placed  between  the  meatus  urinarius  and 
the  external  plate  of  the  canula,  allows  it  to  crowd  back  the  urethra  and  an- 
terior lip  of  the  fistula.  This  proceeding,  which  is  not  attended  with  the 
inconveniences  either  of  tearing  or  perforating  the  vesico-vaginal  septum, 
would  certainly  claim  an  undoubted  preference  over  every  other,  were  it 
really  capable  of  perfecting  a  complete  co-aptation  of  the  edges  of  the  fistula; 
but  this  is  not  the  case,  and  I  fear  that  it  can  be  considered  only  in  the  light 
of  an  adjuvant  to  the  use  of  caustic,  in  itself  so  very  effectual.  ' 

Procedure  of  M.  Laugier. — If  the  suture  is  applicable  only  to  the  longi- 
tudinal fistula,  it  is  evident  that  transverse  ones  alone  are  suitable  to  the  use 
of  the  crotchet  sound.  With  a  view  to  obviate  this  difficulty  I  adopt  the 
method  of  M.  Lallemand  to  fistula  of  every  sort.  M.  Laugier  constructed 
a  crotchet  forceps,  jointed  like  one  of  Smellie's  forceps,  whose  form  depends 
upon  the  shape  of  the  fistula.  If  it  be  for  a  transverse  one,  the  claws  of  the 
instrument  are  merely  bent  on  one  of  its  surfaces,  so  as  to  be  placed  one  on 
the  right  and  one  on  the  left  side,  and  to  look  directly  upwards.  On  the  con- 
trary, when  for  a  longitudinal  fistula,  the  two  crotchets  of  each  claw  must 
be  parallel  to  the  axis  of  the  body,  and  the  end  which  sustains  them  bent  on 
the  edge.  The  forceps,  lastly,  should  be  bent  more  or  less  obliquely  if  the 
fistula  should  happen  to  assume  an  intermediate  direction.    The  crotchets  of 


k 


712  NEW   ELEMENTS   OF 

this  instrument  ought  to  be  very  short,  says  M.  Laugier,  that  they  may  not 
pass  through  and  through  the  vesico-vaginal  septum.  They  are  inserted 
from  within  the  vagina,  and  not  the  bladder.  One  branch  is  first  carried 
some  lines  out&ide  the  fistula  previously  stimulated;  the  other  is  then  applied 
similarly  on  the  other  side ;  after  which  they  are  approximated  by  locking  the 
forceps.  To  graduate  the  strength  of  this  approximation,  and  at  pleasure  to 
increase  or  lessen  its  power,  a  screw  crosses  the  two  handles  of  the  instru- 
ment, very  much  as  it  does  in  the  enterotome  of  M.  Dupuytren.  The  whole 
is  protected  by  lint  properly  disposed  within  the  vagina,  or  at  least  at  its  orifice. 

This  plan  of  M.  Laugier's  has  never  yet  been  practised  on  the  living 
female,  and  though  a  very  ingenious  combination,  I  have  my  doubts  of  its. 
being  of  any  considerable  efficacy.  It  is  difficult  to  understand  how,  upon 
a  part  so  mobile,  hooks  can  be  so  fastened  for  three  or  four  days  together,  as 
to  keep  the  lips  of  a  tolerably  wide  fistula  in  adequate  approximation.  Unless 
they  pass  through  the  whole  thickness  of  parts,  they  will  slip  almost  inevita- 
bly, tearing  with  them  the  vaginal  tunic,  or  else  the  urine  will  settle  into  th^ 
depression  left  in  the  bladder,  and  not  fail  to  find  its  way  out  by  the  sides  of 
the  instrument.  Suppose  them  to  press  into  the  bladder,  would  not  their  pas- 
sage, which  would  be  enlarged  by  subsequent  suppuration  before  they  could 
be  withdrawn,  be  likely  to  create  new  fistula  rather  than  to  heal  the  former 
one  ?  Besides,  to  use  them  the  outline  of  vesico-vaginal  fistula  should  offer  at 
each  point  the  same  thickness.  Now  those  which  are  incomparably  the 
most  common,  which  occupy  the  end  of  the  bas-fond  of  the  bladder,  gene- 
rally have  the  side  near  the  urethra  exceedingly  thick,  and  the  posterior  side 
on  the  contrary  very  thin.  Consequently  the  anterior  claw  of  the  instrument 
ought  to  penetrate  to  a  depth  of  two  or  three  lines,  while  the  other  would  be 
fixed  in  a  tissue  of  a  line,  or  a  line  and  a  half  only  in  thickness.  In  longitu- 
dinal fistula  his  hooks  would  probably  effect  a  partial  union  only,  insomuch 
as  their  edges  offer  almost  always  spots  of  various  resistance.  Lastly,  for 
deeper-seated  fistulas  would  not  sutures  be  a  more  certain  measure,  and  would 
its  adoption  be  attended  with  greater  difficulty  than  this  ? 

Cauterization. — This,  which  at  first  blush  might  not  be  supposed  very  likely 
to  act  otherwise  than  by  creating  additional  loss  of  substance,  is  nevertheless 
one  of  the  best  methods  which  have  hitherto  been  resorted  to.  When  pushed 
far  enough  actively  to  inflame  without  producing  mortification  of  the  tissues, 
it  induces  swelling  and  intumescence,  which  contracts  and  closes,  for  the 
time  at  least,  the  aperture  which  we  are  desirous  of  obliterating.  After  the 
subsidence  of  this  engorgement  the  exudation  and  the  suppuration  of  parts  is 
attended  with  manifest  disposition  to  contraction.  It  is  a  method  there- 
fore which  deserves  from  the  practitioner  the  utmost  attention,  and  is  particu- 
larly likely  to  suffice  in  cases  in  which  the  opening  is  not  of  any  considerable 
extent.  It  may  be  effected  either  with  the  actual  cautery,  or  with  the  nitrate 
of  silver,  the  concentrated  acids,  and  that  of  the  acid  nitrate  of  mercury, 
of  which  M.  Dupuytren  at  first  thought,  should  be  laid  aside.  The  red  hot 
iron  has  the  advantage  of  being  most  rapid  and  energetic  in  its  action.  Un- 
fortunately it  is  disposed  to  form  sloughs,  and  destroy  the  tissues,' which  it  is 
requisite  merely  to  inflame.  The  nitrate  of  silver  is  generally  preferable ; 
and  the  actual  cautery  should  supersede  it  only  in  particular  cases;  for  ex- 
ample^ such  as  exceeding  callosity  of  edges,  which  it  is  impossible  to  irritate. 


OPERATIVE    SURGERV.  71^ 

A  lie  reu  iiut  n  on  u^Ang  decided  upon  a  speculum  I...  _  ,.     The 

common  speculum  "trise"  is  as  good  as  any  other.  However,  for  more  per- 
fectly protecting  the  adjacent  parts,  and  to  leave  nothing  exposed  but  the  fistula, 
we  may  use  a  simple  cylindrical  speculum  pierced  on  one  side.  It  is  scarcely 
necessary  for  me  to  say  that  the  modifications  invented  by  M.  Dubois,  M. 
Erhmann,  &c.,  whilst  they  certainly  answer  the  end  in  view,  are  really  quite 
unnecessary.  Having  introduced  this  instrument  so  that  the  fistula  can  be 
seen,  we  next  carry  a  stylet  at  a  white  heat,  or  a  small  bean -shaped  cau- 
tery iron,  into  the  aperture,  being  cautious  to  leave  it  there  for  an  instant 
only,  and  repeat  the  cauterization  if  the  first  application  be  not  sufficiently 
active.  M.  Delpech,  who  has  been  remarkably  successful  with  it,  thinks  that 
the  cautery  should  act  only  on  the  vaginal  side  of  the  opening,  and  not  on  the 
vesical ;  to  save,  as  he  says,  loss  of  substance,  and  also  to  bring  forcibly  into 
play  the  power  of  contraction  ;  a  remark  which  should  be  borne  in  mind  in 
any  subsequent  attempt  which  may  be  made. 

The  speculum  is  never  indispensable  when  nitrate  of  silver  is  employed. 
A  porte-crayon  ought  never  to  be  used  in  cauterizing  with  this  substance.  It 
then  scarcely  touches  any  thing  but  the  internal  surfaceof  the  vagina,  leaving 
the  fistula  most  commonly  wholly  untouched.  To  the  end  of  a  common  pair 
of  dressing  forceps  a  piece  of  the  nitrate  is  fastened  by  a  thread  so  as  to  pro- 
ject at  a  right  angle  from  the  blades.  With  this  contrivance  nothing  is  easier 
than  to  introduce  the  caustic  into  the  interior  of  the  fistula,  and  apply  it  all 
around  its  circumference ;  a  ring  with  a  little  beak  for  receiving  the  caustic, 
conducted  by  the  extremity  of  a  finger  covered  with  a  leather  stall,  would  do  as 
well  as  the  forceps.  However  the  operation  of  cauterization  may  have  been 
performed,  it  is  proper  to  throw  up  repeated  injections  into  the  vagina,  and 
afterwards  to  place  the  patient  in  a  bath.  A  catheter  is  to  be  left  in  the 
bladder,  and  to  remain  open  at  the  edge  of  some  utensil  placed  for  the  pur- 
pose before  the  vulva,  that  the  urine  may  escape  easily. 

The  operation  is  to  be  repeated  after  pain  and  swelling  have  subsided. 
It  may  be  recurred  to  four,  five,  or  six  times,  according  to  the  benefit  derived, 
until  the  urine  have  ceased  altogether  to  flow  through  the  vagina.  It  would 
be  wrong  to  suppose,  that  after  a  fistula  is  reduced  to  a  very  small  diameter, 
and  seems  no  longer  to  improve  or  contract,  it  will  fail  of  complete  success ; 
we  need  not  despair,  for  in  numerous  instances  it  will  close  at  the  end  of 
some  weeks  although  the  progress  of  recovery  had  appeared  to  be  suspended 
for  ever.  M.  Dupuytren  seems  to  have  had  considerable  success  by  cauteri- 
zation either  with  the  actual  cautery,  or  by  the  use  of  chemical  agents. 
The  cases  are  mentioned  by  M.  Sanson,  who  was  an  eye  witness  to  them. 
Attentive  perusal  of  the  case  published  by  M.  Malagodi  induces  \\\t  belief 
that  in  this  patient  also  the  caustic  did  more  for  the  cure  than  the  suture ; 
and  in  the  other  cases  in  which  caustic  has  been  used  as  accessory,  or  was 
combined  with  means  which  were  considered  as  of  principal  utility,  it  is  very 
possible  that  it  alone  may  have  produced  the  results  spoken  of. 

The  oldest  method,  that  which  alone  is  mentioned  by  M,  Boyer,  and  the  only 
one  which  is  proper  when  a  radical  cure  is  not  attempted,  is  the  method  of  De- 
sault.  It  consists  in  fastening  a  catheter  permanently  in  the  bladder,  whilst 
a  cylinder  of  lint,  linen,  or  better  yet  of  gumelastic,  is  retained  in  the  vagina, 
moderately  to  stretch  the  angles  of  the  wound. 
90 


714  NEW  ELEMENTS  OF 

Desault  and  Chopart  who  were  for  a  long  time  embarrassed  by  the  difficulty 
of  preserving  this  catheter  immovable,  at  length  succeeded  in  discovering  the 
means  of  doing  so.  Instead  of  a  double  T  bandage,  on  which  were  attached 
the  ribands  fastened  to  the  extremity  of  the  instrument;  instead  of  uniting 
these  ribands  with  the  hairs  of  the  vulva,  these  authors  contrived  a  sort  of 
truss,  the  cushion  of  which  came  up  on  the  mons  veneris,  and  which  had  at 
this  spot  a  metallic  plate,  bent  like  a  bow,  which  is  made  to  descend  at  plea- 
sure over  the  forepart  of  the  pudendum,  and  is  perforated  at  its  end  to 
receive  the  catheter.  But  it  seems  an  unnecessarily  complicated  contrivance, 
which  has  no  more  advantage  or  steadiness  than  the  linen  apparatus  employed 
by  others.  Desault  and  Chopart  assert  that  they  have  cured  several  women 
with  it,  and  quote  one  case  in  particular.  Still  in  this  case  they  leave  room 
for  doubt,  by  saying  that  the  woman  appeared  to  be  cured,  and  not  formally 
asserting  that  she  was  cured.  Months,  and  even  years  sometimes  must 
elapse  for  a  perfect  cure  to  be  obtained  in  this  way,  and  is  it  not  fair 
to  suppose  that  the  fistula  during  this  time  may  have  got  spontaneously 
well,  as  has  occurred  under  other  circumstances  when  no  treatment  was 
practised? 

If  notwithstanding  it  is  wished  to  trust  to  the  catheter  permanently  insert- 
ed, it  seems  proper  at  least  to  do  away  with  the  foreign  body  placed  after  the 
manner  of  Desault  in  the  vagina.  This,  by  dilating  the  canal,  must  oppose 
a  natural  obstacle  to  the  contraction  of  the  fistula.  In  such  case  an  egg- 
shaped  gumelastic  ball,  however,  would  be  the  best  thing  to  try. 

If  it  is  admitted  that  the  fistula  is  of  an  incurable  nature,  all  that  art  can 
do  is  to  recommend  measures  of  cleanliness ;  the  object  of  which  is  to  pro- 
tect the  organs  against  the  acridity  of  the  urine,  or  to  receive  this  fluid  in 
such  a  way  as  that  it  may  inconvenience  the  patient  as  little  as  possible. 
For  this  end,  J.  L.  Petit  had  constructed  an  instrument  which  he  called  the 
*'  hole  of  hell"  [trou  d'^enfer)^  and  which  if  we  believe  his  representation  an- 
swered perfectly  ;  but  as  he  has  not  described  it,  it  has  not  been  possible  to 
benefit  by  it  since  his  time.  Fortunately  that  of  Feburier,  which  is  to  be  had  at 
most  manufacturers  of  gum  elastic,  leaves  on  this  head  nothing  to  be  desired. 
It  is  a  sort  of  basin  of  caoutchouc  which  may  be  worn  at  the  vulva,  and  is 
prolonged  into  the  vagina;  and  does  not  interfere  with  the  woman's  walking, 
or  prevent  her  following  her  customary  avocations.  Mr.  Barnes,  who  in  con- 
sequence of  the  frequency  of  vesico -vaginal  fistula  among  English  women, 
has  had  to  treat  them  a  number  of  times,  uses  a  long  bottle  of  elastic  gum, 
which  may  be  introduced  into  the  vagina,  and  which  has  on  its  anterior  sur- 
face an  aperture  in  which  a  sponge  is  fixed,  and  which  is  placed  towards  the 
fistula,  so  that  the  urine  may  enter  it  little  at  a  time.  The  patient  is 
to  withdraw  it  twice  or  three  times  a  day,  squeeze  out  the  fluid  by  sim- 
ple pressure,  which  by  reacting  on  the  sponge  completely  empties  the  instru- 
ment. 

If  neither  of  these  instruments  can  be  procured,  the  only  resource  which 
remains  for  the  woman  is  to  supply  their  absence  by  means  of  fine  sponges, 
pieces  of  linen,  or  silk  paper,  which  are  to  be  changed  more  or  less  often 
every  day, 

A  plan  has  recently  been  suggested  by  M.  Charilly,  of  causing  the  patien 
to  lie  semiflexed  on  her  abdomen ;  with  a  view  to  compel  the  urine  to  flo^ 


OPERATIVE    SURGERY.  7\5 

pu.t,  either  through  the  urethra,  the  catheter,  or  a  syphon,  which  might  be  placed 
there  and  prevent  it  from  gravitating  towards  the  fistula ;  but  it  has  the  great 
objection  of  failing  in  its  object.  Neither  could  it  be  endured  by  most  women 
for  more  than  a  day  or  two.  MM.  Sanson  and  Schroeger  have  tried  it  for  a 
good  while,  have  derived  no  benefit  from  it,  and  have  been  compelled  to  aban- 
don it  by  the  dread  of  eschars  "on  the  knees,  and  elbows,  and  spines  of  the  ilia, 
from  long  continued  pressure. 


^rt,  12. — Mecto -vaginal  fistula. 

The  posterior  surface  of  the  vagina  is  like  the  anterior,  liable  to  be  lacerated 
during  delivery;  to  be  compressed  by  the  child's  head,  or  the  branches  of  the 
forceps  ;  to  perforation  for  gangrene,  &c.  No  operation  is  necessary  when  the 
solution  of  continuity  comprises  only  the  perineum,  so  as  to  produce  an 
increased  size  of  the  vulva ;  neither  is  it  called  for  when  the  perineum  is  per- 
Corated  by  the  head,  elbow,  or  an  inferior  extremity  of  the  foetus,  provided  the 
posterior  commissure  of  the  vagina  and  sphincter  ani  remain  unhurt.  It  is 
uncommon  for  such  injuries  to  have  any  bad  consequences,  and  recovery 
in  general  ensues  without  any  special  treatment.  But  when  the  laceration 
extends  further  than  this,  trenches  on  the  recto-vaginal  septum  fairly,  or  when 
the  sphincter  ani  is  torn  through,  the  aid  of  surgery  is  required.  The 
passage  of  the  greater  part  of  the  fecal  excretions  through  the  vagina, 
render  it  so  disgusting  an  affection,  that  it  is  impossible  to  avoid  seeking 
relief  from  its  continuance.  The  same  may  be  said  ot"  those  cases  in  which 
the  recto-vaginal  septum  is  perforated  or  split  up  above  the  sphincter  ani 
which  remains  entire,  and  with  or  without  laceration  of  the  perineum.  Though 
not  very  uncommon,  this  fistula  is  not  as  often  seen  as  vesico -vaginal  fistulae 
are ;  doubtless,  because  the  head  of  the  child,  or  the  instruments  which  accou- 
cheurs are  occasionally  obliged  to  employ,  by  rubbing  against  the  parts 
behind  the  pubis,  compress  the  bladder  in  a  more  limited  space,  and  on  a  spot 
more  salient  and  irregular  than  is  done  on  the  rectum  behind.  As  they 
have  moreover  a  greater  tendency  to  disappear  spontaneously  than  such 
as  occur  in  the  vesico-vaginal  floor,  it  is  very  natural  that  they  should 
have  been  much  and  generally  neglected.  Ruysch  mentions  a  woman  who  had 
one  in  the  recto-vaginal  septum  as  large  as  the  thumb,  which  healed  without 
any  operation.  A  fact  nearly  similar  was  mentioned  in  1829,  by  M.  Phillippe 
de  Mortagne.  The  patient  of  whom  he  speaks  had.  an  enormous  perforation 
which  caused  a  communication  of  the  rectum  and  the  vagina.  The  most  cele- 
brated surgeons  in  the  metropolis  were  consulted  on  the  case;  they  all  replied 
that  she  would  probabl  y  remain  incurable,  and  that  they  saw  no  operation  which 
they  could  advise  to  be  attempted.  Laying  his  patient  on  her  side,  and  adopt- 
ing measures  of  cleanliness,  constituted  the  whole  of  M.  Phillippe's  treatment. 
After  enlarging  considerably,  the  fistula  began  to  contract,  so  surely  that  it 
-iWas  completely  closed  in  a  few  months.  The  cure,  when  the  case  was  pub- 
lished, was  still  perfect,  no  apprehensions  seemed  warranted  of  a  relapse.  An 
janalagous  case  had  been  published  by  Sedillot,  differing  only  in  so  much  as 
that  it  was  of  that  kind  which  Smellie  in  vain  endeavored  to  cure,  and  over 
'Which  M.  Noel  triumphed  by  using  the  twisted  suture.      Unfortunately  the 


ri6  NEW    ELEMENTS    OF 

organism  will  not  always  lend  herself  to  the  wishes  of  the  practitioner,  and  it 
is  but  too  common  to  see  lacerations  in  this  situation  continue  to  defy  the 
best  directed  efforts  of  medical  art. 

As  to  the  operations  to  be  attempted  two  different  species  of  this  disease 
are  to  be  met  with.  In  the  one  there  exists  a  pure  and  simple  fistula,  that  is, 
perforation,  of  greater  or  less  extent,  in  some  one  part  of  the  recto-vaginal 
septum.  In  the  other  the  laceration  comprises  at  once  the  sphincter  ani,  and 
the  whole,  or  a  part  of  the  perineum.  If  the  perineum  is  completely  torn 
through,  it  resembles  in  some  sort  a  harelip.  If  torn  only  at  its  posterior 
point,  the  wound  after  the  lapse  of  some  time,  cicatrizes  at  this  point,  and  the 
case  becomes  one  of  the  first  kind,  in  which  there  is  mere  fistula  of  the  septum 
properly  so  called.  To  all  these  cases  the  means  advised  for  the  treatment 
of  vesico -vaginal  fistula3,  are  applicable  also.  Cauterization,  for  example, 
seems  often  to  cure  them  when  they  present  themselves  under  the  form  of 
a  harelip  fissure;  In  fact,  it  is  generally  admitted,  that  by  stimulating  in 
any  way  the  angles  of  such  a  separation,  it  rarely  fails  to  effect  union  between 
them,  at  least  for  an  extent  of  some  lines.  To  try  the  effect  of  the  nitras  argent!, 
on  this  principle,  it  is  only  necessary  to  apply  it  each  time  to  the  farthest  por- 
tion, or  commissure  of  the  solution  of  continuity.  Fistulas,  properly  so  called, 
will  not,  indeed,  yield  so  readily,  unless  very  small ;  to  them,  when  very 
large,  it  would  be  useless  almost  to  attempt  the  application  of  caustic,  parti- 
cularly as  the  crotchet  forceps  of  M.  Laugier  will  furnish  us  probably  with  a 
much  more  efficacious  resource.  A  young  woman,  who  had  had  it  for  eight 
months,  was  recently  cured  of  one  in  fifteen  days  in  my  department  at  La 
Pitie,  by  the  use  of  port  wine  injections. 

Suture. — The  operation  which  first  presented  itself  as  suitable  for  recto- 
vaginal fistula,  and  which  at  the  first  glance  seems  to  offer  most  certainty,  is 
suture.  It  is  only  to  be  regretted  that  it  is  so  difficult  of  application ;  and 
that,  thus  far,  very  few  cases  can  be  cited  in  favor  of  it.  M.  Gardien  tells  us 
that  it  was  vainly  attempted  by  M.  Dubois;  and  M.  Boyer  says,  that  if  every 
case  in  which  it  had  failed  had  been  published,  the  number  known  would  now 
be  very  considerable ;  so  that  he  scarce  dares  advise  its  performance.  Still, 
it  has  succeeded ;  and  it  is  probable  that  in  the  end,  as  it  is  rendered  more 
perfect,  greater  benefit  will  be  derived  from  it.  I  therefore  think  that  in 
most  cases  it  should  be  tried. 

The  first  cure  known  to  have  been  produced  by  it,  is  that  mentioned  by 
Saucerotte.  The  patient  labored  simultaneously  under  laceration  of  the  peri- 
neum in  front  of  the  anus,  and  perforation  of  the  recto-vaginal  septum  above 
the  sphincter. 

The  operation  was  thus  performed :  the  surgeon  distended  the  vagina  with 
a  double  branch  speculum,  and  passed  in  at  the  anus,  up  the  rectum,  a  species 
of  wooden  director  [gorgerette,  gorget),  the  convexity  of  which  he  placed 
under  the  fistula  to  serve  as  a  fulcrum  on  which  his  other  instruments  Were 
to  move.  Having  thus  gained  sight  of  the  aperture,  Saucerotte  cut  away  its 
edges,  partly  with  a  bistoury  wrapped  round  with  linen,  partly  with  a  kind  of 
cutting  scraper  {nigine).  The  furrier's,  or  uninterrupted  stitch  which  he 
preferred,  was  applied  by  means  of  two  crooked  needles,  one  shorter  than  the 
other  to  begin  with,  and  the  longer  one  for  the  last.  The  forceps,  or  common 
needleholder,  had  been  altered  a  little  for  the  occasion  ;  that  is  to  say,  its 


OPERATIVE    SURGERY.  7\7 

extremity  had  been  so  arranged  as  to  allow  of  the  needles  being  fixed  in  it 
in  any  direction.  M.  Saucerotte  then  carried  the  first  stitch  up,  with  this 
instrument,  to  the  level  of  the  upper  angle  of  the  irritated  fistula,  where  he 
confined  his  ligature  by  a  piece  of  diachylon  plaster,  so  as  not  to  be  obliged 
to  make  a  knot  in  it.  Then,  with  another  needle,  he  made  six  spiral  or  over-  , 
cast  turns  of  the  suture,  going  from  behind  forwards,  which  he  fastened 
firmly,  by  tying  either  half  of  his  thread  on  some  foreign  body.  During 
several  days,  he  had  reason  to  expect  a  cure  would  follow;  but  the  woman 
who  had  had  no  alvine  discharge,  was  ultimately  obliged  to  strain  so  violently 
to  expel  the  hardened,  scybalous,  fecal  matters  which  had  accumulated  in 
the  rectum,  that  the  suture  gave  way,  and  the  larger  part  of  the  feces  escaped 
per  vaginam.  However,  M.  Saucerotte  perceiving  that  the  adhesion  was  still 
perfect  at  the  upper  part  of  the  fistula,  and  the  woman  being  herself  anxious 
for  the  reperformance  of  the  operation,  renewed  his  attempt  after  the  lapse  of 
a  month.  This  time  he  was  cautious  to  divide  the  frenum  formed  by  the  ! 
sphincter,  so  that  nothing  could  interfere  with  the  fecal  discharges ;  and  his  \ 
success  was  perfect.  M.  Noel  has  likewise  performed  this  operation  of  suture, 
in  a  case  very  analogous  to  that  of  Saucerotte.  The  woman  had,  during  a 
painful  labor,  suffered  laceration  of  the  whole  perineum,  anus,  and  a  part  of 
the  septum.  He  employed  scissors,  to  reanimate  the  edges  of  this  old  separa- 
tion of  parts ;  placed  his  two  needles,  one  at  the  level  of  the  sphincter,  the 
other  an  inch  higher  up;  fastened  them  by  the  aid  of  threads  to  form  the 
twisted  suture ;  then  closed  the  woman's  thighs,  and  encircled  them  with  a 
few  turns  of  a  bandage,  which  surrounded  them  both ;  enjoined  her  to  lay  on 
her  back,  that  the  feces  in  escaping  might  follow  the  posterior  wall  of  the 
rectum;  and  after  the  removal  of  this  second  needle,  became  satisfied  of  the 
complete  union  effected  between  the  sides  of  the  fissure  at  this  point,  but  also 
in  the  whole  upper  extent  of  the  laceration,  in  which  no  stitches  had  been  put, 
and  the  lips  of  which  had  been  approximated  only  as  a  consequence  of  the 
closure  of  the  lower  portion.  This  happy  result,  which  was  not  interrupted, 
is  a  proof,  that  if  Smellie  in  his  cases  had  been  more  methodical  in  his  pro- 
ceeding he  would  probably  have  been  equally  fortunate.  In  a  case  which 
has  recently  been  published  by  Mr.  J.  Nicol,  in  England,  the  operator  was 
thrice  obliged  to  return  to  the  suture;  and  he  likewise  completely  succeeded 
in  his  attempt. 

Another  species,  the  entero -vaginal  fistula,  has  likewise  engaged  the  anxious 
attention  of  surgeons.  A  knuckle  of  the  intestinum  gracilis,  the  iliac  sig- 
moid flexure  of  the  colon,  getting  into  the  recto-uterine  cavity,  may  by  per- 
forating it,  ultimately  make  its  way  through  the  upper  and  back  part  of  the 
vagina  ^  as  in  one  case  was  known  by  Roux,  and  in  another  by  M.  Caza- 
Mayor.  Two  very  different  operations,  both  in  proceeding  and  in  result, 
were  invented  to  remedy  this  species  of  affection,  which  becomes  a  sort  of 
artificial  anus.  M.  Roux's  patient,  a  young  woman,  who  had  had  the  fistula 
for  several  years,  entered  La  Charite  determined  to  be  freed  from  it,  cost 
what  it  might.  The  surgeon  thought  it  possible  to  cure  it  by  seeking  the 
intestine  through  the  abdominal  parietes.  His  intention,  which  has  been 
modified  in  later  years,  was  to  separate  the  end  of  the  ileum  from  the  vagina 
first,  then  invaginate  it  with  the  lower  end  of  the  colon,  and  thus  by  means 
of  stitches,  re-establish  the  continuousness  of  the  digestive  canal.     Never  was 


k 


718  NEW  ELfiMENtS   OF 

bold  attempt  followed  by  more  disastrous  results.  The  woman  died,  and  on 
inspection  of  the  corpse  it  was  seen  that  the  part  of  the  intestine  which  should 
have  been  placed  downwards,  was  inserted  in  an  opposite  direction  !  That 
of  M.  Caza-Mayor  though  to  appearance  more  rational,  and  less  dangerous, 
did  not  completely  succeed  either;  the  patient  dying  suddenly  of  a  pneumo- 
nia, at  the  very  time  when  the  surgeon  was  in  hopes  of  seeing  his  attempt 
crowned  with  complete  success.  The  instrument  which  he  made  use  of 
resembles  in  its  principle  the  enterotome  of  M.  Dupuytren.  It  is  a  kind  of 
forceps,  each  blade  of  which  ends  in  an  oval  plate  or  surface,  eight  lines  long 
by  four  wide ;  slightly  grooved  on  the  intestinal  surface  to  admit  corre- 
sponding elevations.  One  branch  being  introduced  into  the  vagina  by  the 
fistula  as  far  as  into  the  perforated  organ,  the  other  into  the  rectum  to  the 
level  of  the  first,  the  oval  surfaces  come  together,  bringing  into  contact  the 
corresponding  sides  of  the  two  portions  of  intestine,  so  as  to  produce  at  the 
point  of  junction  a  loss  of  substance,  from  the  absorption  of  the  intervening 
septum  the  result  of  the  compression  thus  effected.  The  forceps  altogether 
is  about  eight  inches  long;  its  branches  being  jointed  in  the  usual  way,  leave 
between  them  a  space  sufficient  to  contain  the  entero -vaginal  septum  and  the 
perineum  ;  while  a  screw  which  crosses  the  handles  at  their  base  allows  of 
their  action  being  graduated  at  pleasure.  Things  happened  in  this  case  as 
the  operator  had  anticipated.*  The  fecal  matters  partially  resumed  their 
natural  route,  and  every  thing  led  to  the  belief  that  the  fistula  in  the  vagina 
would  have  closed  ere  long,  when  the  patient  perished,  the  victim  of  her  own 
imprudence.  The  whole  result  is  doubtless  very  encouraging ;  it  is  only  to 
be  feared  that  the  results  will  not  all  be  equally  so.  It  is  easily  conceivable  that 
when  a  hole  is  effected  in  the  rectum  artificially,  feces  may  in  a  measure  pass 
through  it ;  but  how  is  the  vaginal  orifice  to  avoid  receiving  some  intestinal 
matter,  and  how  is  it  to  be  obliterated  ?  The  error  made  by  M.  Roux  in  his 
operation,  in  nowise  effects  the  project  of  proceeding  by  the  failure  of  the 
attempt;  the  conception  remains  what  it  was  before. 

When  fistulse,  opening  into  the  vagina  are  very  near  the  vulva,  they  are  in 
general  easily  cured  if  treated  like  fistula  in  ano.  Two  examples  were 
gleaned  at  La  Charite,  in  1829,  and  I  was  myself  successful  by  the  method, 
in  the  case  of  a  woman  39  years  old.  operated  on  at  La  Pitie  in  the  month 
of  January  last. 

Art.  13. — Dystokia — Difficult  Delivery. 

Operations  which  are  sometimes  required  for  the  extraction  of  the  child, 
have  in  every  age  been  the  subject  of  a  separate  branch  of  medical  science; 
and  can  only  be  discussed  with  propriety  in  works  upon  obstetrics.  It  would 
here  be  superfluous  for  me  to  enter  into  all  the  details  which  they  admit  of, 
yet  as  there  are  among  them  some  which  ought  not  wholly  to  be  omitted,  I 
proceed  briefly  to  describe  the  steps  in  their  execution. 

Symphyseotomy. — Fern  el,  Pineau,  and  several  of  the  older  authors,  im- 
pressed with  the  belief  that  the  articulations,  and  even  the  bones  of  the  pelvis 
are  susceptible  of  softening  during  pregnancy,  imagined  that  benefit  would 

*  The  instrument,  which  was  removed  on  the  fifth  or  sixth  day,  brought  with  it  on  one  of  its 
flat  surfaces,  the  double  intestinal  layer,  sloughed  off. 


OPERATIVE   SURGERY.  719 

result  from  promoting  this  relaxation  in  cases  of  narrowness  of  the  pelvis ;  and 
tliis  might  be  effected  by  means  of  embrocations,  poultices,  and  general  and 
topical  bathing.  Certain  of  our  modern  writers,  proceeding  on  the  vulgar  tradi- 
tions spoken  of  bj  Riolan  and  Pare,  which  assures  the  people  that  among  many 
nations  it  is  customary  to  fracture  the  pelvis  of  little  girls  soon  after  birth,  to 
facilitate  in  them  the  process  of  parturition ;  and  likewise  on  the  saying  of 
Galen,  when  on  the  subject  of  the  pelvis:  "non  tantum  dilatari,  sed  et  secari 
tuto  possunt  ut  internis  succurratur,"  have  supposed  that  this  section  of 
the  symphysis  must  have  been  known  from  the  very  remotest  antiquity. 
Certainly,  Lacourvee,  who  wrote  in  1655,  does  mention  a  mis-shapen  woman 
who  died  before  delivery ;  and  in  whose  dead  body  he  separated  the  pubic 
symphysis,  with  the  intention  of  enlarging  the  pelvis ;  it  is  true,  likewise,  that 
Plenks,  in  1766,  did  the  same  thing  upon  another  individual.  But  it  is  as 
certain  notwithstanding,  that  to  no  one  had  it  ever  occurred  to  propose  it 
formally  as  an  operation  practicable  on  the  living  female,  until  Sigault,  then 
only  a  student,  made  it  the  subject  of  a  paper  which  he  read  before  the  Aca- 
demy of  Surgery  in  1768.  It  is  the  only  safe  means  which  can  be  resorted 
to  of  preserving  the  child,  under  these  circumstances ;  1st,  where  its  head  is 
strongly  impacted  in  the  upper  strait,  or  below  it;  2d,  when  the  head  having 
passed  the  abdominal  strait,  is  arrested  by  the  contraction  of  tlie  perineal 
circle :  3d,  when  the  trunk  being  delivered,  the  head  remains  behind  in  the 
pelvic  cavity.  In  these  cases  it  is  preferable,  even  after  the  death  of  the 
mother,  to  theCesarian  section,  for  it  would  be  nearly  impossible  to  remove  the 
foetus  alive  through  the  incision  in  the  abdomen. 

Metlwd  of  Operation. — The  patient  being  placed  upon  an  operating  table, 
or  upon  a  bed,  in  the  manner  adopted  for  applying  the  forceps,  is  to  have  the 
lower  limbs  slightly  flexed  and  held  asunder  at  a  proper  distance ;  one  assis- 
tant supports  her  shoulders,  two  others  take  possession  of  the  knees ;  a  fourth 
makes  tense  the  integuments  over  the  abomen,  and  a  fifth  is  selected  to  hand 
the  instruments  to  the  operator  as  he  requires  them.  The  surgeon  seated  or 
standing  up,  or  to  the  right  of  the  patient,  or  between  her  legs,  armed  with  a 
convex  bistoury,  makes  an  incision  which  is  to  commence  a  little  above  the 
symphysis,  and  be  continued  as  far  as  the  upper  surface  of  the  clitoris. 
The  integuments,  previously  shaved,  and  all  the  soft  paits  of  the  mons 
veneris,  are  divided  by  this  cut,  which  is  parallel  to  the  axis  of  the  body,  and 
as  nearly  as  possible  in  the  centre  of  tlie  articulation.  It  is  well  however,  in 
coming  to  the  lower  part,  to  incline  the  incision  a  little  to  one  side  between 
the  summits  of  the  labii  majus  and  minus,  and  also  to  separate  one  of  the 
roots  of  the  clitoris  from  the  ramus  pubis  in  order  to  avoid  afterwards  any 
dangerous  laceration.  The  arteries  to  be  tied  can  be  but  very  small  ones, 
unless  the  internal  pudic  have  been  divided  by  an  incautious  prolongation  of 
the  section  into  the  parts  below.  Some  have  advised,  that  to  divide  the  car- 
tilage we  should  proceed  from  below  upwards;  others  from  above  down- 
wards; many  from  behind  forwards,  or  from  within  outwards;  but  the 
majority  recommend  that  it  should  be  done  from  before  backwards.  To 
effect  this,  a  bistoury,  a  scalpel  of  a  shield-like  shape  {en  rondache),  the 
flexible  knife  of  Aitken,  a  bistoury  with  a  small  button  at  its  extremity,  or  a 
common  bistoury,  the  point  of  which  M.  Gardien  thinks  should  be  protected 
from  causing  internal  organic  lesions  by  the  nail  of  the  left  index  finger, 
■  oyp  Kppn  pmnloved. 


720  NEW    ELEMENTS    OF 

•  None  will  dispute  the  right  of  every  one  in  such  a  case  to  choose  for  him* 
self  the  instrument  to  which  he  is  most  partial.  For  my  own  part  I  think 
that  in  this,  as  in  every  other  case,  it  is  to  the  hand,  and  not  to  the  instrument 
that  regard  is  to  be  had  ;  and  that  the  only  requisite  about  the  knife  is  that  it 
be  solid,  and  very  sharp.  The  surest  way  is  to  divide  the  cartilage  from  above 
downwiirds,  £md  from  the  cutaneous  towards  the  pelvic  surface  of  the  sym- 
physis. The  incision  should  be  extended  upward  for  half  an  inch  or  an  inch 
on  the  linea  alba,  to  avoid  injuring  the  bladder  or  urethra ;  for  it  has  happened 
that  surgeons  at  one  stroke  have  gone  through  both  bladder  and  uterus  down 
to  the  head  of  the  foetus.  It  will  always  be  enough  to  hold  the  bistoury  at  a 
few  lines  from  its  point  with  the  first  two  fingers  of  the  left  hand,  whilst  the 
cutting  is  done  with  the  right.  The  previous  introduction  of  a  catheter  will 
also  obviate  this  risk  ;  or  if  not  beforehand,  at  least  just  before  beginning  the 
second  stage  of  the  operation.  The  bladder  is  thus  emptied,  and  then  the 
catheter  serves  to  draw  the  urethra  gently  to  the  right,  whilst  the  incision  of  the 
sub-pubic  ligament  is  slightly  inclined  to  the  left.  The  ligamentous  tissue 
once  divided,  increased  precaution  is  necessary;  the  cutting  is  done  rather 
by  scratching  with  the  point  of  the  bistoury,  which  is  to  be  laid  aside  so  soon 
as  nothing  more  that  is  firm  or  elastic  remains  to  be  cut  through.  Should  it  so 
happen  that  the  cartilage  is  found  to  be  ossified,  there  would  be  so  little 
chance  of  obtaining  any  considerable  increase  of  room,  except  by  sawing 
through  the  articulation  as  was  done  by  Siebold,  that  I  should  prefer  to  have 
recourse  to  the  Cesarian  section.  If  the  plan  of  Desgranges  of  applying  the 
saw  beyond  the  symphysis  pubis  upon  the  body  of  the  bone  be  practised,  the 
operation  would  be  equally  dangerous,  for  it  is  in  the  sacro-iliac  symphysis, 
and  not  in  front,  that  the  difficulty  is  experienced.  No  sooner  is  the  separa- 
tion of  the  symphysis  effected  than  the  posterior  branch  of  the  curved  lever, 
formed  by  the  os  innominatum  drawn  backwards  by  its  posterior  ligaments, 
produces  a  separation  of  six  or  twelve  lines  between  the  ossa- pubis;  the 
extent  of  which  will  vary  according  to  the  degree  of  contraction  in  tlie  pelvis, 
and  that  of  the  consistence  or  softening  of  the  cartilages.  Though  it  is  some- 
times effected  equally  at  the  expense  of  both  bones,  it  must  also  sometimes 
depend  much  more',  upon  one  bone  than  on  the  other.  Be  this  as  it  may,  I 
can  scarcely  believe  it  possible  that  it  can  of  itself  grow  to  such  a  degree  as  to 
become  dangerous ;  and  that  it  can  be  needful  to  guard  against  this  by  con- 
fining the  hips  before  the  end  of  the  operation,  as  has  been  recommended.  On 
the  contrary  it  is  almost  always  necessary  to  press  upon  the  spines  of  the  ilia 
frgm  before  backwards,  and  from  within  outwards,  with  slowness  and  in 
moderation;  or  else  to  separate  the  thighs  of  the  female  tenderly  to  carry  it 
to  a  sufficient  extent. 

The  delivery  being  effected,  the  surgeon  wipes  the  parts,  approximates  the 
pubes  one  to  the  other,  covers  the  wound  with  a  rag  spread  with  cerate,  some 
lint,  and  a  compress,  all  kept  on  by  means  of  a  bandage  round  the  body  ap- 
plied sufficiently  tight  as  at  least  partially  to  oppose  any  fresh  separation  of 
the  joint.  The  patient  is  to  lie  on  her  back  in  a  state  of  perfect  immobility. 
The  thighs  at  least  are  in  need  of  the  most  absolute  repose  fw  six  weeks  or 
two  months,  which  is  the  time  requisite  for  the  reconsolidation  of  the  sym- 
physis. She  is  moreover  to  be  restricted  to  the  regimen  suitable  after  serious 
operations ;  and  the  untoward  symptoms,  if  any,  which  arise  are  to  be  met  and 


OPERATIVE    SURGERY.  721 

treated  with  promptitude  and  energy.  As  the  time  for  recovery  draws  near, 
walking  and  motion  are  to  be  allowed  with  the  utmost  limitation;  if  there  be 
still  pain,  and  a  degree  of  mobility  in  the  pelvis,  the  state  of  rest  is  for  a  cer- 
tain time  to  be  resumed.  Nothing  undoubtedly  can  be  more  desirable  than 
consolidation  in  the  divided  symphysis;  but  women,  in  whom  it  could  not  be 
effected,  have  nevertheless  been  ableto  walk,  stand  upright,  and  even  to  leap, 
without  any  sensible  inconvenience;  a  peculiarity  explicable  onjy  by  sup- 
posing an  acquisition  of  greater  solidity  in  the  posterior  articulations.  MM. 
A.  Leroy  and  Lescure  go  so  far  even  as  to  say  that  this  should  be  encouraged 
by  dispensing  with  the  bandage  round  the  pelvis ;  they  assert,  and  perhaps 
not  entirely  erroneously,  that  the  interpubic  space  becomes  filled  up  with  cel- 
lulo-fibrous  tissue,  which  detracts  nothing  from  the  resistance  of  the  articula- 
tions, and  which  in  the  end  would  have  the  effect  of  causing  the  woman  to 
lic-in  with  the  greater  facility. 

The  few  advantages  of,  and  great  danger  in  symphyseotomy  are  now  so 
fully  established  that  it  is  seldom  performed ;  and  it  is  really  a  sort  of  event 
in  surgery  that  M.  Stork  should  have  had  a  successful  issue  from  it  in  1829. 
Upon  the  whole,  when  it  is  considered  that  of  forty -three  women  on  whom  it 
has  been  performed,  fourteen  have  died ;  that  many  have  remained  cripples 
for  life,  and  particularly  the  two  operated  on  at  La  Maternite,  of  whom 
Mdme.  Lachapelle  speaks  :  that  in  many  it  v/as  not  indispensable,  for  as  may 
be  seen  in  the  w^ork  of  Baudelocque,  they  would  have  been  delivered  at  a 
later  period ;  that  in  most  of  the  cases  the  foetus  has  not  survived,  and  that 
in  fact  it  must  perish  in  most  of  the  cases,  owing  to  turning  beino;  performed, 
ilr  to  the  use  of  forceps,  which  it  is  almost  always  necessary  to  attempt ; 
lastly,  that  as  Lauverjat  has  said,  out  of  eighteen  ojierations  twenty-one  per- 
sons, mothers  and  children  have  lost  their  lives ;  that  in  two  cases  it  has  been 
necessary  to  recur  to  the  Cesarian  section ;  that  five  liave  been  followed  by 
incontinence  of  urine,  and  one  by  limping;  that  in  thirty-four  cases  spoken 
of  by  Baudelocque,  only  eleven  children  were  saved;  when  1  say  these 
dangers  are  considered,  and  fairly  weighed  against  the  advantages  gained 
even  in  the  happiest  termination  of  the  proceeding,  it  is  difficult  to  avoid 
siding  with  Desormeaux  in  the  conclusion  that  section  of  the  pubis  is  not  less 
serious  than  the  Cesarian  operation,  and  that  its  use  must  be  restricted  to  very 
narrow  limits  indeed. 

Procedure  of  M.  Catolica. — If  I  rightly  understood  what  was  said  to  me 
by  Professor  Vulpes,  it  would  appear  that  Dr.  Catolica  of  Naples  has  substi- 
tuted for  symphyseotomy  another  operation,  which'strictly  speaking  is  merely 
a  modification  of  that  already  proposed  by  Desgranges  of  Lyons.  Instead 
of  dividing  the  cartilage,  he  advises  a  section  of  the  body  and  ramus  of  the 
pubis  on  either  side,  to  be  made  between  the  sub-pubic  or  thyroid  foramina, 
as  formerly  proposed  by  Aitken.  Thus  the  sacro-iliac  symphysis  woiild  re- 
main unharmed ;  no  danger  of  wounding  either  the  bladder  nor  urethra  is 
incurred;  the  cellular  tissue  of  the  pelvis  is  scarcely  disturbed  ;  consolida- 
tion is  easily  effected;  no  abscess,  no  caries,  no  fistula,  no  limping,  no  peri- 
tonitis is  to  be  feared;  and  a  considerable  increase  of  the  sacro-pubic 
diameter  obtained  notwithstanding.  I  know  not  enough  of  tiie  reasoning  of 
the  author  of  the  plan  to  warrant  me  in  condemning  or  approving  of  it;  and 
shall  rest  satisfied  with  this  brief  statement  until  I  become  possessed  of  more 
91 


722  NEW    ELEMENTS    OF 

ample  information.  I  shall  only  say  that  some  experiment  on  the  dead  body, 
and  some  attempts  made  by  Mr.  Ashmead,  lead  me  at  first  sight  not  wholly 
to  reject  the  idea  of  the  professor  at  Naples. 

Abdominal  Ulerotomia. — Cesarian  Operation. — Hyslerotomia. — Hysterotomo- 
kia. — Cesarian  Delivery. — Gastro-hysterotomia, 

y  The  name  Cesarian  section  is  given  to  the  opening  made  in  the  female  abdo- 
men and  uterus,  for  the  purpose  of  removing  thence  the  foetus  when  incapable 
of  passing  joer  vias  naturales.  It  has  been  extended  also  since  the  time  of 
Simon  to  the  incision  or  incisions  which  it  sometimes  becomes  necessary  to 
make  in  the  neck  of  the  uterus,  with  a  view  of  facilitating  the  passage  of  the 
head  of  the  child. 

HisioricaL — Lost,  as  it  were,  in  the  darkness  of  ages,  the  history  of  this 
operation  none  have  thus  far  been  able  to  trace.  In  the  fabulous  periods  we 
are  told  that  an  infant,  the  child  of  Jupiter,  was  taken  by  Mercury  from  the 
womb  of  Semele,  his  mother.  The  Romans  said  the  same  of  Esculapius,  who 
was  taken  from  his  mother  by  Apollo  whilst  she  lay  upon  the  funeral  pile 
which  was  soon  to  consume  her.  Lycus,  we  are  told  by  Virgil,  came  thus 
into  the  world.  These  vague  traditions,  a  passage  in  Pliny,  and  some  edicts 
of  the  Roman  law,  lead  to  the  belief  that  the  Cesarian  section  was  in  use  in 
very  remote  ages.  In  a  work  by  Mr.  Mansfield,  of  which  an  extract  may  be 
found  in  the  Bulletin  des  Sciences,  the  author  has  attempted  to  prove  that  it 
was  practised  also  by  the  Jews.  It  is  stated  in  the  Talmud,  and  in  the  Mis- 
chajoth,  that  a  child  born  by  a  section  of  the  belly  enjoys  none  of  the  rights 
of  primogeniture.  Jaschi  has  described  it  in  his  commentary  on  the  Nidda, 
and  asserts  that  women  on  whom  it  had  been  performed  were  not  liable  to  the 
forty-days'  purifying. 

Nothing  however  exists  to  prove  at  all  authentically  that  it  was  ever  prac- 
tised on  the  living  subject  before  the  year  1520,  unless  the  case  of  a  certain 
lady  of  Craon,  who,  according  to  Goulin,  submitted  to  the  section  of  the  abdo- 
men in  1424,  and  with  her  child  survived  it,  be  admitted  as  accurate.  The 
ancient  Greek  and  Latin  physicians  in  no  way  allude  to  it.  Guyde  Chauliac, 
proceeding  on  that  passage  of  Pliny  which  follows,  seems  first  to  have  de- 
scribed it.  "  Auspicatus,  enecta  parente,  gignuntur,  sunt  Scipio  Africanus, 
prior  natus,  priusque  Csesus,  Caesomatris  utero,  dictus,  quade  causa,  Caesariis 
appellati,  simile  modo  natus  est  Manlius  qui  Carthaginem  cum  exercitu  in- 
travit;"  and  he  seems  to  think  it  derived  its  name  from  Julius  Cesar.  Others, 
on  the  contrary,  contend  that  it  was  from  the  operation  that  tliis  person  and 
his  family  derived  the  appellation.  Bayle  however  has  noticed  that  since  the 
mother  of  Cesar,  Aurelia,  was  living  when  her  son  invaded  Britain,  the  ac- 
count given  by  Pliny  must  be  rejected  as  fabulous.  The  researches  of  Weid- 
mann  and  Sprengel  having  failed  to  throw  any  additional  light  on  the  subject, 
we  can  only  admit  the  etymology  of  the  Cesarian  section  to  be  no  better 
known  than  its  origin. 

According  to  M.  Baudelocque  himself,  the  Cesarian  section  has  been  twenty- 
four  times  practiced  with  success  since  1750  up  to  the  beginning  of  the  present 
century;  since  which  time,  exclusive  of  too  cases  not  admitting  of  any  doubt, 
mentioned  by  Lauverjat,  it  has  been  practiced  twice  at  Nantes,  by  Bacqua. 


OPERATIVE    SURGERY.  7£3 

and  upon  the  same  female ;  once  by  M.  Le  Maisti*e,  of  Aix;  once  at  Martini- 
que, by  a  Mr.  Dariste;  once  in  1823,  at  Dahlen,  by  Vonderfuhr ;  again  on 
the  lith  of  May,  1827,  by  the  surgeons  at  the  hospital  at  Florence;  twice  by 
Schenck ;  once  again  by  Bulk ;  once  by  Graefe ;  once  by  Luch ;  once  by 
Burns :  again  very  recently  in  the  colonies  ;  so  that  it  is  now  quite  impossible 
to  deny  that  some  women,  at  least,  may  be  saved  through  its  intervention. 
Yet  neither  can  the  danger  which  attends  it  be  denied.  Boerhaave  and  Boer 
were  certainly  incorrect  in  the  assertion,  that  scarce  one  instance  of  success 
occurs  in  fourteen  cases,  but  it  is  quite  certain  that  it  has  been  performed 
four  times  in  twenty  years,  at  the  Maternite  in  Paris,  and  that  all  four  patients 
died ;  that  out  of  seventy-three  cases  quoted  by  Baudelocque,  death  resulted 
in  forty-two  of  them  ;  that  forty-five  cases  out  of  one  hundred  and  six  re- 
lated by  Sprengel,  failed ;  and  that  of  the  two  hundred  and  thirty-one  cases 
mentioned  by  Kellie  and  Hull,  one  hundred  and  twenty-three  did  notsucceed 
in  preserving  the  lives  of  the  women.  Thus  far  it  then  may  be  said  that  one 
out  of  every  two  cases  of  Cesarian  section  has  been  fatal ;  and  Tenon  was 
certainly  wrong  in  his  statement,  that  since  the  days  of  Bauhin  seventy  women 
had  been  operated  on  at  the  Hotel  Dieu,  and  recovered.  According  to 
Messrs.  S.  Cooper  and  J.  Burns,  although  it  has  been  done  fifteen  or  twenty 
times,  there  is  as  yet  no  instance  on  record  of  a  successful  result  of  the 
operation  in  Great  Britain, 

Nevertheless,  it  does  not,  a  priori,  appear,  how  it  should  be  of  so  terrifying  a 
nature.  The  wounds  which  it  is  necessary  to  make  through  the  parietes  of  the 
abdomen  is  very  large,  it  is  true  ;  yet  the  parts  cut  through  are  by  no  means 
delicate;  there  are  no  arteries,  no  nerves  of  any  size,  no  important  parts  to 
be  avoided.  The  peritoneum  is  wounded  ;  but  the  viscera  are  easily  pro- 
tected. How  very  common  it  is  to  see  the  most  extensive  and  complicated 
wounds  of  the  abdomen,  and  punctures  of  every  kind  occurring;  and  yet 
give  rise  to  slight  symptoms,  and  the  patients  to  get  well.  Do  we  not  every 
day  divide  the  serous  membrane  of  the  belly  unhesitatingly  in  patients 
affected  witli  strangulated  hernia?  Is  it  the  incision  into  the  uterus  alone 
which  is  so  very  dangerous  then  ?  On  the  contrary,  there  is  every  indication 
about  the  organs  of  feeble  irritability;  of  very  little  inclination  to  take  on 
inflammation  ;  and  the  best  condition  of  parts  for  safe  and  speedy  cicatriza- 
tion. Are  there  not  cases  on  record,  and  particularly  that  recently  published 
by  Dr.  Frank,  of  women  who  have  submitted  to  and  recovered  from  the 
Cesarian  section,  after  laceration  of  the  uterus.  The  wound  at  first  is 
very  extensive;  but  soon  is  reduced  to  four-sixths,  or  five-sixths  of  its  length ; 
and  hemorrhage,  when  the  organ  is  free  to  contract,  ceases  too  soon  to  be 
even  alarming.  Is  it  not  also  possible,  by  means  of  proper  precaution,  to 
])revent  any  effusion  of  the  liquor  amnii,  of  blood,  and  other  fluids  into  the 
peritoneum,  during  and  directly  after  the  operation.  It  would  appear  from 
this,  that  it  is  not  alone  owing  to  the  operation  itself,  but  to  some  particular 
condition  of  the  patient  operated  on,  that  hysteriotomy  is  so  fatal ;  and  I 
cannot  therefore  help  thinking,  that  if  it  were  done  as  soon  as  it  is  positively 
indicated,  and  not  after  the  woman  is  exhausted  by  vain  efforts ;  after  the 
uterus  has  become  passive,  or  has  taken  on  incipient  inflanmiation,  if  not 
positively  phlogosed  ;  after  peritonitis,  or  enteritis  are  imminent,  or  decided; 
after  life  is  in  short  in  serious  jeopardy,  the  Cesarian  section  would  not  be  so 


^^^  ♦^mP  ^^^   ELEMENTS    OF 

frequently  fatal,  as  unhappily  it  has  so  far  proved  to  be.  It  is  not  only  to  be 
practiced  on  the  living  females,  but  is  also  proper  to  perform  it  on  the  bodies 
of  such  as  die  undelivered  after  the  seventh  month  of  pregnancy.  • 

The  Roman  law,  lex  regla^  which  is  attributed  to  Numa  Pompilius,  even 
then  made  it  incumbent  on  physicians  to  open  all  women  who  died  pregnant, 
as  a  means  of  preserving  citizens  for  the  state.  The  senate  in  Venice,  to 
strengthen  this  ancient  custom,  passed  a  decree  in  1608,  and  1721,  which 
subjected  practitioners  to  very  severe  penalties  if  they  did  not  operate  on  the 
supposed  dead  person  with  all  the  care  which  they  would  have  exercised  if 
she  had  been  living.  The  king  of  Sicily  enacted  another  law,  by  which  he 
subjected  to  the  punishment  of  death,  such  physicians  as*  should  omit  to  per- 
form the  Cesarian  section  on  patients  who  had  died  in  the  latter  months  of 
pregnancy.  As  to  the  necessity  of  acting  immediately  after  the  death  of  the 
mother,  with  equal  caution  as  during  her  life,  it  will  be  judged  of  by  recol- 
lecting the  difficulty  of  forming  any  certain  opinion  as  to  her  actual  decease, 
and  the  haste  which  is  then  to  be  exercised.  Van  Swieten  and  Baudelocque 
relate  three  cases  of  women  believed  to  be  dead,  and  who  recovered  from 
their  lethargy,  just  as  the  operation  was  to  have  been  performed  upon  them, 
Peu  gives  another  instance,  justly  much  more  alarming.  He  was  in  the  act 
of  making  his  incision,  when  the  woman  started,  ground  her  teeth,  and  moved 
her  lips !  Another  equally  remarkable,  is  mentioned  by  Rigaudaux.  He  was 
sent  for  two  leagues  from  Douai,  to  see  a  poor  patient,  whose  labor  gave  rise 
to  the  most  lively  anxiety.  Ere  he  reached  her  she  was  supposed  to  have  been 
dead  two  hours.  Unwilling  to  cut  into  the  abdomen  without  some  further  ex- 
amination, he  explored  the  sexual  organs,  perceived  that  the  pelvis  was  an 
informed  one;  passed  up  his  hand  to  the  feet  of  the  child,  and  delivered  it 
apparently  lifeless;  but  which  by  care  and  attention  was  recusitated  at  the 
expiration  of  a  couple  of  hours.  As  the  limbs  of  the  mother  preserved  their 
flexibility,  Rigandaux  forbid  her  interment  before  the  abdomen  became  green. 
The  woman  happily  recovered  so  perfectly  in  a  few  hours  from  her  state  of 
asphyxia,  as  herself  to  call  on  the  surgeon  four  years  afterwards,  and  inform 
him  of  her  being  still  in  existence. 

When  the  Cesarian  operation  was  performed  after  death,  the  incision  was 
made  always  on  the  left  side  of  the  abdomen,  "  the  woman,"  says  Guy  de 
Chauliac,  '*  being  opened  with  a  razor  on  her  left  side,  because  of  the  liver, 
this  side  being  so  much  more  free  than  the  right."  But  since  it  has  been 
attempted  on  the  living  female,  better  principles  govern  its  performance.  Five 
methods  of  proceeding  on  the  part  of  accoucheurs,  among  the  m^any  which 
there  are,  particularly  require  notice.  1st,  That  in  which  the  incision  is  made 
along  the  median  line,  parallel  to  the  axis  of  the  body ;  £d,  that  in  which  it  is 
made  outside  of  the  rectus  abdominis  muscle  ;  3d,  that  in  which  theparietes 
of  the  abdomen  are  divided  transversely  on  one  side ;  4th,  that  in  which  the 
wound  is  situated  directly  above,  and  in  the  direction  of  the  Fallopian  liga- 
ments ;  5th,  that  which  is  performed  on  a  level  with  the  crista  of  the  ileum. 
Solayres,  Henckel,  Deleurye,  and  others,  have  erroneously  given  the  credit 
of  the  first  of  tliese  procedures,  that  of  incising  on  the  median  line,  to  Plat- 
ner,  Guerin,  or  Varoquier.  Mauriceau  had  previously  expressed  himself 
on  tiie  subject  with  great  clearness.  The  majority  are  in  favor  of  cutting 
into  liie  left  side  of  the  abdomen;  but,  he  continues,  the  opening  would  be 


d 


OPERATIVE    SURGERY.  mlm  725 

better  made  between  the  recti  muscles,  for  there  is  nothing  but  muscles  and 
integuments  to  be  divided.  This  metliod — the  one  to  which  Baudelocque 
gives  the  preference,  that  generally  pursued  in  France,  Germany,  and  Eng- 
land— by  being  done  on  the  linea  alba,  enables  us  to  avoid  the  muscles,  and 
to  give  but  little  pain  :  no  artery  can  be  wounded,  and  the  uterus  moreover 
is  opened  in  a  direction  parallel  to  its  principal  fibres.  It  has  also  been  urged 
against  it  that  it  incurs  the  risk  of  wounding  the  bladder ;  that  the  flow  of  fluids 
during  or  after  the  operation  can  be  effected  only  with  difliculty ;  that  the 
wound,  consisting  only  of  fibrous  tissues,  is  slow  in  healing;  and  that  the 
uterus,  by  being  opened  in  almost  the  whole  extent  of  its  anterior  surface, 
tends  by  contracting  rather  to  separate  than  approximate  the  lips  of  the  in- 
cision into  it. 

In  the  lateral  operation  the  older  accoucheurs  preferred  generally  the  left 
side,  and  made  their  incision  sometimes  straight,  sometimes  slightly  oblique ; 
and  at  others  of  a  crescentic  shape,  but  always  outside  of  the  rectus  muscle. 
This  method,  according  to  those  practitioners  who  adopt  it,  has  the  advantao;e 
over  the  other  of  shielding  the  bladder  wholly  from  any  accident ;  of  admit- 
ting of  easy  cicatrization ;  and  of  interfering  less  with  the  escape  of  fluids 
which  ought  to  pass  out  by  the  wound.  As  the  uterus  is  almost  always  bent 
a  little  on  its  axis  by  inclining  to  either  the  right  or  left  side,  it  has  been 
thought  that  the  incision  into  the  median  line  would  fall  rather  on  its  left  edge 
than  on  the  middle  o^  its  anterior  surface.  Pursuant  to  this  view  it  has  been 
advised  to  operate  on  that  side  to  which  the  uterus  naturally  inclined.  Ad- 
mitting the  reality  of  these  advantages,  they  would,  I  think,  be  more  than 
overbalanced  by  the  danger  of  cutting  the  epigastric  artery,  or  its  branches  ; 
of  producing  an  opening  whose  lips  could  with  difliculty  be  kept  in  contact, 
owing  to  the  retraction  of  the  oblique  and  transversalis  muscles  ;  and  by  the 
impossibility  of  obviating  the  defect  in  the  parallelism  with  two  incisions, 
that  of  the  abdomen,  and  that  of  the  womb. 

To  avoid  the  inconveniences  connected  with  these  two  proceedings,  jUiu- 
verjat,  who  at  first  had  thought  that  hysterotomy  in  the  median  line  offered  great 
advantages,  endeavored  to  methodize  a  plan  which  had  by  some  physicians 
been  before  practised,  and  recommends  that  a  transverse  incision,  five  inches 
long,  be  made  between  the  rectus  muscle  and  the  spinal  column;  more  or  less 
below  the  last  false  rib,  according  to  the  distance  of  the  fundus  uteri.  Thus, 
says  he,  the  fibres  of  the  transversalis  are  separated  rather  than  cut  through  ; 
the  lumbar  and  epigastric  arteries  are  avoided ;  and  the  fundus  uteri  come 
down  upon,  whose  cavity  forms  a  funnel,  so  as  to  render  the  escape  of  the 
lochia  both  by  the  vagina  and  the  wound  very  easy.  Sutures  are  unneces- 
sary, and  the  parallelism  easily  preferred.  Simple  position  is  sufficient  to 
keep  the  edges  of  the  division  in  exact  contact.  The  outer  angle  of  the 
wound  having  a  depending  direction,  there  is  incomparably  less  fear  of  abdo- 
minal effusion  than  by  any  other  method :  but  it  may  be  objected  that  the 
fleshy  fibres  of  the  great  and  lesser  oblique  muscles  are  necessarily  divided  ; 
that  the  least  effort  must  expel  the  viscera;  that  the  uterus  is  opened  at  its 
fundus  where  its  vessels  are  largest,  speedily  retracts  from  the  external  aper- 
ture, and  that  the  contraction  of  its  fibres  ought  to  hinder,  rather  than  promote 
the  healing  of  its  cut  edges;  so  that  in  fact,  notwithstanding  Lauverjat's  two 
successful  cases,  and  the  seeming  preference  given  to  it  by  M.  Sabatier  and 


726  NEW    ELEMENTS    OF 

M.  Gardien,  this  method  evidently  is  not  less  dangerous  than  the  two  which 
preceded  it.  Fearing  above  all  things  injury  of  the  peritoneum  and  the  body 
of  the  uterus,  M.  Ritgen  has  advised  us,  lately,  to  incise  transversely  the 
attachments  of  the  broad  muscles  of  the  abdomen  to  the  crista  of  the  ileum ;  to 
detach  the  peritoneum  as  far  as  the  upper  straits,  and  divide  the  cervix  uteri 
to  an  extent  sufficient  to  admit  of  the  extraction  of  the  foetus.  In  the  first 
place,  I  do  not  see  how  it  can  be  possible  to  divide  the  summit  of  the  uterus, 
"without  also  dividing  the  serous  membrane  which  envelopes  it;  and  the  other 
inherent  difficulties  in  the  measure,  added  to  the  detachments  which  must  take 
place  in  the  fossa  iliaca,  seem  to  me  such  as  cannot  fail  to  render  this  equally 
dangerous  with  any  operation  previously  spoken  of.  So  far  as  my  knowledge 
extends,  however,  it  is  a  mere  project;  and  as  yet  has  never  been  practised 
by  any  one  upon  the  living  female. 

The  nephew  of  M.  Baudelocque,  who  attributes  the  principal  dangers  which 
attend  the  Cesarian  section  to  the  double  lesion  inflicted  on  the  peritoneum, 
and  believing  wounds  of  the  uterus  to  be  essentially  fatal,  has  proposed  a  new 
method  which,  in  this  double  respect,  seems  to  him  more  advisable  than  any 
other;  from  which  indeed  it  differs  very  considerably. 

The  incision  begins  near  the  spine  of  the  pubis,  extends  laterally,  parallel 
toPoupart's  ligament,  to  a  little  below  the  antero-superior  spine  of  the  ileum. 
He  selects  the  left  side  on  account  of  the  obliquity  of  the  neck,  when  the 
uterus  is  inclined  to  the  right;  the  right  side  in  an  opposite  state  of  things. 
Having  divided  the  Wall  of  the  abdomen,  not  injuring  the  epigastric  artery, 
he  pushes  back  the  peritoneum  from  the  fossa  iliaca  into  the  pelvic  cavity, 
and  from  off  the  upper  part  of  the  vagina,  which  he  then  opens.  This  operation 
must  be  of  some  extent;  and  through  it  the  finger  is  carried  to  the  os  uteri, 
which  it  endeavors  to  draw  towards  the  wound  in  the  abdomen,  whilst  pres- 
sure is  made  upon  the  fundus  in  an  opposite  direction  to  favor  its  reversion. 
When  we  have  succeeded  in  bringing  the  cervix  in  opposition  with  the  open- 
ing through  the  parietes  of  the  abdomen,  the  delivery  may  be  left  to  the 
natural  efforts  of  the  uterus,  or  if  absolutely  necessary  the  uterine  orifice  is 
dilated  with  the  fingers,  and  the  foetus  removed  either  by  the  hand  or  the 
'  forceps. 

The  conception  of  this  operation,  called  "  elytromia"  by  its  inventor,  is 
certainly  highly  ingenious.  He  has  made  on  the  dead  subject,  either  pregnant 
oi*  unimpregnated,  many  experiments,  which  have  confirmed  him  in  the 
favorable  opinion  he  had  formed  of  it ;  and  which  have  been  of  sufficient  in- 
fluence to  cause  several  practitioners  to  hesitate  in  their  opinions  as  to  its 
importance.  Sir  C.  Bell  and  Mme.  Boivin,  fearing  hemorrhage  more  parti- 
cularly after  the  Cesarian  operation,  had  equally  felt  the  necessity  of  incising 
the  womb  as  near  its  summit  or  neck  as  possible,  in  which  spot  the  fewest 
vessels  exist.  I  cannot  bring  myself  to  believe  that  in  most  cases  such  an 
operation  is  practicable;  or  that  the  laceration  of  the  vagina,  combined  with 
the  injury  effected  in  the  fossa  iliaca  and  pubic  excavation,  can  be  much  less 
dangerous  than  the  simple  straight  forward  incision  through  the  peritoneum 
and  uterus,  which  can  be  made  in  performing  ordinary  hysterotomy.  I  may 
add,  that  recently  M.  Baudelocque,  junior,  has  himself  been  obliged  to  have 
recourse  to  the  Cesarian  operation,  properly  so  called,  in  the  case  of  a  woman 
he  had  watched  for  a  good  while,  after  performing  on  her  his  "  elytromia," 


OPERATIVE    SURGERY.  727 

and  being  assisted  in  the  operation  by  M.  Herves  de  Chegom.  1  Know  the 
impropriety  of  drawing  sweeping  conclusions  from  a  single  fact;  but  the 
result  of  this,  the  only  experiment  made  on  a  living  female,  with  me  adds 
great  strength  to  the  apirori  opposition  offered  by  reflection  to  the  views  of 
the  author.  Another  mode  of  operating,  somewhat  analogous  to  that  of  M. 
Ritgen,  and  not  very  far  removed  either  from  that  of  M.  Baudelocque,  seems 
to  have  been  suggested  about  the  same  period  by  Dr.  Physick.  The  surgeon, 
after  observing  that  in  many  cases  of  pregnant  women  it  was  easy  to  separate 
the  peritoneum  from  the  bladder  and  from  round  about  the  neck  of  the  uterus, 
thought  that  by  making  a  horizontal  incision  directly  above  the  pubis,  the 
cervix  uteri  might  be  arrived  at  and  opened  without  any  interference  with  the 
serous  abdominal  membrane.  The  operation,  whatever  Dr.  W.  E.  Horner 
may  say  of  it,  is  rather  unworthy  of  its  inventor,  and  not  worth  dis- 
cussing. 

Method  of  Operation. — Never,  and  if  particularly  the  operation  recom- 
mended by  Mauriceau  be  followed,  should  evacuation  of  bladder  and  rectum 
previous  to  its  being  commenced  be  neglected.  The  instruments,  &c. 
required,  are  a  straight  and  a  convex  bistoury,  a  probe-pointed  bistoury,  for- 
ceps, scissors,  suture  needles,  ligatures,  quills,  strips  of  adhesive  plaster, 
little  balls,  and  square  cakes  of  lint.  Besides  which,  pieces  of  linen  spread 
with  cerate,  long  square  compresses,  a  bandage  to  go  round  the  body,  large 
soft  sponges,  a  syringe,  gumelastic  tubes  in  case  injections  are  necessary, 
tepid  and  cold  water,  vinegar,  wine,  and  eau  de  Cologne,  are  equally 
requisite. 

The  patient  should  lie  as  much  as  possible  upon  the  bed  to  which  she  is 
intended  to  be  confined  for  the  first  few  days  after  the  operation ;  and  in  as 
comfortable  a  posture  as  possible.  She  is  to  be  placed  upon  her  back,  her 
head  genth^  raised,  the  legs  and  thighs  very  slightly  flexed ;  assistants  are 
directed  to  watch  over  her  motions,  lest  she  should  make  any  inconsiderately 
under  the  influence  of  pain.  Two  experienced  persons  are  to  apply  their 
hands  upon  the  sides  and  fundus  of  the  uterus,  so  that  no  other  part  may 
slip  between  its  anterior  surface  and  the  parietes  of  the  abdomen,  and  so 
that  it  may  make  as  it  were  but  one  substance  with  this  latter  part.  I 
think  it  is  better  to  apply  the  bare  hands  themselves  than  to  place  them  on 
large  sponges,  as  is  advised  by  Drs.  Hedenus  and  Kluge. 

The  surgeon  with  the  convex  bistoury,  cuts  through  the  integuments  from 
about  the  umbilicus  to  the  pubis,  a  distance  of  five  or  six  inches,  it  not  being 
necessary,  or  always  possible  to  make  for  this  purpose  the  large  fold  advised 
by  Levret. 

Next  he  divides  in  the  same  manner  the  subcutaneous  tissue,  the  muscu- 
lar aponeurosis  and  fibres,  unless  the  incision  is  over  the  median  line  ;  and 
also  the  cellular  tissue.  This  incision  must  not  be  carried  too  low  down 
towards  the  symphysis  on  account  of  the  nearness  of  the  bladder,  and 
because  the  abdominal  parietes  just  here,  are  usually  very  thick.  It  would 
be  better  to  extend  it  above  the  umbilicus,  being  careful  to  pass  to  the  left  of 
this  cicatrix  to  avoid  the  umbilical  vein,  and  particularly  the  anastomosis 
which  may  possibly  exist  between  it  and  the  epigastric  vein,  which  distribu- 
tion has  of  late  years  been  noticed  by  MM.  Mesniere,  Clement,  and  Martin. 


728  NEW   ELEMENTS  OF 

Having  laid  open  the  peritoneum  to  an  extent  sufficient  to  admit  the  intro- 
duction of  the  left  index  finger,  on  which  the  instrument  is  to  be  conducted, 
the  wound  in  the  membrane  is  to  be  enlarged  with  a  probe-pointed  bistoury 
until  it  acquires  the  same  length  as  the  incision  in  the  skin.  The  uterus  is 
then  laid  bare.  It  is  cut  through  slowly,  layer  by  layer,  until  we  come  down 
to  the  surface  of  the  ovum.  The  assistants  are  then  desired  gently  to  press 
down  the  fundus  uteri,  by  giving  it  a  see-saw  motion  forward,  with  a  view 
To  preserve  as  much  length  of  neck  as  possible ;  or  we  might  follow  the 
advice  of  M.  Kluge,  and  hook  the  finger  in  the  lower  angle  of  the  wound  in 
this  organ,  to  produce,  or  at  any  rate  favor,  a  like  movement,  which  in  giving 
an  opportunity  to  prolong  very  considerably  the  section  upwards,  allows  the 
cervix  to  be  spared.  To  avoid  wounding  the  vessels  of  the  placenta,  it  is 
better  to  finish  the  incision  with  a  probe-pointed  bistoury,  than  to  use  the 
convex  bistoury  upon  a  director.  I  know  of  no  objection  to  detaching  the 
placental  mass  and  its  membranes  beforehand  to  some  extent  with  the  finger. 

Now  it  is,  and  not  before  the  operation,  that  we  may  perhaps  be  allowed  to 
follow  the  advice  of  Pianchon,  to  rupture  the  membranes  high  up  in  tlie 
vagina  with  the  fingers,  or  as  is  customary  in  Germany  with  Siebold's  instru- 
ment. If,  which  I  think  is  peferable,  the  membranes  inclosing  the  ovum  are 
punctured  from  the  wound,  it  then  becomes  necessary  for  the  assistants  to  be 
doubly  careful  not  to  permit  the  abdominal  parietes  to  leave  the  matrix. 
Thus  we  shall  guard  against  effusion  of  the  waters  into  the  peritoneal  cavity, 
and  do  away  the  tendencies  which  the  intestines  have  to  escape  outwardly. 

Removal  of  the  foetus  is  to  be  effected  without  delay.  When  it  presents 
by  the  feet,  head,  or  breech,  it  is  removed  in  that  position  ;  and  to  aid  its  exit, 
the  assistants  are  desired  to  press  slightly  on  the  sides  of  the  matrix  through 
the  parietes  of  the  abdomen. 

;  If  it  be  in  any  other  position,  the  feet  must  be  taken  hold  of,  and  the 
extraction  made  with  as  much  precaution  as  in  a  natural  delivery,  being 
above  all  particularly  careful  not  to  confound  or  injure  by  violence  the  lips- 
of  the  incision  into  the  uterus. 

After  the  delivery  of  the  foetus,  we  may  follow  Pianchon  by  the  assistance 
of  a  gumelastic  catheter,  bring  out  the  funis  through  the  uterus  so  as  to 
deliver  the  after-birth  by  the  vagina;  although  no  future  advantage  is  gained, 
and  the  operation  is  materially  lengthened  by  so  doing.  Besides  which  the 
contraction  of  the  uterus,  which  most  often  renders  it  impossible,  soon  obliges 
the  placenta  to  engage  in  the  wound,  indicating  thereby  the  preferable  mode 
for  its  extraction,  that  it  may  offer  less  bulk  and  resistance.  It  is  even  better 
to  take  hold  of  it  by  the  edge  when  we  can  do  so,  than  to  pull  merely  on  the 
cord.  Care  is  to  be  taken  as  in  a  natural  delivery  to  twist  the  membranes 
into  a  rope,  to  prevent  any  from  remaining  behind  in  the  uterus.  If  it  con- 
tain clots  of  effused  blood  they  must  be  taken  out  with  the  hand.  It  is  also 
admissible  to  wash  out  the  parts  with  an  injection  of  warm  water ;  although  I 
do  not  think  that  with  a  view  of  keeping  open  the  os  uteri,  the  plug  of  lint 
which  Baudelocque  recommends,  the  hollow  bougie  of  Ruleau,  the  tent 
of  Rousset,  tlie  catheter  of  Tarbe,  or  any  other  species  of  tube  whatsoever, 
are  necessary.  They  do  not  prevent  closure  of  the  orifice,  and  would  only 
increjise   the  irritation   without  any  counterbalancing  good.     The    intro- 


OPERATIVE    SURGERY.  '729 

ductioB  of  the  finger  from  time  to  time  will  serve  to  open  it  again  if  it  cease 
to  transmit  fluids,  which  nothing  can  prevent  from  passing  wholly  or  in  part 
tlirough  the  wound  after  all. 

The  operation  being  over,  the  flow  of  blood  is  next  to  be  attended  to  and 
arrested.  In  the  lateral  procedure,  especially  in  that  of  Lauverjat,  many 
small  arterial  branches  may  have  been  divided.  These  are  now  to  be  tied, 
unless  it  lias  been  thought  better  to  do  so  during  the  progress  of  the  opera- 
tion as  they  were  successively  opened.  Whilst  the  operation  is  going  on  the 
orifice  of  the  uterine  artifices  are  to  be  stopped  by  the  fingers  of  the  assist- 
ants. Tiiere  can  be  no  need  of  t}4ng  them,  but  it  has  been  advised  to  caute- 
rize them  in  tlie  plugs  of  vitriol,  or  more  often,  to  trust  the  uterine  contrac- 
tions, which  if  slow  in  occuiTing,  are  to  be  solicited  by  stimulating  the  cavity 
of  the  organ  or  the  wound  with  the  fingers,  or  with  pieces  of  linen  dipped 
in  vinegar  and  water. 

At  the  end  of  a  few  minutes,  the  incision  is  reduced  to  an  extent  of  only 
one  or  two  inches,  after  which  every  kind  of  hemorrhage  becomes  impossible. 
It  is  usual  in  England,  Germany,  and  even  in  France,  to  unite  the  wound  in 
the  abdomen  by  the  interrupted  or  twisted  suture,  because  it  is  said  it  is  the 
only  means  of  keeping  the  surfaces  in  contact,  and  guarding  against  ventral 
hernia.  Still  we  are  recommended  to  do  without  it  by  Sabatier,  who  says,  that 
unless  the  sutures  were  to  go  through  both  thicknesses  of  the  abdominal  pari- 
etes,  which  would  be  dangerous,  straps  of  adhesive  plaster  do  quite  as  well 
as  stitches,  and  do  not,  like  them,  involve  the  safety  of  the  patient.  I 
think  it  preferable,  notwithstanding  the  reasons  assigned  by  this  learned 
writer,  to  employ  stitches,  even  when  we  have  pursued  the  plan  of  Lauverjat. 
In  every  case  the  lower  angle  of  the  wound  is  to  be  left  free,  to  allow  of  the 
escape  of  the  fluids,  and  to  permit  the  pledget  or  tent  which  has  been  left  in 
the  uterus  to  conduct  them  outwardly.  The  insertion  of  stitches  moreover 
does  not  prevent  the  application  of  adhesive  strips  between  them ;  nor  do 
they  interfere  with  the  use  of  a  bandage  and  favorable  position  to  facilitate  the 
action  of  the  plasters.  The  wound  is  then  to  be  covered  with  a  linen  rag 
perforated  with  holes,  or  with  strips  spread  with  cerate.  Two  large  long 
compresses  are  placed  on  the  sides,  little  cushions  of  soft  lint,  common  com- 
presses, and  a  bandage  well  put  on  around  the  body,  conclude  the  dressings. 
We  are  before  leaving  the  woman  to  take  from  her  person  the  linen  which 
has  been  soiled  during  the  operation  ;  then  to  carry  her  as  gently  as  possible 
into  the  middle  of  her  bed,  where  we  try  to  dispose  her  so  as  that  every 
muscle  shall  be  in  a  state  of  relaxation. 

An  anti-spasmodic  draught,  containing  a  gentle  opiate  to  overcome  nervous 
agitation  ;  proper  precautions  for  insuring  the  lochial  discharge  by  the  vagina, 
and  guarding  against  its  effusion  into  the  abdomen;  demulcent  drinks  ;  vene- 
section, and  leeches,  if  the  least  inflammatory  symptom  shows  itself: 
together  with  recommending  the  utmost  calmness  and  tranquillity  both  of 
body  and  mind,  comprise  all  that  can  be  done  by  the  surgeon  for  his  patient 
to  save  her  from  the  dangers  by  which  she  is  menaced. 


I 


Art.  14. —  Vaginal  liter otomy. 

According  to  authors,  verv  many  causes  may  require  the  performance  of 

92 


730  .    NEW  ELEMENTS  OF 

this — the  vaginal  Cesarian  operation.  Such  as  are  most  frequent,  are  oblitera- 
tion, and  fibro-cartilaginous  induration  of  the  cervix,  as  in  the  case  of  which 
Simson  speaks,  and  in  that  also  related  by  Van  Swieten ;  violent  convulsions, 
which  threaten  the  life  of  the  patient,  whilst  the  orifice  is  too  tense  and  too 
imperfectly  dilated,  to  allow  of  the  introduction  of  the  hand  into  it,  as  is  seen 
by  the  cases  of  Duboscq  and  Lambron ;  extreme  backward  obliquity  of  the 
orifice,  the  head  of  the  child  all  the  while  dragging  the  anterior  wall  of  the 
uterus  before  it  as  far  as  the  vulva,  distending  and  thinning  to  a  degree  which 
must  end  in  rupture,  unless  we  hasten,  as  Lauverjat  did,  to  make  an  incision 
into  it.  It  may  be  useful  also,  when  the  uterus,  which  had  prolapsed  from 
the  pelvis  during  pregnancy,  has  never  been  reduced,  and  that  its  neck  cannot 
be  dilated  by  the  fingers,  although  there  be  danger  in  protracting  the  delivery, 
of  which  circumstantial  examples  are  ftirnished  by  M.  Thenance,  Jacomet, 
and  a  surgeon  at  Vaux,  quoted  by  M.  Bodin.  It  is,  however,  in  cases  of 
scirrhosity,  that  it  has  more  especially  been  proposed,  in  which,  so  great  is 
the  resistance  offered  by  the  part,  that  the  woman  exhausts  herself  in  vain 
efforts  to  accomplish  its  dilation.  Lastly,  it  would  be  equally  proper  to  resort 
to  it,  as  M.  Bodin  has  endeavored  to  prove,  in  case  of  an  arm  presenting,  and 
it  was  ever  really  impossible  to  grope  for  the  t'eet,  and  no  other  means  left  of 
avoiding  amputation  of  the  member. 

The  speculum  employed  by  some  is  unnecessary.  With  a  probe-pointed 
bistoury  wound  round  with  a  strip  of  linen  to  about  ten  or  twelve  lines  of 
its  point,  carried  upon  the  fore  finger,  the  neck  is  easily  reached,  unless 
it  be  very  far  from  the  axis  of  the  pelvis.  If  this  on  the  contrary  be  the  case, 
the  probe-pointed  one  should  be  laid  aside,  and  Pott's  curved  bistoury  sub- 
stituted for  it.  One  incision  in  strictness  would  suffice ;  but  as  it  is  important 
that  it  should  not  be  too  deep,  it  is  better  to  make  several  at  short  distances 
from  one  another.  It  might  at  first  seem  as  if  the  head  could  not  effect  a 
.passage  without  enlarging  such  wounds  considerably,  almost  to  carry  them 
into  the  body  of  the  uterus,  and  lacerate  the  peritoneum.  However,  no  such 
thing  happens,  and  they  remain  most  commonly  limited  in  extent  with  the 
thickness  of  the  neck.  When  they  are  practised  for  scirrhous  or  fibrous 
induration,  scarcely  more  than  an  ounce  of  blood  escapes  from  the  part.  It  is 
in  this  case  that  M.  Duges,  I  think  justly,  recommends  the  removal  of  the 
diseased  parts  instead  of  a  mere  incision  into  them.  When  the  anterior 
surface  of  the  uterus  is  divided,  without  one  incision  extending  quite  as  far 
as  the  mouth,  a  straight  or  convex  bistoury,  not  buttoned  at  the  point,  must 
be  employed  for  commencing  the  operation,  which  is  much  more  delicate  in 
this  than  the  preceding  cases.  Too  much  care  cannot  be  taken  to  avoid 
wounding  the  presenting  part  of  the  child  in  making  the  incision.  When, 
however,  the  uterus  is  opened  into,  the  finger  becomes  a  sure  director,  and  on 
it  the  insti'ument  may  enlarge  the  incision  as  far  as  it  is  found  necessary 
without  any  danger.  Let  me  remark,  that  less  risk  is  incurred  in  carrying  it 
backwards  than  forwards,  on  account  of  the  situation  of  the  bladder,  and  that 
moreover  it  is  needless  to  give  it  too  great  an  extent. 

The  wound  after  delivery  rapidly  contracts,  and  often  before  twelve  hours 
has  elapsed,  the  cervix  resumes  its  natural  position.  Should  the  flow  of  blood 
be  too  abundant,  injections  of  oxycrate,  and  the  use  of  a  tampon,  will  generally 
arrest  it  without  difficulty ;  and  cauterization,  which  by  the  way  is  easily 


OPERATIVE  SURGERY.  731 

tried,  will  in  such  cases  be  rarely  indispensable.  As  to  the  lochia,  they 
t^.scape  either  through  the  os  uteri  or  by  the  wound ;  .and  as  concerns  them, 
the  woman  requires  no  other  attention  than  that  usual  after  ordinary  labor. 
All  details  relative  to  cephalotomy,  the  use  of  crotchets,  fillets,  forceps,  the 
operation  of  turning,  &c.,  being  fully  entered  into  in  the  2d  volume  of  my 
Treatise  on  Tokology,  I  do  not  propose  to  reinsert  them  here,  particularly  as 
these  are  operations  which  it  is  exclusively  the  province  of  the  accoucheur  to 
perform.  1  have  spoken  of  symphyseotomy,  and  the  Cesarian  section,  only 
because  a  surgeon  is  sometimes  called  on  by  those  who  have  wholly  devoted 
themselves  to  the  study  of  obstetrics  to  perform  them. 


CHAPTER  V. 

THE- URINARY  APPARATUS. 

SECTION  I. 

The  Operation  of  cutting  for  Stone  or  Lithotomy. 

A.  In  the  Male. 

The  operation  for  stone  which  is  one  of  the  most  ancient  in  surgery,  is  also 
one  of  the  most  important  and  severe.  None,  perhaps,  has  given  rise  to  more 
treatises,  to  more  discussions,  to  more  labor  of  every  description.  The  object 
which  it  has  in  view  is,  the  extraction  of  whatever  substances  may  have  become 
lodged  or  formed  in  the  bladder  by  an  artificial  passage  or  aperture. 

Although  the  word  "  taille"  (cutting)  is  a  very  insignificant  one,  and  not 
very  scientific  either,  I  shall  employ  it  in  preference,  nevertheless.  The 
term  "  lithotomy"  is,  in  this  case,  of  vicious  acceptation  ;  that  of  •*  cystotomy," 
is  no  better,  since  the  urethra,  and  not  the  bladder  is  most  commonly  divided. 
The  fact,  that  every  one  knows  what  is  meant  by  "la  taille,"  is  another  very 
good  reason  for  its  use. 

Hippocrates,  who  does  not  describe  it,  nevertheless  alludes  to  it  at  some 
length,  and  proves  that  there  were  in  past  ages,  as  there  are  in  the  present, 
surgeons'  errant,  whose  whole  occupation  was  to  perform  it. 

To  the  father  of  medicine  it  appeared  either  so  dangerous  or  so  unwortny, 
that  he  required  from  his  pupils  an  oath  that  they  would  never  perform  it; 
an  oath  which,  if  history  may  be  trusted,  was  not  a  useless  one ;  since  some 
of  the  lithotomists  of  the  day,  bribed  by  Tryphorus,  the  usurper,  were  im- 
moral enough  to  perform  it  on  the  young  Antiochus  VI,  who  had  no  stone, 
in  such  a  way  as  that  he  died  under  their  hands. 

Celsus,  the  first  who  has  truly  described  it,  endeavors  to  prove  that  it  was 
applicable  only  to  persons  at  least  fifteen  years  of  age.  This,  it  appears,  was 
the  doctrine  of  the  Alexandrians,  from  whom  the  materials  for  his  chapter 
seem  to  have  been  collected ;  and  this  view  was  also  taken  of  it  by  most 
authors  until  tiie  time  of  Marianus  Santus.  Since  then  both  sexes  have  been 
subjected  to  it,  and  at  all  ages.  Still,  with  all  the  numerous  improvements 
wliich  have  been  in  the  method  of  doing  it,  and  in  all  that  concerns  it,  it  has 


732  NEW   ELEMENTS   Or 

always  been  looked  on  as  so  dangerous,  that  some  measure  is  ever  being  sug- 
gested to  render  it  unnecessary.  None  of  them  having  answered ;  and  all 
belonging  properly  to  the  head  of  true  pathology,  we  shall  not  here  engage  in 
their  examination. 

Neither  shall  I  say  any  thing  in  refutation  of  the  strange  idea  of  Dr.  Dudon, 
who  recommends  plunging  an  immense  trochar  into  the  bladder  through 
the  hypogastrium,  as  a  means  of  getting  at  the  stone,  inclosing  it  in  a  little 
bag,  and  dissolving  it  in  appropriate  chemical  reagents  before  its  extraction. 

To  feel  all  the  danger  and  all  the  absurdity  of  such  a  measure,  it  requires 
only  to  allude  to  it.  I  should  not  even  have  done  that  much,  however,  if  the 
inventor  had  not,  to  my  knowledge,  been  daring  enough  to  put  it  in  practice 
on  a  living  being;  and  if  the  man  who  was  himself  brave  enough  to  submit 
to  a  second  equally  fruitless  attempt,  had  not  very  near  fallen  a  victim  to  his 
credulity.  Other  practitioners  have  contrived  to  break  and  pound  the  stone 
in  the  bladder  into  smaller  portions,  and  in  this  way  to  withdraw  them  from 
it  by  the  natural  passage. 

These  trials  are  ilow  made  regular  methods  under  different  names,  and  will 
be  considered  hereafter  in  a  separate  article. 

Diagnosis. — Most  persons  who  labor  under  stone,  experience  from  time  to 
time,  if  not  constantly,  a  dull  pain  and  a  sense  of  weight  about  the  funda- 
ment; the  pain  increases  on  motion  on  the  receipt  of  jars,  as  when  the  patients 
ride  on  horseback  or  in  a  carriage,  or  when  they  are  compelled  to  undergo  the 
least  jolting. 

The  urine  deposits  a  whitish  sediment  or  flaky  mucus,  sometimes  viscid 
and  ropy.  The  deposits  are  likewise  sandy  and  turbid,  seeming  to  be  puru- 
lent, fetid,  and  tinged  with  blood.  During  its  emission  it  often  happens  that 
the  flow  is  suddenly  suspended ;  and  a  very  simple  change  in  the  position  of 
the  body  will  allow  it  again  freely  to  gush  forth,  as  if  some  valve  for  a  mo- 
ment had  been  placed  over  the  orifice  of  the  urethra.  The  pain  felt  in  the  neck, 
sensibly  increases  as  the  bladder  becomes  empty,  and  particularly  immediately 
after  it  is  completely  so.  The  extremity  of  the  penis  is  the  seat  of  a  pruritus, 
which  leads  the  patient  to  be  constantly  rubbing  and  pulling  at  it;  and  whicli 
is  the  reason  why  great  length  either  of  the  penis  or  prepuce  is  in  children  a 
strong  symptom  of  calculous  disease  in  the  bladder.  The  patient  has  a  fre- 
quent desire  to  urinate ;  and  some  pass  from  time  to  time  gravel,  or  sometimes 
considerable  portions  of  stone.  However,  it  is  not  common  to  see  all  these 
symptoms  combined  in  any  one  individual ;  many  have  scarcely  any  one  of 
them.  Again,  ipany  diseases  of  the  urinary  passages  present  frequently  the 
reunion  of  them  all.  Catarrhus  vesicas,  for  example,  may  be  attended  with 
all  the  changes  which  occur  in  the  urine  in  cases  of  calculus.  If  with  it  there 
exists  any  irritation  in  or  alteration  of  the  urethral  funnel,  the  pain,  the  fre- 
quent desire  to  micturate,  and  friction  of  the  penis,  may  exist  as  if  a  stone 
were  present.  The  feeling  of  weight  about  the  anus  equally  exists  in  enlarged 
prostate.  Hundreds  of  people  have  sandy  deposits  and  gravel,  who.  yet 
have  not  stone.  Of  all  the  symptoms,  that  which  seems  to  be  the  most  con- 
clusive, tlie  sudden  stoppage  of  urine  as  it  flows  when  the  bladder  is  not  yet 
empty,  i^  likewise  met  with  under  other  circumstances.  The  prostate  gland 
may  produce  a  fold  behind  the  urethra,  capable  of  creating  a  mistaken  notion 
on  this  point.  The  same  thing  would  be  caused  by  a  fungous  tumor,  or  cere- 
broid  xnass  springing  from  the  bas-fond  of  the  bladder,  one  of  which  occurred 


OPERATIVE  SURGERY.  733 

last  year  at  the  Hotel  Dieu.  It  would  occur  with  still  greater  facility  even, 
if  the  inferior  wall  of  the  urethra  were  to  give  rise  to  any  polypous  or  pedun- 
culated mass,  one  of  which  was  met  with  by  Mr,  Samuel  Cooper,  which  should 
extend  into  the  neck  of  the  bladder. 

.  A  patient  who  died  at  the  hospital  St.  Antoine  whilst  I  was  in  attendance 
there  in  1829,  presented  this  peculiar  disposition.  It  had  frequently  hap- 
pened that  his  urine  stopped  before  the  bladder  had  been  emptied.  Sounding 
failing  to  convince  me  of  the  existence  of  a  stone,  I  did  not  think  ofjcutting 
the  man.  The  uvula  vesicae  gave  origin  to  a  tumor  like  the  fibrous  masses 
of  the  uterus  in  density  and  structure.  The  tumor,  whose  footstalk  was  very 
delicate  and  much  flattened  in  the  course  of  the  urethra,  was  as  large  as  a 
small  hen's  egg,  and  when  pushed  a  little  forward,  closed  the  urethra  with 
great  exactness  like  a  cork.  The  proof,  moreover,  that  no  one  of  these  signs 
is  conclusive,  is  that  experienced  surgeons  have  often  cut  patients  in  whom 
no  stone  was  found ;  and  they  alone,  therefore,  can  never  justify  the 
operation. 

Catheterism, — Sounds  and  bougies  not  metallic  do  not  answer  for  the  ex- 
amination of  calculi.  Instruments  of  silver,  copper,  gold,  or  platina,  are 
employed  for  this  purpose.  The  three  latter  however  which  have  the  merit 
of  being  more  sonorous,  are  rarely  made  use  of;  the  silver  instrument  being 
generally  preferred.  Some  have  also  thought  that  a  solid  sound,  or  ordinary 
staff,  should  be  substituted  for  the  hollow  instrument,  because  as  being  more 
firm  and  weighty  these  stems  of  metal  would  allow  the  calculus  to  be  more 
distinctly  felt.  There  are  unimportant  minutia  which  a  really  clever  surgeon 
should  neglect.  When  the  instrument  is  in  the  bladder  its  stylet  must  be 
withdrawn,  lest  it  might  mislead  our  senses  by  some  unexpected  friction 
against  the  sheath  which  contains  it.  The  thumb  which  is  applied  over  its 
orifice,  whilst  the  index  and  medius  fingers  hold  it  behind  its  rings,  must  com- 
pletely cover  it,  for  if  it  were  permitted  to  vacillate,  the  result  might  be  a 
vulvular  movement  producing  a  noise  equally  capable  of  deceiving  us.  By 
following  M.  Boyer's  advice,  and  plugging  it  with  a  cork,  &c.,  this  no  longer 
would  be  to  be  feared.  "We  must  be  careful  to  introduce  the  sound  when  the 
bladder  is  full  of  urine ;  as  in  that  way  we  contrive  to  explore  the  whole 
organ  most  surely.  If  the  patient  lies  down,  we  begin  by  moving  the  point 
backwards  upon  the  median  line  to  the  right  and  to  the  left,  inclining  it  with 
greater  or  less  force  to  either  side.  Then  we  raise  the  beak  up  as  high  as 
possible  towards  the  top  of  the  bladder,  powerfully  depressing  the  open  ex- 
tremity ;  after  which  it  is  proper  to  pass  the  heel  (curve)  of  the  instrument 
over  the  neck  and  parts  adjacent,  and  upon  various  points  in  thebas-fond.  If 
all  this  is  done,  and  no  stone  met  with,  the  patient  is  made  to  sit  down  on  the 
edge  of  his  bed ;  or  he  may  be  requested  to  rise  and  walk  a  few  steps,  and 
it  is  also  sometimes  of  use  to  let  him  lie  first  on  one  side  and  then  on  the 
other.  As  a  last  measure,  the  surgeon  gives  exit  to  the  urine,  and  without 
disturbing  the  instrument  waits  until  the  bladder  contracts  upon  itself,  so  as 
to  push  the  calculus  towards  the  urethra,  and  in  contact  with  the  metallic 
sound . 

In  a  majority  of  cases  these  varied  researches  will  speedily  assure  us  with 
certainty  that  a  stone  exists ;  but  only  because  we  do  not  discover  one  it  is  not 
certain  that  a  stone  is  not  present.    Very  small  stones  sometimes  escape  the 


,  34  NEW    ELEMENTS   OF 

fnanipulatioiis  of  the  most  skillful.  There  are  often  cavities  of  such  a  depth 
as  that  the  sound  passing  above  them  gives  no  sensation  of  encountering  a 
solid  bod  J.  It  is  not  very  uncommon  to  meet  an  excavation  directly  behind 
the  prostate,  either  on  the  right  or  left  side,  or  in  the  whole  extent  of  the  bas- 
fond  of  the  organ  in  which  stones  of  a  certain  size  easily  escape  the  notice 
of  the  searcher,  as  the  fact  which  is  related  by  M.  Belmas  proves.  In  other 
cases  the  stone  is,  as  it  were,  pinched  between  two  folds  of  the  urinary  blad- 
der; it  iffey  also  be  fixed  in  some  particular  cul-de-sac,  whether  the  mucous 
project  as  a  hernia  between  a  separation  of  the  fibres  of  the  bladder,  as  often 
happens  in  what  are  called  ''  vessies  a  colonnes"  (bladders  in  which  there  are 
fibres  resembling  tlie  columnse  carneae  of  the  heart),  or  whether  a  true 
cyst  have  formed  around  the  stone  as  M.  Meckel  says  he  has  observed.  It  is 
clear  that  if  the  foreign  body  is  not  quite  unconfined  at  any  part  of  its  surface, 
sounding  will  not  indicate  its  presence;  and  that  in  the  other  cases  it  is  only 
by  the  changes  made  in  the  position  of  the  patient  and  the  motions  of  the 
sound  that  we  can  hope  to  discover  it.  It  has  been  thought  that  when  the 
difficulty  arose  from  the  small  size  of  the  stone,  or  that  the  friction  of  the 
instrument  was  too  feeble  to  be  accurately  perceived,  auscultation  might  be 
of  some  assistance.  M.  Lisfranc  was  one  of  the  first  who  proposed  this  plan ; 
the  ear  or  the  stethoscope  is  applied  to  different  spots  on  the  hypogastric  re- 
gion with  the  usual  care,  while  the  instrument  is  manipulated  in  the  bladder 
at  the  same  time.  This  is  done  with  the  hope  that  no  sound  will  escape  atten- 
tion, and  that  the  slightest  echo  of  the  sound  as  it  touches  the  stone  will  be 
detected  by  the  ear.  To  render  this  resort  yet  more  delicate,  a  young  Ame- 
rican surgeon,  Dr.  Ashmead,  recollecting  that  air  conducts  sound  better  than 
liquids  do,  conceived  the  idea  of  filling  the  bladder  with  this  fluid.  It  is  not 
worth  while  to  deceive  oneself  about  the  value  of  such  improvements  as 
these. 

Every  time  that  a  sound  fairly  touches  a  calculus  the  surgeon  will  feel  it  as 
well  by  his  hand  as  by  his  ear.  I  could  never  advise  any  one  to  assert  upon 
the  evidence  of  auscultation  that  there  existed  in  the  bladder  a  stone,  the 
presence  of  which  simple  sounding  did  not  otherwise  convince  him.  To  re- 
turn; the  only  difficult  thing  is  not  to  feel  or  to  hear  the  stone,  but  to  touch 
it — to  strike  it  on  its  bare  surface.  If  in  a  great  many  cases  the  catheter  de- 
tects no  stone,  although  there  are  realiy  several,  cases  again  occur  in  whichit 
is  possible  to  commit  the  opposite  error.  Exostoses  behind  the  pubis — several 
of  which  have  been  met  with  by  Houstet,  Garengeot,  Jules  Cloquet,  Belmas, 
and  Brodi  particularly,  who  encountered  one  weighing  twenty  ounces — and 
other  osseous  tumors  which  grow  from  the  ischion  as  is  related  by  M.  Damou- 
rette,  from  the  sacrum  or  os  coccygis  as  in  the  plate  given  us  by  M.  Haber 
in  his  thesis;  an  osseous  cyst  in  the  thickness  of  the  parietes  of  the  bladder 
of  which  M.  ]5oyer's  book  offers  an  example;  all  tliese  things  have  led  sur- 
geons into  error  on  this  subject.  The  projection  of  the  sacro-vertebral  pro- 
montory does  the  same  thing.  But  it  is  in  the  texture  of  the  bladder  itself 
that  the  commoner  causes  of  error  are  to  be  found.  I  have  frequently  per- 
ceived that  in  slipping  the  point  of  the  sound  from  the  median  line  to  one  side 
there  occurs  a  jerking  motion,  w^hence  results  a  feeling  of  resistance  or  of 
inequality,  very  liable  indeed  to  deceive  those  who  are  not  aware  of  this 
peculiarity.     This  is  owing  to  the  cavity  of  the  bladder  being  frequently 


i 


OPEBATIVE    SURGERY.  735 

rugous,  as  is  were  knobbed ;  and  to  the  fibres  of  its  muscular  membrane 
being  almost  always  gathered  into  bundles  more  or  less  distinct. 

Also,  it  may  depend  on  the  presence  of  masses  of  a  fibrinous,  or  of  any 
other  character,  either  free  or  adherent,  which  may  have  been  developed  upon 
its  inner  surface.  If  there  be  any  doubt,  the  operator  must  not  neglect  to 
introduce  one  or  two  fingers  of  the  left  hand  into  the  rectum,  to  lift  up  the 
bas-fond  of  the  bladder,  and  favor  its  contact  with  the  instrument  as  well  as 
other  proceedings  usual  in  sounding.  Moreover,  we  know,  that  more  than 
once,  the  fingers  thus  situated,  aided  by  pressure  with  the  other  hand  on  the 
hypogastrium,  have  alone  been  successful  in  establishing  the  presence  of  stone 
without  the  assistance  of  the  sound.  These  details  might  appear  superfluous 
were  it  not  to  be  recollected  that  it  is  proved  by  innumerable  observations, 
that  immense  stones  may  remain  in  th«  bladder  for  many  years  unperceived 
by  the  patient;  and  that  the  operation  of  lithotomy  has  notwithstanding  skill- 
ful researches,  been  practised  in  other  cases  upon  individuals  who  had  no 
stone.  Every  one  knows  the  history  of  the  monk  who  bequeathed  his  body 
to  the  surgeons;  so  certain  was  he  of  having  a  stone,  which  none  of  them 
could  discover.  Lapeyronnie,  D'Alembert,  the  ''  taillmr/^*  named  Portalier, 
the  watchmaker  spoken  of  by  MM.  Deschamps,  Sabatier,  and  Richerand,  had 
each  of  them  an  enormous  stone  in  the  bladder,  of  which  they  gave  no  evi- 
dence nor  had  any  symptom.  Another  case  is  mentioned  by  M.  Texier  of 
this  kind,  which  M.  Marjolin  in  his  lectures  used  to  relate;  it  was  necessary 
to  saw  through  the  pubis  to  extract  it.  In  Desault's  Journal,  on  the  other 
hand,  we  may  read  the  admission  of  Leblanc,  that  he  had  cut  a  person  in 
whom  there  was  no  stone.  Desault  himself  seems  to  have  committed  a  similar 
error.  Mr.  Samuel  Cooper  asserts  that  he  knows  of  seven  instances  which 
happened  to  as  many  difterent  surgeons.  I  can,  for  my  own  part,  affirm  to 
four.  The  first  was  in  one  of  the  provinces ;  it  was  done  by  a  well  informed 
surgeon,  and  the  patient  did  perfectly  well :  the  second  was  done  at  a  Parisian 
hospital  upon  a  child  who  died:  the  third  occurred  also  in  an  establishment 
in  tlie  capital :  the  fourth  concerns  a  young  colleague  who  still  lives.  Now, 
as  all  these  mistakes  have  been  committed  by  men  whose  knowledge  and  skill 
cannot  be  doubted,  we  may  safely  be  permitted  to  hesitate  before  we  engage  in  a 
like  undertaking.  Warned  by  these  dangerous  errors,  the  prudent  surgeon 
will  never  decide  upon  the  operation  for  stone,  unless  he  has  carefully 
detected  the  calculus  by  the  sound,  not  once  only,  but  twice,  thrice,  or  even 
more  times,  if  the  least  doubt  exists  in  his  mind  after  the  first  examination. 
To  be  more  certain  still,  he  should  take  the  precaution  to  let  others  perceive 
for  themselves,  what  he  believes  himself  to  have  felt. 

On  this  point,  I  cannot  help  mentioning  a  fact  which  observation  has 
established,  and  one  of  the  most  curious  of  all,  viz.  that  those  symptoms 
which  most  often  simulate  those  of  calculus,  which  in  Roux*s  opinion  depend 
on  some  specific  irritation  of  the  neck  of  the  bladder,  disappear  in  general 
soon  after  the  performance  of  the  operation.  Anotlier  remarkable  thing  is, 
that  these  persons  recover  in  much  larger  proportion  than  do  those  who  have 
really  calculus  in  the  bladder;  notwithstanding  that  the  numerous  manipu- 
lations which  then  become  almost  necessary,  might  lead  us  to  infer  that  the 
contrary  would  be  tlie  case. 

*  This  word  may  mean  lilhotomist  or  tailor. 


736  NEW  ELEMENTS  OF 

Catheterism,  in  fact,  can  indicate  to  a  certain  point  the  state  and  condition 
of  the  calculi  whose  existence  it  detects;  their  bulk,  density,  position,  fixed- 
ness, or  mobility.  A^hen  a  stone  is  felt  now  at  one  point,  and  now  at  another, 
when  it  glides  away  on  the  slightest  touch,  andwhen  after  having  touched  it,  it  is 
difficull  to  meet  with  it  again,  two  things  are  evident;  1st,  that  it  is'entirely 
unadherent,  and  2d,  that  its  bulk  is  inconsiderable. 

If,  on  the  contrary,  it  is  felt  at  the  neck  of  the  bladder,  and  the  instrument 
strikes  it  in  whatever  direction  it  is  moved,  it  follows  that  it  is  very  large; 
unless  perhaps  it  may  be  fastened  on  the  vesical  trigonal  space,  or  at  the  com- 
mencement of  the  urethra. 

The  size  of  a  calculus  being  a  very  important  subject  of  inquiry,  it  has 
been  attempted  in  all  ages  to  acquire  some  method  of  ascertaining  it.  The 
catheter  once  in  the  bladder,  can,  in  the  hands  of  a  person  very  much  accus- 
tomed to  its  use,  give  very  accurate  information  upon  this  particular.  To 
obtain  this  the  patient  must  n(l>t  move,  while  the  surgeon  is  to  remark  atten- 
tively the  first  contact  of  the  two  bodies  ;  then  to  carry  the  beak  of  the  sound 
from  before  backwards  over  the  entire  surface  of  the  stone,  or  else  to  attempt 
to  hook  it  in  the  concavity  of  the  instrument,  as  if  to  draw  it  towards  the  urethra. 
This  manoeuvre,  when  performed  in  an  empty  bladder,  often  succeeds  in  giv- 
ing us  a  very  near  approach  to  the  dimensions  of  the  stone. 

Surgery  has,  besides,  other  means  than  these  of  arriving  at  this  result.  One 
of  the  best,  I  think,  will  be  found  to  be  the  sound  which  I  have  had  con- 
structed, and  of  M^iich  we  shall  speak  farther  on.  This  instrument  is  so 
arranged,  that  when  introduced,  the  two  halves  which  compose  it,  sliding  one 
over  the  other,  much  like  the  foot  measure  used  by  shoemakers,  render  its  beak 
an  instrument  capable  of  seizing  the  stone  in  its  grasp,  and  of  determining  its 
size.  The  forceps  for  lithotrity  would  answer  much  more  surely  for  this  pur- 
pose, but  they  are  inconvenient  from  being  straight  and  more  difficult  to  use. 
We  are  not,  however,  to  expect  that  with  these  instruments  we  shall  always 
be  able  to  ascertain  exactly  the  size  of  a  calculus.  This  could  only  happen  if 
it  were  invariably  perfectly  round,  or  that  we  could  be  sure  of  having  seized 
it  in  the  proper  position.  Now  there  are  flat  ones,  oval  ones,  and  stones  of  all 
shapes  imaginable.  The  forceps  may  have  hold  of  them  by  one  angle,  or  at 
one  end.  They,  in  turn,  may  have  got  too  near  the  roots  of  the  instrument,  or 
may  be  held  only  by  their  extremities. 

A  stone  may  be  considered  as  friable,  and  of  no  great  cohesiveness,  when 
the  sound  emitted  on  striking  it  is  dull,  or  that  notwithstanding  the  calculus 
appears  to  be  of  considerable  size  it  is  very  feeble.  If  the  collision,  on  the 
other  hand,  is  attended  with  a  clear  sound,  and  the  calculus  is  not  displaced 
without  a  certain  degree  of  diificulty,  its  density  must  be  considerable.  When 
it  Is  met  with  always  upon  the  same  side,  follows  the  changes  in  the  position 
of  the  patient,  and  when  after  having  touched  it  at  one  point,  the  instrument 
may  be  carried  all  round  in  the  bladder  without  meeting  with  another,  it  is 
probably  single.  If,  on  the  contrary,  the  sound  strikes  on  a  calculus  to  th^ 
right  and  to  the  left;  and  if,  after  having  laid  the  patient  on  one  side,  it  no 
longer  meets  with  any  thing  in  the  upper-most  part  of  the  bladder;  if  during 
the  operation  of  sounding  another  collision  is  heard  different  from  that  made 
with  the  first  stone;  if  the  staft' successively  displaces  several  mobile  bodies, 
we  may  naturally  conclude  that  more  than  one  calculus  exists  in  the  bladder. 


OPERATIVE    SURGERY.  737 

Still  nothing  is  easier  tlian  to  err  on  the  subject,  and  the  most  accurate  re- 
searches give  at  best  only  probable  results,  except  in  some  few  exceptions, 
in  which  the  proof  amounts  almost  to  certainty. 

It  is  not  easy  either  to  decide  on  the  fixedness  or  adhesions  of  vesical  cal- 
culi. A  stone  appears  to  be  immovable  sometimes  because  it  fills  nearly  the 
whole  of  the  bladder ;  at  others  this  appearance  is  owing  to  the  contraction  of 
tlie  organ;  and  again,  sometimes  because  of  the  size  of  the  stone  itself:  and 
also  because  it  is  situated  in  a  cavity  of  greater  or  less  depth,  though  it  may  per- 
haps be  met  with  soon  after  in  some  other  place.  It  may  cling  by  one  extremity 
to  the  ureter.  This  position,  which  many  writers  have  noticed,  is  remarkable 
in  that  the  stone,  though  it  may  be  several  inches  in  length,  may  project 
a  very  little  way  into  the  bladder.  We  may  suspect  such  a  case,  when  the 
catheter  encounters  a  sort  of  point,  which  nothing  can  displace,  near  the  neck 
and  a  little  outwards  towards  the  base  of  the  trigonal  space.  We  cannot 
probably,  however,  thus  distinguish  those  which  are  enclosed  in  pouches,  or 
abnormal  sacs,  from  those  which  have  really  contracted  adhesions  with  some 
part  of  the  mucous  lining.  Of  this,  as  with  other  diagnostic  essays,  the  same 
may  be  said ;  sounding,  well  performed,  will  always  excite  stronger  or  less 
powerful  presumption,  but  never  can  be  attended  with  absolute  certainty. 
Nevertheless,  if  a  stone  incarcerated  by  one  of  its  ends  iij^  the  prostatic  por- 
tion of  the  urethra,  project  by  the  other  into  the  anterior  of  the  bladder,  of 
which  MM.  Le  Dran  and  Blanding  each  mention  an  instance,  its  situation 
might  be  known  by  carrying  a  finger  up  into  the  rectum,  whilst  the  sound 
was  kept  on  the  head  of  the  stone.  To  these  particulars  we  shall  return 
when  speaking  of  the  last  stage  of  lithotomy. 

Indications. — Cutting  is  the  only  remedy  applicable  to  individuals  affected 
with  urinary  calculus,  unless  lithotrity  can  be  performed  in  their  case.  Some 
few,  it  is  true,  get  well  without  this  operation  ;  others  suffer  so  little  frojn  the 
disease,  that  to  cut  them  would  be  worse  than  imprudent;  yet  the  sponta- 
neous disappearance  of  calculi  is  so  rare,  that  it  should  never  be  calculated 
on.  It  is  not  uncommon  to  see  them  escape  through  the  urethra,  unless  they 
are  not  larger  than  a  grape  seed  or  of  a  small  kidney  bean,  in  which  case  it 
is  sometimes  seen.  Others,  which  have  made  their  way  by  ulceration  through 
the  perineum  or  the  rectum,  and  thus  perforating  the  tissues,  are  merely  excep- 
tions, in  themselves  almost  as  dangerous  as  is  the  operation  itself.  The 
calculus  acting  only  as  being  a  foreign  body,  may,  when  it  is  enclosed  in  the 
parietes  of  the  bladder,  or  in  small  adventitious  sacs,  cause  but  very  little 
suffering  to  the  patient ;  and  its  existence  may,  under  such  circumstances,  be 
compatible  not  only  with  life,  but  with  the  enjoyment  of  perfect  health. 

The  facts  related  by  Deschamps  and  several  others,  prove  also  that  immense 
unattached  calculi  may  exist  in  the  bladder,  and  yet  permit  those  who  have 
them  to  run  long  careers,  and  be  perfectly  well  notwithstanding.  For  all 
this,  none  of  these  uncommon  circumstances  in  any  way  weaken  the  general 
rule,  and  as  soon  as  the  presence  of  stone  is  conclusively  established  the  idea 
of  the  operation  immediately  presents  itself  to  the  mind. 

The  size,  form,  or  situation,  nor  the  nature  of  the  stone  scarcely  ever  con- 
stitute obstacles  to  its  performance;  and  the  circumstances  which  contra- 
indicates  it,  are  much  the  same  as  those  of  any  other  great  operation.  It  is 
well  to  state,   that  catarrhus  vesicae,  swelling  of  the  prostate,  and   most 


738  NEW  ELEMENTS  OF 

changes  in  the  structure  of  the  bladder,  are  frequently  the  results  of  the  pre- 
sence of  the  stone,  and  that  it  is  common  to  see  them  disappear  upon  its  extrac- 
tion. 

Lastly,  a  remark  which  has  been  already  made  by  a  great  many  authors, 
and  one  which  cannot  be  too  often  repeated  is,  that  those  persons  who  have 
suffered  severely  from  their  stone,  do,  ceteris  paribus^  much  better  after  the 
operation  than  those  who  have  scarcely  perceived  it,  or  who  have  only 
recently  felt  the  symptoms. 

Formerly  lithotomy  was  practised  only  during  the  spring  of  the  year.  At 
this  season  all  the  patients  with  calculi  were  collected  into  the  hospitals,  and 
they  gathered  also  in  tlie  towns,  to  which  the  wandering  lithotomists  flocked 
to  operate  upon  them. 

This  is  now  no  longer  the  case.  Cutting  for  stone  like  every  other  opera- 
tion in  surgery,  is  done  at  every  period  of  the  year ;  only,  as  stone  is  a  slow 
disease,  and  that  in  most  cases  there  is  no  danger  in  protracting  the  operation 
for  some  months,  as  likewise  very  hot,  or  very  cold  seasons  seem  rather  less 
favorable  than  others  to  its  success,  it  is  still  customary  to  prefer  the  spring 
and  fall,  when  no  reason  exists  for  hastening  events. 

An  indispensable  precaution  to  be  taken  before  cutting  a  patient,  is  to  see 
that  his  urethra  is  perfectly  free.  It  is  a  fortunate  occurrence,  that  we  are 
obliged  to  do  this  in  spite  of  ourselves ;  for  to  detect  the  stone  Ave  must  pass 
through  the  canal.  If  it  be  strictured  sounding  cannot  be  practised.  Care 
therefore  must  be  taken  to  treat  this  disease  by  proper  means,  before  litho- 
tomy is  had  recourse  to.  The  other  preparations  consist  of  venesection 
or  of  leeches  to  the  anus ;  of  a  low  regimen  for  some  days,  and  a  slight  pur- 
gative to  relax  the  intestines,  and  guard  against  sanguinous  congestion. 

I  need  not  say  that  if  there  exist  other  accessory  lesions  besides  the  prin- 
cipal affected,  they  must  be  combated  and  wholly  removed,  before  any  thing 
else  is  done.  Lastly,  it  should  never  be  neglected  to  administer  on  the  pre- 
ceding evening,  or  on  the  morning  of  the  day  fixed  for  the  operation,  an 
injection,  so  as  completely  to  empty  the  organ  of  defecation. 

The  operation  decided  on,  a  great  question  arises  as  to  the  particular  man- 
ner in  which  the  stone  shall  be  extracted.  There  are  three  principal  ones, 
viz.,  one  which  consists  in  opening  the  bladder  through  the  perineum ;  one 
which  does  it  through  the  rectum,  or  vagina ;  and  thirdly,  one  which  attains 
the  end  by  going  through  the  hypogastric  region  into  the  urinal  reservoir. 

Art.  1. — Of  the  cutting  through  the  Perineum  {by  the  lower  apparatus). 

The  method  of  cutting  for  the  stone  through  the  perineum  is  the  most 
ancient  of  them  all.  The  parts  which  it  is  necessary  to  pass  through  in  per- 
forming it,  require  such  exact  knowledge  of  their  position  and  relations,  that 
it  is  indispensable  for  me  to  point  them  out  acurately  before  I  proceed  to  any 
further  details  about  it. 

§  1 .  Anatomical  Remarks, 

The  pelvis  ends,  as  is  well  known,  by  an  aperture  known  by  the  appellation 
of  lower  strait;  the  form  of  which  is  oval,  or  that  of  a  heart,  of  which  the 


OPERATIVE  SURGERY  739 

larger  end  is  turned  backwards.  In  treating  of  lithotomy,  it  is  unnecessary 
any  farther  to  consider  the  diameters  of  this  stcait,  as  is  done  wlien  speaking 
of  delivery  of  women.  That  which  extends  from  one  tuber  ischii  to  the 
other,  is  in  general  not  more  than  about  three  inches  in  the  male,  which  length 
tapers  off  insensibly  forwards,  and  is  only  eight  or  twelve  lines,  or  less  even 
near  the  symphysis  of  tlie  pubis.  It  diminishes  in  length  equally  as  we  near 
the  coccyx,  but  in  a  much  less  proportion  than  in  the  preceding  direction. 
Its  dimensions  may  be  lessened  by  numerous  anomalies  and  pathological  alte- 
rations, to  a  degree  wMch  may  present  an  obstacle  to  the  extraction  of  the 
calculus. 

Besides  the  facts  of  which  I  spoke  as  calculated  to  impose  upon  a  surgeon 
for  stone,  he  should  also  remember  that  Bonetus  saw  it  so  contracted 
as  scarce  to  admit  the  finger ;  that  in  a  patient  mentioned  by  Delannay  it 
was  almost  entirely  closed  by  the  head  of  the  femur ;  that  the  same  thing 
was  effected  by  an  exostosis  mentioned  by  M.  Thierry ;  by  an  ossification  of 
the  falciform  edge  of  the  sacro-sciatic  ligaments  described  by  M.  Belmas; 
and  that  Noel  of  Rheims  was  also  arrested  by  a  similar  difficulty  in  a  pelvis 
which  was  shown  me  by  M.  Loze.  The  soft  parts  which  fill  up  the  whole, 
are  numerous  and  important.  The  transverse  diameter  divides  them  into  two 
parts  ;  the  anterior  comprising  the  perineum  properly  so  called,  the  posterior 
forming  the  anal  region.  To  this,  we  shall  return  in  our  description  of  the 
recto-veislcal  operation. 

The  perineal  region,  which  is  represented  by  a  triangle,  the  base  of 
which  rests  upon  the  fore  part  of  the  anus,  is  divided  into  two  equal  parts  by 
the  median  line  or  raphe  of  the  perineum,  and  its  free  upper  part  surmounted 
by  the  scrotum  and  genital  organs. 

1.  Its  Integuments,  which  are  soft  and  wrinckled,  enjoy  extreme  mobility ; 
which  renders  it  necessary  to  stretch  and  make  them  tense  when  we  are 
going  to  divide  them.  The  subcutaneous  cellular  tissue  here  is  of  equal 
laxity.  As  we  penetrate  deeper  it  becomes  more  and  more  filamentous,  and 
more  loaded  with  fatty  cells ;  and  even  forms  on  either  side,  in  the  cavity 
which  separates  the  bulbo-cavernosus  (acceleratores  urinae)  muscles  from  the 
ischio-pubic  ramus,  a  flocculent  mass,  sometimes  of  considerable  thickness, 
and  which  often  becomes  the  thicker  still  as  it  extends  backwards  between 
the  ischium  and  the  end  of  the  rectum. 

2.  The  aponeuroses  deserve  so  much  the  more  attention  from  rae,  as 
that  notwithstanding  the  numerous  researches  made  into  them  the  descriptions 
given  of  them  are  as  yet  very  obscure.  Nevertheless,  in  the  perineal  triangle 
they  may  be  easily  understood.  There  are  observable  two  laminae ;  the  one, 
the  superficial  or  inferior,  which  covers  the  free  surface  of  the  bulbo  and 
ischio  cavernosus  muscles  [erectores  penis)  like  a  thin  veil,  goes  posteriorly 
to  blend  with  or  lose  itself  in  the  other,  and  thus  it  remains  distinct  from  the 
fascia  superficialis,  of  which  many  from  inadvertence  doubtless  have  con- 
sidered it  to  be  an  appendage.  The  second  of  these  two  laminae,  starting 
from  the  sub-pubic  ligament  passes  back  as  a  septum  adhering  to  the  inner  lip 
of  the  ramus  of  the  pubis  and  ischium,  and  is  continuous  with  the  edges  of  the 
sacro-sciatic  ligaments.  This  layer,  which  has  been  called  by  CoUes  the  tri- 
angular ligament  of  the  urethra,  and  by  others  the  median  aponeurosis,  is 

„      perforated  at  its  posterior  part  by  the  membranous  portion  of  the  urethra. 

r 


740  NEW    ELEMENTS   OF. 

At  this  point  it  forms  a  pretty  solid  barrier  betwixt  tlie  prostate  and  bulb  of 
the  urethra,  and  continues  itself  with  the  superior  pelvic  aponeurosis  after 
having  supplied  a  fibrous  expansion  to  the  gland  I  have  just  named  the  pro- 
state. This  horizontal  direction  it  does  not  retain  in  its  whole  extent. 
When  it  reaches  the  anal  region  it  bounds  or  circumscribes  an  excavation 
more  than  an  inch  in  depth,  into  which,  when  a  certain  method  of  operation 
for  the  stone  which  may  be  called  the  ischio-rectal  is  performed,  the  instrument 
is  obliged  to  penetrate.  This  excavation,  which  is  bounded  without  by  an 
aponeurotic  layer  continuous  with  the  sacro-sciatic  ligaments  inferiorly,  and 
by  the  inner  lamina  of  the  fascia-pelvica  superiorly,  contains  within  it  a 
much  thinner  fibrous  lamella,  ^nd  the  exterior  surface  of  the  extremity  of 
the  rectum  extending  backwards  on  the  deep  surface  of  the  great  gluteus 
muscle,  it  forms  anteriorly  a  slight  cul-de-sac  above  the  transversus-perinei 
muscle,  which  is  more  or  less  entirely  filled  up  by  the  cellulo-adipose  mass  I 
mentioned  a  short  distance  back. 

3.  The  bidbo-cavernosus  muscles,  which  extend  from  the  point  of  the  sphinc- 
ter-ani  upon  the  lower  surface  and  sides  of  the  bulb  of  the  urethra,  as  well  as 
the  ischio-cavernosus  muscles,  which  embrace  each  root  of  the  corpus  spon- 
giosum of  the  penis,  have  here  no  real  importance ;  unless  it  be  through  the 
medium  of  the  aponeurosis  which  separated  them  from  the  cellular  layer,  and 
of  the  triangle  of  which  they  are  the  boundaries  ;  a  triangle  whose  base  dips 
down  into  the  ischio-rectal  excavation,  and  which  like  this  excavation  is  filled 
up  with  filamentous,  cellular,  or  adipose  tissue. 

The  transverse  perinei,  extending  from  the  ascending  ramus  of  the  ischium 
in  front  of  the  anus,  intercrosses  with  that  of  the  opposite  side ;  and  blending 
itself  at  the  same  time  with  the  origin  of  the  bulbo-cavernosus  and  some 
fibres  of  the  sphincter-ani  externus,  it  forms  below  the  membranous  portion 
of  the  urethra  a  decussation,  a  fibro-muscular  mass,  which  is  cut  through  in 
almost  every  operation  for  stone. 

4.  The  Arteries  of  the  Perineum  spring  principally  from  the  pudica  interna. 
The  first  we  have  to  examine  is  the  inferior  hemorrhoidal. 

This  vessel  comes  oft'  from  the  primary  trunk,  and  crosses  the  aponeurosis 
very  far  backwards,  so  that  as  it  goes  almost  entirely  to  the  environs  of  the 
anus,  its  wounds  are  but  little  to  be  feared  in  the  extraction  of  calculi.  The 
second  is  the  superfcialis  perinei.  It  arises  a  little  before  the  tuberosity  of 
the  ischium,  and  behind  the  transverse  perinei  muscle;  quits  the  aponeurosis 
directly,  dips  down  to  pass  below  its  horizontal  portion,  and  passes  forward 
as  far  as  into  the  septum  of  the  dartos,  ploughing  up  the  cellular  tissue, 
and  following  the  ischiobulbus-triangle.  In  its  course,  the  superficialis  artery 
is  sometimes  nearer  to,  sometimes  further  from  the  median  line  or  the  integu- 
ments. Its  size,  which  is  sometimes  larger,  and  its  varying  position,  are 
causes  why  it  is  often  wounded,  and  why  the  hemorrhage  it  affords  is  in  some 
patients  serious. 

The  third,  or  transversa  perinei ^  points  from  the  pudic  artery,  in  the  thick- 
ness of  the  triangular  ligament  or  horizontal  aponeurosis ;  tending  gradually 
downwards  and  inwards,  crosses  the  muscle  of  that  name,  and  soon  divides 
into  three  branches,  one  of  which  goes  to  the  fore  part  of  the  anus,  the  second 
to  the  tissues  below  the  membranous  portion  of  the  urethra,  the  third  to  the 
bulb  of  tlie  urethra  itself.     Though  usually  not  so  large  as  the  artery  preced- 


OPERATIVE    SURGERY.  t4l 

ing,  this  vessel  is  far  from  always  occupying  the  same  place.  It  is  found 
sometimes  three,  four,  and  even  five  lines  more  in  advance,  and  then  is  dis- 
tributed almost  entirely  to  the  bulbous  and  spongy  portions  of  the  urethra. 

At  other  times  it  follows  the  posterior  edge  of  the  transverse  muscle  so  ex- 
actly, that  at  its  union  with  the  one  on  the  opposite  side  it  seems  a  mere  arch 
in  front  of  the  anus. 

The  Pudic  Jirteryy  the  starting  point  for  all  the  others,  follows  a  less 
variable  course.  It  is  to  be  found  supported,  as  it  were,  by  the  pelvic  surface 
of  the  outer  aponeurotic  layer  of  the  ischio-rectal  excavation,  and  of  the  falci- 
form fold  which  ends  the  sacro-sciatic  ligament  in  the  properly  so  called  peri- 
neal region,  that  is  to  say,  in  the  pubic  arch.  It  lies  betwixt  the  laminse  of 
the  horizontal  or  triangular  aponeurosis,  and  so  proceeds  until  it  gets 
above  the  root  of  the  penis,  where  it  is  lengthened  out  and  takes  the  name  of 
arteria  dorsalis  penis.  Thus  it  will  be  seen,  that  in  its  whole  course  it  is 
powerfully  protected ;  first  by  the  aponeurosis  of  this  region,  and  again  by  the 
ramus  of  the  ischium  and  pubis  itself,  as  well  as  by  the  edge  of  the  tuber 
ischii  behind.  From  its  position  it  can  only  be  got  at  after  all  the  fibrous 
laminae  of  which  we  have  spoken  above  are  cut  through,  to  do  which  we  must 
proceed  downwards  to  a  great  depth. 

Some  abnormal  arteries  have  also  been  met  with  in  the  perineal  region. 
For  instance :  the  hypogastric  has  been  seen  by  M.  Blandin  to  send  oft*  the 
dorsal  branches  of  the  penis,  and  there  to  pass  up  on  the  side  of  the  neck  of 
the  bladder,  and  then  above  the  prostate  gland  to  reach  their  natural  situa- 
tion. I  have  myself  twice  encountered  this  peculiar  distribution,  which  is 
likewise  noticed  by  M.  Senn,  and  which  is  said  by  Vesalius,  Sylvius,  High- 
more,  Winslow,  Burns,  Tiedemann,  Shaw,  and  others,  not  to  be  uncommon. 
x\l though  mention  of  it  has  been  omitted  in  many  modern  treatises  on  anatomy. 
Dr.  Shaw  cites  an  anomaly  more  remarkable.  Still,  and  much  more  dange- 
rous, a  large  artery,  given  oft*  by  the  hypogastric,  at  the  bottom  of  the  pelvis 
extends  from  below  upwards,  and  from  behind  forwards,  upon  the  sides  of 
the  prostate,  before  it  passed  outwardly.  In  the  operation  for  stone  it  was 
completely  divided,  and  gave  rise  to  a  hemorrhage  which  nothing  could  arrest, 
and  carried  off*  the  patient. 

5.  The  Veins  which  surround  the  prostate,  and  which  in  old  men  sometimes 
form  an  abundant  and  crowded  plexus,  alone  require  special  notice  in 
this  particular  situation.  It  is  unnecessary  for  more  obvious  reasons  to  ex- 
amine the  nerves  and  absorbent  vessels. 

6.  The  Bulbf  and  with  it  a  small  part  of  the  membranous  portion  of  the 
urethra  situated  between  the  two  fasciae,  are  separated  from  the  skin  only  by 
a  lamellar  cellular  tissue,  not  abundant;  by  the  superficial  layer  of  the 
aponeurosis ;  and  the  bulbo-cavernosus  muscle.  From  the  front  of  the  anus  also 
it  is  separated  by  a  space  of  only  eight  or  ten  lines,  and  sometimes  of  six 
only.  Its  mobility  is  sufficient  to  allow  of  its  being  moved  to  the  right  side, 
or  to  the  left,  and  at  its  sides  it  receives  the  transversa  perinei  artery.  In  a 
single  case  I  have  seen  it  extend  as  far  as  two  lines  from  the  anus,  as  if  to 
close  the  recto -urethral  triangle  which  will  soon  be  mentioned. 

7.  The  Membranous  and  prostatic  portion  of  the  urethra  which  is  to  be 
found  above  the  horizontal  aponeurosis,  is  enclosed  in  u  space  which  it  is 
essential  accurately  to  define.     Backwards  it  is  circumscribed  by  the  anterior 


T42  NEW  ELEMENTS  Of 

face  of  the  rectum;  below  by  the  perineal  aponeurosis;  above,  by  the  fascia 
pelvica;  and  the  space  itself  is  filled  up  by  lax  cellular  tissue,  small  venous 
trunks,  and  by  small  muscles  coming  off  from  the  pelvis  to  spread  themselves 
out  on  the  fore  part  of  the  urethra,  cal  led  the  muscles  of  Winslow.  The  several 
objects  not  being  as  dense  as  the  tissue  traversed  by  the  urethra,  the  aponeu- 
rotic layer  which  exists  on  the  back  part,  and  appertains  to  the  parietes  of  the 
ischio -rectal  excavation,  being  generally  pretty  thin,  it  results  from  it  that  that 
portion  of  the  urethra  which  is  the  least  movable,  is  just  that  which  is  en- 
closed or  strictured  in  the  horizontal  fibrous  layer  of  the  perineum. 

8.  77ie  Prostate  Gland,  which  plays  so  important  a  part  in  the  different 
species  of  perineal  operation  for  stone,  resembles  a  cone  of  such  ver}^ 
variable  dimensions  according  to  the  age  and  condition  of  different  individuals, 
that  scarcely  any  thing  decided  can  be  said  about  it.  However,  the  investi- 
gation of  several  anatomists,  M.  Senn  amongst  others,  and  those  in  which  I 
was  myself  earnestly  engaged,  allow  us  as  a  general  rule  to  say,  that  its 
antero-posterior  diameter  is  from  twelve  to  fifteen  lines ;  that  vertically  it 
is  from  ten  to  twelve  lines,  and  from  fifteen  lines  to  eighteen  across ;  that  is 
to  say,  it  represents  a  pyramid  whose  base,  hollowed  out,  receives  the  bottom 
of  the  bladder ;  whose  point  extends  forwards  to  the  membranous  portion 
of  the  urethra ;  and  whose  anterior  edge  is  sometimes  deficient  to  create  a 
fissure,  in  which  the  excretory  duct  of  the  urine  is  lodged.  The  gland  seems 
to  have  developed  itself  between  the  mucous  membrane  and  the  truly  fleshy 
portion  of  the  urinary  passages ;  and  is  enveloped  in  a  layer,  in  which  I  have 
often  detected  fleshy  fibres  continuous  on  one  side  with  the  median  mem- 
brane of  the  bladder,  on  the  other  with  the  evidently  muscular  layer  of  the 
membranous  portion  of  the  urethra,  and  on  a  third  with  the  muscles  of 
Winslow.  More  outwardly,  the  gland  receives  from  the  perineal  aponeurosis 
a  sheath  of  greater  or  less  density,  which  we  may  call  prostatic  aponeurosis, 
and  which  as  I  have  said,  is  continuous  with  the  fascise  pelvica ;  from  the 
rectum  it  is  separated  merely  by  a  thin  layer  of  cellular  tissue,  in  which  fat 
is  scarcely  ever  deposited  no  matter  how  embonpoint  may  be  the  subject. 
Its  base  ascends  to  about  two  inches  above  the  anus,  while  its  tip,  on  the 
contrary,  inclines  from  it  more  or  less.  In  front  it  is  separated  from  the 
sub-pubic  ligament  by  the  muscle  of  Wilson,  by  cellular  tissue,  by  flakes  of 
fat,  small  veins,  and  by  the  pubio-prostatic  ligaments,  which  separate  the 
gland  from  the  pubis  for  six  or  eight  lines.  The  urethra  which  crosses  it  is 
generally  nearer  on  its  pubic  than  its  rectal  wall ;  so  much  so  that  M.  Amussat 
thought  it  did  not  completely  enclose  this  canal,  but  formed  merely  a  groove 
for  it,  itself  remaining  below.  This  gentleman's  error  arose  from  taking  the 
exception  for  the  rule.  What  he  asserts  as  a  principle  does  indeed  sometimes 
exist;  but  the  contrary  is  not  without  proof  either.  I  have  in  three  subjects 
seen  the  urethra  in  its  passage  across  the  prostate,  nearer  the  rectum  than  to 
the  pubis.  M.  Senn  mentions  having  once  met  with  it  near  the  posterior  part 
of  the  gland,  and  M.  Tanchou  showed  me  a  case  in  which  it  is  almost  entirely 
beneath.  The  following  are  the  dimensions  of  its  different  radii,  taken  at  its 
base,  the  interior  of  the  urethra  being  taken  as  the  centre.  The  pubic  radius 
is  usually  three  lines  or  four  long ;  the  rectal  six  or  eight,  the  transverse  eight  to 
ten  ;  and  that  radius  which  goes  obliquely  downwards  and  outwards  ten  io 
twelve;  it  being  understood  that  the  diameter  of  the  urethra  itself  enters 
into  the  calculations. 


OPERATIVE  SURGERY  743 

Moreover,  the  prostate  is  crossed  from  behind  forwards,  and  from  with- 
out a  little  inwardly,  by  the  ejaculatory  duds  which  open  on  its  summit, 
or  upon  the  sides  of  the  verumontanum.  The  portion  of  urethra,  which  like 
itself  is  about  twelve  or  fifteen  lines  long,  and  which  it  embraces,  deserves  in 
turn  particular  examination.  Midway  in  its  lower  wall  exists  a  cavity  of 
more  or  less  depth,  as  if  it  were  divided  into  two  on  the  median  by  the  crista 
of  the  urethra.  As  the  verumontanum  is  the  organ  to  be  avoided  in  cutting 
for  stone,  it  is  important  not  to  forget  its  situation.  As  to  the  vulvular  fold 
and  the  species  of  sphincter^  of  which  some  persons  speak  as  in  this  neighbor- 
hood, they  exercise  so  little  influence  over  lithotomy  that  I  shall  defer  any  con- 
sideration of  them  until  I  come  to  the  operations  performed  on  the  urethra  itself. 

The  last  point,  the  development  of  the  prostate,  is  worthy  of  all  surgeons' 
attention.  Morgagni,  Serres,  and  Sir  E.  Home,  have  thought  that  it  was  origi- 
nally organized  in  two  halves,  by  two  lateral  lobes  destined  after  birth  to  become 
blended ;  andthatin  the  adult,  a  third  was  added  to  these  two  original  portions. 
In  this  statement,  judging  from  numerous  observations  made  on  the  foetus,  and 
the  investigations  made  by  pathological  anatomy  in  the  adult,  there  is  a  double 
error.  The  prostate  gland  is  formed  of  a  series  of  glandules,  which  are  developed 
simultaneously  almost  all  around  the  urethra  ;  and  Sir  E.  Home's  third  lobe  is 
nothing  but  a  morbid  tumor  of  the  organ.  This  tumor,  which  is  truly  a  very 
remarkable  one,  is  far  from  being  uniform,  and  from  only  appearing  on  the 
median  line  as  the  English  surgeon  asserts.  I  have  met  with  eight  in  a  single 
gland.  It  is  a  true  pathological  production,  to  appearance  like  the  structure 
of  the  gland,  but  in  reality  much  of  the  same  nature  as  the  fibrous  bodies  of 
the  womb. 

9th.  The  recto-urethral  triangle. — Between  the  rectum  and  the  beginning 
of  the  urethra  exists  a  space  through  which  instruments  pass  in  many  species 
of  operation  to  reach  the  bladder.  This  space  of  which  M.  Dupuytren  has  said 
much  and  with  great  propriety  since  1812,  is  bounded  below  by  the  integu- 
ments, backwards  by  the  anterior  surface  of  the  termination  of  the  rec- 
tum, and  before  by  the  membranous  portion  and  commencement  of  the 
spongy  portion  of  the  urethra,  so  that  it  may  be  likened  to  a  triangle  whose 
base  would  be  the  skin,  and  its  apex  the  posterior  surface  of  the  point  of  the 
prostate.  Going  from  without  toward  the  bladder,  we  encounter  the  sub- 
cutaneous cellular  layer,  the  superficial  perineal  aponeurosis,  blending  itself 
with  the  base  of  the  horizontal  aponeurosis,  the  origin  of  the  erector  penis 
muscle,  the  end  of  the  sphincter,  the  free  portion  of  tlie  bulb  of  the  urethra, 
and  one  of  the  terminating  branches  of  the  transverse  perineal  artery ;  in  other 
words,  the  recto-urethral  space  is  filled  up  by  the  decussations  of  the  sphinc- 
ter ani,  the  erector-penis  and  transversus-perinei  muscles,  as  well  as  by  some 
branches  of  the  transverse  perineal  artery,  cellular  tissue,  and  the  mingling 
of  the  several  aponeuroses. 
» 

p'  §  2.  Methods  of  Operation, 

Perineal  lithotomy  has  been  performed  in  so  many  ways,  that  to  analyze  the 
processes  with  any  advantage,  it  is  indispensable  that  they  should  be 
collected  together  in  a  groupe,  and  that  those  v/hich  have  most  analogy  be 
assembled  to  constitute  so  many  principal  methods. 


744  NEW  ELEMENTS  Ot 

In  some  the  stone  Is  reached  without  any  division  of  the  urethra,  while  In 
others  again  the  furthermost  portion  of  this  canal  is  always  laid  open  by  the 
instrument.  To  the  first  of  these  it  seems  correct  to  refer  all  that  is  said 
about  lateral  cutting;  the  method  which  seems  to  me  to  include  the  procedures 
of  the  ancients,  of  frere  Jacques,  Foubert,  and  others.  The  median  operation, 
or  that  by  the  apparatus  major  oblique,  or  by  the  lateralized  method  of  frere 
Come,  &c.,  belong  to  the  second  genus. 

1.  Lateral  method  (Cystotomy  properly  so  called). 

a.  Procedure  of  Antyllus,  or  of  Paulus  ^ginetus,  commonly  called  appa- 
ratus  minor. 

The  description  of  lithotomy  given  by  Celsus,  has  until  the  present  time 
been  the  subject  of  apparently  very  faulty  interpretations.  From  this  it  has 
resulted  that  the  procedure  called  methodus  Celsianss^  is  not  in  reality  his. 
For  his  principles,  reference  must  be  made  to  the  Grecian  authors.  It  will, 
perhaps,  appear  from  the  most  extended  researches,  that  it  originated  in 
ancient  Egypt ;  whilst  the  true  apparatus  of  Celsus  belongs  to  the  Alexandrian 
school.  In  as  much  as  Antyllus  has  first  clearly  pointed  it  out,  I  think  it 
proper  to  name  it  after  this  ancient  author.  To  do  it  the  surgeon  passes  two 
fingers  into  the  rectum,  and  endeavors  to  hook  the  stone  with  them  through 
the  parietes  of  the  bladder  ;  whilst  by  pressing  with  his  other  hand  upon  the 
hypogastrium,  or  causing  it  to  be  compressed,  the  descent  of  it  is  favored. 
Having  once  seized  the  stone,  he  pushes  it  against  the  urethra,  so  as  to  make 
it  project  between  the  anus  and  scrotum,  a  little  to  the  left  of  the  perineum. 
He  then  with  a  small  knife  cuts  all  the  soft  parts  down  to  it,  in  the  direction 
of  a  line  drawn  obliquely  from  above  downwards,  and  from  before  backwards, 
to  the  side  of  the  left  ischium ;  thus  he  opens  the  bladder  and  removes  the 
stone  through  the  aperture,  by  pushing  it  with  the  fingers  he  has  kept  in  the 
rectum.  When  the  fingers  of  the  operator  are  insufficient  to  effect  its  expul- 
sion, a  sort  of  curette  furnished  with  points  in  its  interior  is  carried  into  the 
wound  to  hook  the  stone  and  bring  it  out. 

This  operation,  from  its  great  simplicity  called  apparatus  minor,  and  subse- 
quently by  the  name  of  the  Gmdonian  method^  because  it  had  been  forgot- 
ten until  revived  by  Guy  de  Chauliac  in  1363,  was  nevertheless  described 
by  a  host  of  authors  who  preceded  the  one  last  named.  G.  de  Salicet,  for 
example,  correctly  describes  it  as  Antyllus  does  ;  Paul  of  Egina,  Albucasis, 
and  most  of  the  Arabian  surgeons  similarly  understood  it.  Amongst  others, 
Ali-Ebn-el-Abbas,  thus  expresses  himself  as  to  it,  "  You  shall  take  the  cut- 
ting instrument,  and  you  shall  cut,"  says  he,  "  between  the  anus  and  the  tes- 
tes, not  on  the  median  part,  but  directing  your  excision  on  the  left  part  of  the 
thigh.  The  incision  should  be  oblique,  so  that  the  opening  may  be  large  and 
proportionate  to  the  stone." 

A  very  analagous  account  of  it  is  given  by  another  author  of  the  same 
period.  Ebn-el-Coof,  of  whose  work  M.  Clot,  of  Abou  Zabel,  in  Egypt,  has 
translated  some  fragments.  I  place  this  proceeding  under  the  head  of  lateral 
cutting,  or  cystotomy  proper,  because  in  pursuing  it  we  strike  generally  the 
side  of  the  neck  of  the  bladder,  and  not  the  urethra  or  prostate.  It  is  easily 
conceivable  that  the  fingers  very  seldom  engage  the  stone  in  the  prostatic 


OPERATIVE    SURGERY.  745 

portion  of  the  urethra,  but  that  they  merely  place  it  in  the  vesical  trigonal 
space,  and  that  it  is  depressed  towards  the  perineum,  and  laid  bare  by  the  cut- 
ting instrument  through  the  parietes  of  the  bladder  itself. 

By  examination  and  operations  on  the  dead  body,  I  have  learned  that  we 
then  divide  skin,  cellular  tissues,  the  posterior  edges  of  the  transversus 
perineal  muscle,  the  superficial  and  horizontal  aponeurosis,  as  well  as  the  in- 
ternal layers  of  those  which  cover  over  the  ischio-rectal  cavity  ;  then  the  left 
side  of  the  prostate  and  the  lateral  part  of  the  neck  of  the  bladder,  vi^ithout 
really  cutting  the  urethra;  that  sometimes  the  bladder  is  cut  two  or  three  lines 
more  outwardly,  and  again,  on  the  contrary,  very  near  the  entrance  of  this 
duct;  that  it  is  a  very  easy  thing  to  wound  the  vesiculae  seminales,  and  also  the 
anus  ;  and  that  in  most  cases  the  deepest  part  of  the  wound  is  not  parallel 
with  the  superficial  part  after  the  operation. 

The  objections  then  which  lie  against  this  operation,  are  exclusive  of  the 
difficulty  of  seizing  and  hooking  the  stone  with  the  fingers,  of  cutting  exactly 
those  tissues  which  lie  over  the  stone,  and  of  taking  it  out  of  so  irregular  an 
aperture;  those  of  dividing  the  bladder  itself  outside  of  the  prostate  and 
thereby  exposing  to  eiFusion  into  the  cellular  tissue  under  the  peritoneum  to 
urinary  fistulse,  and  above  all  of  wounding  the  vesicular  seminales,  without 
perfectly  protecting  either  the  rectum  or  vessels  of  the  perineum  from  lesion. 

b.  Procedure  offrere  Jacques. — I  have  said  that  the  method  of  brother 
Jacques  (I  speak  now  of  that  which  he  originally  adopted)  belongs  to  the 
lateral  operations. 

This  singular  man,  who  was  at  first  only  a  servant  of  Paulini,  the  Venetian, 
and  who  soon  turned  monk,  wishing  to  imitate  his  master,  commenced  opera- 
ting at  Besaneon,  in  the  year  1695,  and  when  two  years  later  he  came  to 
Paris  recommended  to  the  canons  of  Notre  Dame  by  many  influential  persons 
as  possessing  a  new  method  of  extracting  calculi,  went  about  it  as  follows.  A 
cylindrical  sound  having  no  groove  in  it  was  introduced  into  the  bladder, 
and  enabled  him  to  press  out  the  neck  of  this  organ  on  the  left  side  of  the 
perineum.  Brother  Jacques  then  plunged  in  a  long  knife  between  the  anus  and 
tuber  ischii  from  below  upwards,  or  from  the  skin  towards  the  pelvis  pene- 
trated into  the  urinary  bladder,  enlarged  his  incision,  carrying  it  obliquely 
inwards  towards  the  symphysis  pubis,  and  if  it  did  not  appear  to  him  large 
enough  when  his  lithotome  was  withdrawn, he  increased  it  again  with  a  second 
knife  shaped  like  an  erasure  knife  ;  then  he  passed  in  forceps  to  seek  for  the 
stone,  and  concluded  like  Pare,  by  saying  to  his  patients,  *'  I  have  operated 
upon  you,  may  God  cure  you  !"  Every  one  must  see  at  once,  that  by  pass- 
ing on  one  side  of  his  catheter,  brother  Jacques  avoided  entering  the  urethra, 
and  went  at  once  into  that  portion  of  the  bladder  which  is  protected  by  the 
prostate  or  a  little  without  the  gland.  Thus  he  cut  much  the  same  tissues  as 
the  Greek  and  Arabian  physicians,  with  this  dift'erence,  that  his  bistoury 
acted  on  parts  regularly  stretched  ;  that  he  cut  partly  from  within  outwards, 
instead  of  acting  on  an  irregular  surface  such  as  that  of  a  stone;  and  that  his 
incision  was  necessarily  more  equal,  while  its  dimensions  could  be  more  easily 
altered  according  to  circumstances. 

The  experiments  made  by  the  lithotomist  Baulot,  or  as  he  was  yet  called 
Beulieu,  on  the  cadaver  at  the  Hotel  Dieu  before  Mery,  and  at  La  Charite 
before  Marechal,  prove  that  he  was  far  from  always  falling  on  the  same  parts 
94 


746  NEW  ELEMENTS  OF 

that  in  women  he  often  divided  the  rectum  or  vagina ;  in  men  the  vesicute 
seminales ;  and  aimed  particularly  at  the  side  of  the  bladder  just  where  it  enters 
the  prostate  to  form  the  urethra.  The  shoemaker  shown  himatFontainbleau 
by  Duchesne,  and  on  whom  he  operated  in  the  presence  of  Felix,  Bourdelot, 
Bessieres,  and  Fagon,  and  who  in  three  weeks  was  walking  in  the  streets, 
continued  according  to  F.  Collot  to  have  urinary  fistula.  Of  sixty  patients 
entrusted  to  him  in  the  two  largest  hospitals  of  Paris,  only  thirteen  completely 
recovered;  twenty-three  died,  the  others  remaining  with  fistulas,  wounds  of 
the  rectum,  &c.,  whence  I  think  it  follows  that  his  method  did  not  in  reality 
differ  from  that  of  Antyllus,  except  in  the  staff  which  he  used,  and  which 
enabled  him  freely  to  enter  the  bladder  without  the  precaution  of  fixing  the 
stone  firmly  against  the  perineum.  As  soon  as  brother  Jacques  had  adopted 
the  simple  modification  which  was  pointed  out  to  him  by  Mery,  Fagon,  Du- 
verny,  and  Hunault  d' Angers,  which  consisted  in  grooving  the  convexity  of 
his  staff,  this  method  of  operation  was  no  longer  the  same,  and  from  this  time 
only  can  be  said  to  be  enrolled  among  the  urethra  prostatic  methods,  and  to 
have  become  the  origin  of  so  many  useful  improvements.  We  shall  return 
to  it  when  on  the  lateral  operation. 

c.  Procedure  of  Raw. — If  it  be  true,  as  S.  Albinus  asserts,  that  Raw  reached 
the  side  of  the  bladder  without  carrying  his  lithotome  along  the  groove  of  the 
staff,  then  his  method  is  that  of  the  lateral  operation,  after  frere  Jacque's  or  the 
Arabians  J  but  as  we  have  no  positive  historical  facts  upon  this  subject  it  is 
needless  to  discuss  it. 

d.  The  Procedure  of  Cheselden, — It  is  very  clear  that  the  first  procedure  of 
Mr.  Cheselden,  the  skillful  surgeon  at  St.  Thomas's  Hospital,  belonged  to 
this  category;  since  he  simply  laid  bare  the  membranous  and  prostatic 
portions  of  the  urethra,  afterwards  to  divide  the  parts  from  behind  for- 
ward, beginning  at  the  neck  of  the  bladder,  and  not  following  the  groove  in 
the  staff. 

e.  TTie  Procedure  ofFoubert. — The  secret  so  inviolably  kept  by  Raw  as  to 
the  mechanism  of  his  method,  which  after  all  was  probably  no  other  than 
that  of  frere  Jacques,  at  first  so  violently  criticized  by  him,  induced  many 
surgeons  to  endeavor  to  discover  a  method  by  which  to  perform  what  they 
then  called  lateral  cutting,  that  is  to  say,  cutting  by  the  side  of  the  body 
of  the  bladder.  After  seeking  to  attain  their  end  by  varying  in  every  possible 
way  the  use  of  the  staff,  the  length  and  extent  of  incision,  &c.  Foubert  at 
last  hit  upon  one  different  in  appearance  from  every  other,  and  which  he  sup- 
posed to  be  the  one  performed  by  Raw. 

This  surgeon  began  by  filling  the  bladder  with  tepid  water  if  the  patient 
could  not  contain  his  urine  long  enough,  passed  in  a  long  trocar  at  some  lines 
from  the  tuber  ischii,  and  carried  it  obliquely  upwards,  inwards,  and  for- 
wards, into  the  reservoir  of  urine.  The  canula  of  the  instrument  instantly 
allowing  of  the  escape  of  some  drops  of  liquid  outwardly,  added  to  a  want 
of  resistance  offered  to  the  surgeon,  served  to  indicate  the  entrance  of  the 
trocar  into  the  bladder.  This  canula  then  acted  as  a  director  for  Foubert's 
lithotome,  which  consisted  of  a  bistoury  four  or  five  inches  long,  rather  con- 
vex, and  bent  at  an  angle  of  twenty  or  thirty  degrees  on  its  cutting  side  near 
the  handle.  When  it  had  entered  the  bladder,  this  knife  was  carried  parallel 
to  the  ischio-pubic  ramus,  in  other  words,  obliquely  from  behind  forwards. 


OPERATIVE    SURGERY.  747 

and  from  without  inwards,  so  as  to  make  a  wound  in  the  bladder  and  peri- 
neum equal  to  the  supposed  dimensions  of  the  stone. 

f.  M.  Thomas,  surgeon  at  La  Salpetriere  Hospital  adopting  the  same  no- 
tions, thought  it  better  to  pursue  another  course.  He  plunged  his  trocar  in 
the  spot  at  which  Foubert  ended  his  incision,  with  the  intention  of  dividing 
the  parts  from  above  downwards,  and  from  within  outwards,  instead  of  acting 
in  the  opposite  direction  as  was  advised  by  the  inventor  of  the  method. 
Moreover,  lie  finished  by  transforming  into  a  species  of  concealed  lithotome, 
the  instrument  with  which  he  had  effected  the  puncture,  because,  said  he,  the 
lithotome  thus  constructed  w^ould  allow  of  giving  to  the  wound  a  determinate 
extent,  and  greater  certainty  to  the  operation.  Many  patients  were  operated 
on  by  his  method  in  the  Parisian  hospitals.  It  was  submitted  to  tlie  test  also 
in  England  and  in  Germany.  But  it  soon  became  subject  to  many  objections. 
Most  patients  cannot  retain  their  urine,  and  the  injections  however  mild 
they  may  be,  are  always  painful  when  carried  to  such  a  point  as  to  distend 
the  bladder. 

The  direction  of  the  pelvic  axis,  and  the  deep  situation  of  the  urinal  reser- 
voir, do  not  permit  of  blindly  passing  a  trocar  through  the  perineum  without 
danger.  Nothing  could  be  easier,  in  such  a  case,  than  to  stray  aside,  back- 
ward or  forward,  so  as  to  wound  the  rectum,  vesiculae  seminales,  ureters, 
the  peritoneum  itself,  or  to  enter  the  bladder  too  high  up  in  its  body. 

To  all  these  undisputed  risks  one  other  must  be  added,  which  now  alone 
could  suffice  to  cause  the  method  of  Foubert  to  be  rejected,  could  it  ever  be 
reproduced.  It  is,  that  the  end  aimed  at  is  an  extremely  pernicious  one. 
The  incision  into  the  bladder  being  to  be  made  outside  of,  and  above  the  pros- 
tate, between  the  peritoneum  and  fascia  pelvica,  it  follows  that  the  least  drop 
of  urine  which  should  be  effused  at  the  bottom  of  the  wound  might  give  rise  to 
inflammation  of  the  cellular  layer  which  clothes  the  pelvic  excavation,  and  be 
speedily  fatal. 

It  will  be  seen,  that  in  the  transverse  or  lateral  operation  nearly  the  same 
elements  are  passed  through  as  in  the  procedures  of  Antyllus,  Guy  de  Chau- 
liac,  and  of  brother  Jacques ;  only  that  it  inclines  a  little  to  the  side,  and 
that  therefore  it  is  perhaps  rather  more  liable  to  give  rise  to  incurable  fistulas, 
or  to  endanger  the  ureters  or  vesiculae  seminales.  The  mode  proposed  by 
Pallucci,  of  previously  dividing  the  perineal  layers,  so  as  to  allow  the  fore- 
finger to  detect  the  fluctuation  in  the  bladder  before  it  is  punctured  by  the 
trocar,  does  not  remedy  the  least  even  of  these  inconveniences. 

Nor  would  the  ingenious  instrument  invented  by  Lecat  answer  better, 
which  is  introduced  closed,  and  in  opening  stretches  the  bladder  at  the  bas- 
fondj  and  thus  renders  the  introduction  of  the  principal  instrument  more  easy. 

2.  Median  Operation  for  the  Stone. — /Ipparatus  Major, 

Those  procedures  in  which  the  incision  comprises  the  greater  or  less  part 
of  the  urethra,  being  in  truth  the  only  ones  which  ought  to  be  adopted  in  cut- 
ting below  the  pubis,  have  likewise  engaged  more  of  surgeons'  attention. 
Among  them  will  be  found  the  median  operation  by  the  apparatus -major ;  the 
lateral  operation,  or  perfected  jnethod  of  brother  Jacques;  the  transverse 
operation,  and  all  their  modifications 


748  NEW    ELEMENTS    OF 

a.  Procedure  of  Mariano. — As  the  method  called  that  of  Guy  de  Chauliac, 
had  alone  been  recommended  by  the  ancients,  and  did  not  appear  calculated 
for  any  but  young  subjects,  it  was  not  possible  that  lithotomists  should  not 
have  thought  of  some  other. 

That  which,  owing  to  the  great  number  of  instruments  it  requires,  is  called 
the  *'  apparatus-major,'^'^  remained  for  a  long  time  a  family  secret.  It  appears 
to  have  been  invented  by  some  of  the  inhabitants  of  ancient  Italian  Norcia,  who, 
under  the  common  title  of  Norcini,  acquired  great  reputation  as  operators 
during  the  14th  and  15th  centuries.  If  M.  Bonino,  however,  is  correct,  and 
the  archives  of  Turin  prove  that  its  real  inventor  was  Battista  di  Rapallo,  who 
died  in  1510,  the  master  of  Giovani.  Be  this  as  it  may,  Giovani  de  Romani  is 
the  first  to  whom  history  refers  it ;  and  it  was  published  by  his  friend  Mariano 
Santo  about  1520  or  1530.  It  was  probably  known  to  A.  Benedetti ;  for,  after 
announcing  that  certain  calculi  may  be  extracted  without  a  bloody  operation, 
he  says,  *'  nunc  inter  anum  et  cutem,  recta  plaga,  cervicem  vesica  incidunt." 

It  was  raised  to  celebrity  by  the  success  of  Laurent  Collot,  to  whom  it  had 
been  taught  by  Octavius  Davilla,  and  who,  owing  to  this,  was  appointed  litho- 
tomist  to  the  court  of  Henry  II.  At  this  period  of  time  the  apparatus -major 
was  still  a  secret  to  the  public.  Philip  Collot  and  Restitut  Giraud,  who  suc- 
ceeded their  relation,  succeeded  so  ill  in  instructing  ten  students  by  order  of 
the  government,  that  their  children  would  have  alone  retained  it  until  Francis 
Collot  had  thought  fit  to  publish  the  steps  of  the  operation,  had  not  the  pupils 
of  La  Charite  and  the  Hotel  Dieu  thought  of  making  a  hole  in  the  floor  of  the 
operating  room,  and  by  watching  their  proceedings,  discovered  the  secret. 

It  consists  in  the  following  process  :  A  grooved  statf  carried  into  the  blad- 
der allows  the  perineum  to  be  depressed  a  little  to  the  left  of  the  raphe,  and 
not  as  Heister  states  exactly  on  the  median  line.  With  a  lithotome,  like  an 
immense  lancet,  the  surgeon  makes  his  incision  into  the  skin,  the  cellular  tis- 
sue, and  the  muscles,  from  the  root  of  the  scrotum  to  some  lines  from  the 
anus,  and  which  incision  crosses  the  bulb  of  the  urethra,  and  so  strikes  upon 
the  groove  into  the  staff.  A  director  (a  sort  of  stem,  formed  of  a  male  and  a 
female  branch,  differing  from  one  another  in  as  much  as  that  the  first  ends  by 
a  rather  flat  and  smooth  extremity,  whilst  the  other  is  forked  in  the  same 
direction)  is  then  carried  instead  of  the  lithotome  quite  into  the  bladder. 
The  staff,  now  useless,  is  forthwith  drawn  out.  The  female  branch  of  the 
director,  which  until  now  remains  outside,  is  then  slipped  by  the  assistance  of 
its  bifurcation  upon  the  square  edge  of  the  male  branch  into  the  interior  of 
the  urinary  pouch.  Fixed  thus  one  upon  the  other,  the  two  branches  of  this 
instrument  allowed  the  surgeon  to  dilate  the  wound,  by  separating  them  with 
their  outer  ends,  which  terminated  in  a  cross  to  render  manipulation  more 
easy ;  but  their  principal  use  was  to  direct  the  forceps  in  seizing  the  stone. 
Moreover,  a  common  gorget,  and  even  another  instrument  called  a  dilator, 
formed  of  two  branches  jointed  like  scissors,  which  were  introduced  closed, 
and  opened  by  pressing  on  the  rings  affixed  to  their  handles,  were  substituted 
occasionally  for  the  one  before  mentioned. 

The  apparatus -major,  practised  by  following  to  the  letter  the  instructions 
given  by  Mariano  Santo,  is  one  of  the  very  worst  operations  which  has  ever  been 
invented.  The  incision,  evidently,  only  bore  upon  the  spongy  portion,  or  at 
most  upon  the  membranous  portion  of  the  urethra.      The  dilators  could  only 


OPERATIVE    SURGEKV.  749 

widen  the  wound  by  lacerating  the  prostate.  The  urethra  itself  was  some- 
times burst  entirely,  and  the  rents  extended  even  as  far  sometimes  as  the 
neck  of  the  bladder  and  vesiculae  seminal es.  Bruising  the  verumontanum, 
tearing  the  ejaculatory  canals,  bring  with  it  fistula,  incontinence  of  urine, 
swelling  of  the  testicles,  and  even  impotency  frequently.  The  external  inci- 
sion prolonged  too  much  in  front,  facilitated  infiltration  of  blood,  pus,  or 
urine  into  the  scrotum;  and  the  bottom  of  the  wound,  moreover,  became  in 
many  a  starting  place  for  purulent  deposits,  which  passed  in  the  direction 
either  of  the  pelvis,  around  the  rectum,  or  on  the  upper  parts  of  the  tliighs. 
Altogether  the  operation  was  so  excessively  painful  and  dangerous  to  such  a 
degree,  that  according  to  the  statement  of  the  editor  of  the  works  of  F.  Collot 
himself,  it  was  scarcely  possible  to  save  one  third,  or  half  of  the  patients  who 
had  the  courage  to  undergo  it. 

However,  it  would  be  unjust  to  attribute  to  the  apparatus -major  all  the 
reproaches  which,  from  the  detail  just  given  of  the  steps  in  it,  it  may  seem  to 
deserve.  It  had  in  fact  undergone  many  changes  in  the  hands  of  different 
operators.  For  instance,  since  tlie  time  of  Dionis  and  LaCharriere,  the  con- 
ductor and  dilator  were  used  no  longer ;  after  freely  incising  the  urethra 
they  merely  conducted  a  gorget  upon  the  groove  of  the  staff  to  beyond  the 
neck  of  the  bladder,  which  gorget  afterwards  served  as  a  guide  to  the  common 
forceps.  It  had  been  still  further  simplified  by  the  surgeon-in-chief  of  La 
Charite,  M.  Marechal.  After  making  his  first  incision  like  Collot,  he  passed 
in  his  lithotome  with  a  complicated  see-saw  motion  to  the  bladder,  perfomiing 
what  was  called  by  surgeons  at  that  day  the  "  coup  de  maitre,^^  in  such  a  way 
as  to  divide  the  whole  thickness  nearly  of  the  prostate  in  its  posterior  radius, 
D.  Scacclii  and  C.  De  Solingen  had  before  formally  advised  cutting  all  those 
parts  which  Mariano  Sarto  preferred  to  tear.  It  is  evident  that  in  this  wav 
Marechal  cut  the  bulbous  part,  tlie  membranous  and  prostatic  portions 
of  the  urethra,  and  consequently  that  he  had  an  aperture  of  eight  or  ten  lines 
in  the  neck  of  the  bladder  which  would  allow  of  the  easy  passage  of  bulky 
stones  without  the  slightest  rupture.  This  surgeon  obtained  numerous  suc- 
cessful results,  and  concluded  his  operations  with  wonderful  celerity.  Dila- 
tation with  the  finger,  as  mentioned  by  De  la  Faye,  had  certainly  been  less 
formidable  than  the  instruments  of  Giovani,  but  could  not  compare  with  the 
modification  of  Marechal. 

b.  Procedure  of  Vacca. — Regarded  in  this  light,  the  apparatus-major  had  so 
lost  its  terrors  that  a  surgeon  of  eminence  has,  in  later  years,  reintroduced  it 
as  a  method  of  his  own  invention.  After  for  a  long  while  extolling  and  prac- 
tising the  recto-vesical  operation,  Vacca  Berlinghieri  at  last  replaced  it  by  a 
procedure  which  differs  but  little  from  that  of  Mery.  The  Tuscan  surgeon 
makes  his  incision  upon  the  median  line  as  did  Mariano,  comes  down  to  the 
membranous  part  of  the  urethra  with  a  common  bistoury,  then  inserts  in  the 
groove  of  the  staff  the  beak  of  his  "  bistoury  lithotome,"  which  he  pushes 
into  the  bladder,  and  lastly  draws  it  from  within  this  organ  outwards,  raising 
his  wrist  so  as  to  divide  the  prostates  as  extensively  as  may  be  wished. 

Auotlier  alteration  of  the  median  operation  is  contained  in  a  thesis  defended 
at  the  commencement  of  this  century  by  M.  Treyheram.  The  urethra  is 
opened,  and  also  the  prostate,  from  before  backwards  ;  a  dry  carrot  is  then 
placed  every  morning  in  the  bladder  through  the  wound,  and  the  stone  only 


750  NEW    ELEMENTS   OF 

extracted  at  the  end  of  some  days.  The  writer  states  that  M.  Guerin  of  Bor- 
deaux, the  inventor,  has  obtained  from  it  the  happiest  success ;  and  the  papers 
of  the  country  have  again  recently  taken  notice  of  it.  The  median  method 
of  cutting  for  stone,  when  reduced  to  its  greatest  simplicity,  offers  but  one 
indisputable  advantage,  that  of  not  giving  rise  to  any  danger  from  hemorrhage. 
Vacca,  who  in  addition  to  this  assigns  to  it  the  merit  of  allowing  the  stone  to 
be  extracted  in  the  widest  point  of  the  lower  strait,  could  never  have  con- 
sidered of  his  assertion;  for  in  this  respect  it  offers  nothing  more  than  a 
host  of  other  procedures  belonging  to  lateralized  cutting.  As  improved  by 
Mery  and  by  Vacca  it  is  less  painful,  more  reasonable,  and  in  every  point 
of  view  infinitely  superior  to  the  old  plan  as  it  came  from  the  hands  of 
Mariano ;  but  it  is  not  the  less  of  all  the  most  threatening  to  the  rectum,  and 
does  not  guard  against  wounding  the  ejaculatory  ducts.  Moreover,  as  it 
divides  the  prostate  from  before  backwards  in  the  direction  of  one  of  the 
smallest  radii  of  the  gland,  it  is  not  really  worthy  of  the  eulogiums  recently 
lavished  upon  it  by  the  professor  of  Piso  and  his  countryman  M.  Balardini. 

S.  Oblique t  or  Lateralized  Operation  for  Stone, 

Owing  to  a  mal  a  propos  confusion  between  the  operation  described  in  the 
works  of  Celsus,  with  that  which  is  described  by  Paulus  of  Egina,  and  An- 
tyllus,  the  lateral  method  as  first  performed  by  brother  Jacques  has  ultimately 
been  confounded  with  the  lateralized  mode  of  cutting  on  which  so  much  labor 
has  since  been  bestowed.  A  great  difference  exists  between  the  modes  of 
performing  them.  In  one,  the  principal  object  in  the  incision  is  to  reach  the  side 
of  the  neck  of  the  bladder  without  necessarily  involving  the  urethra;  in  the 
other,  on  the  contrary,  the  posterior  portion  of  this  canal  is  always  divided, 
whilst  the  bladder  itself  may  be  most  strictly  avoided.  The  lateralized 
method  consisting  essentially  in  an  incision  of  greater  or  lesser  obliquity  into 
the  prostatic  portion  of  the  urethra,  including  in  it  a  greater  or  less  extent  of 
the  membranous  portion  of  the  same  passage,  the  only  procedures  evidently 
whiich  belong  under  its  head  are  those  in  which  the  operator  employs  a  grooved 
staff  to  direct  his  cutting  instrument  into  the  urinary  bladder. 

a.  Procedure  of  Franco,  or  of  d^Hunault. — So  little  is  the  conception  of  the 
oblique  method,  the  right  of  frere  Jacques,  that  this  monk  attained  to  it  only 
as  a  consequence  of  the  representations  of  his  antagonists,  and  after  it  had 
been  neatly  set  forth  by  Franco  and  Fabricius  Hildanus.  Franco  says  dis- 
tinctly, that  to  incise  the  perineum  in  lithotomy,  a  curved,  grooved  staff  must 
be  introduced  previously  into  the  bladder ;  that  this  staff  must  act  as  a 
director  to  the  bistoury,  and  that  the  neck  of  the  bladder  should  be  divided 
obliquely  from  within  outwards  towards  the  ischium.  True,  he  wishe!§  it  to 
be  made  on  the  right  side ;  but  rt  is  possible  that  by  this  expression  he  means 
the  right  side  of  the  surgeon,  which  corresponds  with  the  patient's  left  side. 
G.  Fabricius  evidently  followed  the  same  advice  previously  also  given  by  A. 
de  la  Croix.  It  is  to  Hunault  of  Angers  notwithstanding,  that  we  owe  our 
knowledge  on  this  subject.  Plates  which  he  caused  to  be  executed,  but  which 
were  never  published,  show  that  with  a  grooved  staff  we  may  always  cut  with 
certainty  the  same  parts,  and  it  was  in  consequence  of  having  adopted  his 
counsels  that  brother  Jacques  succeeded  in  1701  in  cutting  thirty-eight  pa- 


OPERATIVE    SURGERY.  751 

tients  with  stone  at  Versailles  without  the  loss  of  a  single  one,  and  also  the 
twentj-two  persons  collected  by  the  Marechal  de  Lorges  at  his  hotel  in  1703, 
that  he  obtained  such  brilliant  success  in  Holland,  and  afterwards  on  his 
return  to  France.* 

b.  Procedure  of  Garengeot  and  Per  diet. — Garengeot — who  made  the  disco- 
very during  the  course  of  some  examinations  which  he  was  making  on  the 
dead  body  with  Perchet,  a  surgeon  at  La  Charite,  and  who  put  it  in  practice 
upon  a  child  nine  years  and  a  half  old,  in  the  year  1729,  whilst  Morand  had 
gone  to  England  to  teach  it  to  Mr.  Cheselden — is  the  first  who  seems  to  have 
re-established  it  upon  the  grounds  first  laid  down  by  Hunault.  The  staff 
introduced  into  the  bladder  is  entrusted  to  an  assistant,  who  presses  it  upon 
the  left  side  of  the  perineum  to  make  it  bulge  in  that  direction.  The  surgeon 
makes  an  oblique  incision  from  the  raphe  towards  the  middle  of  the  space 
which  lies  between  the  ischium  and  the  anal  aperture  with  a  common  bistoury 
or  lithotome.  This  cut,  which  should  begin  an  inch  above  the  anus,  goes 
through  skin  and  sub-cutaneous  tissue.  The  left  index-finger  then  serves  as 
a  guide  to  the  cutting  instrument,  whilst  the  other  tissues  are  layer  by  layer 
divided,  and  the  urethra  laid  open.  The  lithotome  slipped  from  before  back- 
wards, and  from  above  downward,  upon  the  groove  of  the  staff*  enters  the 
bladder,  crossing  obliquely  the  prostate  outwardly  from  right  to  left;  after 
which  the  surgeon  makes  use  of  it  for  enlarging  the  wound  by  withdrawing 
and  pressing  upon  it  with  more  or  less  strength.  With  a  view  to  favor  its 
entrance,  as  soon  as  the  membranous  portion  of  the  urethra  is  opened,  the 
operator  requests  his  assistant  to  lower  the  handle  of  the  staff,  or  he  does  it 
nimself,  so  as  to  raise  the  concavity  behind  the  pubis,  whilst  at  the  same  time 
he  inclines  the  wrist  of  the  right  hand  a  little  downwards.  In  this  way  he 
runs  no  risk  of  straying,  and  the  bladder  is  in  no  danger  whatever  of  being 
wounded. 

c.  Procedure  of  Cheselden. — Morand  in  his  description  of  the  process 
of  Cheselden  has  given  nearly  a  similar  idea  of  lateralized  cutting  as  had 
Garengeot,  save  that  it  would  seem  that  his  principal  intention  was,  after 
dividing  the  prostate,  to  spare  as  much  as  possible  the  other  tissues,  and  to 
make  his  wound  resemble  a  sort  of  oblique  canal  from  behind  forward,  and 
from  the  bladder  towards  the  perineum.  But  Cheselden  has  several  times 
modified  his  method  of  operating.  His  first  method  I  have  already  described 
when  speaking  of  lateral  operation,  and  the  second  is  that  described  by  Morand. 
The  third  at  which  he  stopped  is  very  diff'erent  from  the  notion  generally 
entertained  in  France.  The  English  surgeon  in  every  case  extends  his  ex- 
ternal incision  to  a  length  of  two  to  four  inches,  and  it  always  fell  betwixt 
the  bulbo-cavernosus  and  ischio-cavernosus  muscles,  so  as  to  lay  bare  the  ure- 
thra to  the  summit  of  the  prostate. 

The  second  stage  of  his  operation  comprised  the  incision  of  the  deeper 
seated  parts,  which  the  former  had  denuded.     To  accomplish  it  Cheselden 

*  Sabatier  is  In  error  in  saying  that  brother  Jacques  died  in  1713.  Having"  arrived  at 
L'Etendonne  from  Rome,  or,  according  to  Norman,  at  his  village,  Arbagne,  in  June,  1714, 
he  went  to  pass  several  months  at  Besancon,  and  then  lived  long  enough  among  the 
Benedictines  to  build  there  a  small  house,  which  he  afterwards  quitted  to  go  and  live 
with  his  triend  L.  Decart,  where  he  died  aged  69  years  ;  and  as  he  was  born  in  1651,  of 
course  in  the  vear  1720. 


759.  NEW    ELEMENTS   OF 

pushed  forcibly  the  anus  backwards  and  to  the  right  side,  by  introducing  the 
forefinger  of  his  left  hand  into  the  hinder  angle  of  the  wound,  then  on  the 
nail  of  this  finger  passed  in  a  slightly  concave  bistoury,  following  the  ante- 
rior face  of  the  rectum  up  to  the  neck  of  the  bladder,  struck  upon  the  groove 
of  the  staff"  to  divide  the  whole  extent  of  the  prostate  gland  from  behind  for- 
wards, and  from  below  up,  by  drawing  towards  him  his  lithotomc,  with  its 
cutting  edge  turned  towards  the  pubic  articulation. 

This  procedure  of  Cheselden's  will  be  seen  to  be  quite  distinct  from  the 
oblique  or  lateral  operation  for  stone,  as  practised  by  French  surgeons. 
It  encounters,  it  is  true,  the  same  parts  as  that  of  Garengeot;  yet,  while  it 
bears  the  semblance  of  more  perfectly  protecting  the  rectum  from  injury, 
adds  in  reality  to  the  difficulty  of  manipulation. 

d.  Boudou,  who  performed  the  lateralized  operation,  perhaps  before  ever 
it  had  been  described  by  any  one  in  Paris,  adopted  a  method  which  differed 
from  that  of  Mery,  only  in  the  direction  which  he  gave  his  incision.  De  La 
Faye  states  in  his  addenda  to  the  Treatise  of  Dionis,  that  Boudou  caused  the 
handle  of  his  staff*  to  lean  towards  the  right  groin,  and  that  after  having  cut 
into  the  membranous  portion  of  the  urethra,  he  plunged  his  lithotome  along 
the  groove  of  the  staff',  then  raised  up  towards  the  pubis  beyond  the  neck, 
and  divided  the  prostate  obliquely  to  the  left,  drawing  the  cutting  instru- 
ment towards  himself. 

e.  Procedure  of  Le  Bran. — Le  Dran  one  of  the  most  learned  practitioners 
of  the  age,  had  also  his  own  particular  method  of  operating.  When  he  had 
cut  into  the  urethra,  he  introduced  a  thick  grooved  sound  into  the  bladder, 
immediately  withdrew  the  catheter,  and  ended  by  dividing  the  prostate  with 
a  convex  bistoury  *'  en  rondache,  shield-shaped,"  which  was  about  six  lines 
in  width.  Notwithstanding  that  it  is  insignificant  in  itself  and  fitter  to  com- 
plicate than  simplify  the  operation,  this  modification  has  had  its  partisans; 
and  even  now  has  some  still  in  Great  Britain.  Allan  Burns,  for  instance, 
adopts  the  principle,  preferring  however  the  common  lithotome  or  bistoury  to 
the  instrument  of  Le  Dran.  Mr.  J.  Bell,  who  Avas  of  the  same  opinion, 
incises  from  the  prostate  towards  the  first  opening  of  the  urethra,  as  Chesel- 
den  did,  instead  of  following  Le  Dran,  and  carrying  the  bistoury  from  before 
backwards;  and  Allan  who,  like  his  countrymen  also  carries  in  the  bis- 
toury to  the  staff*  passing  behind  the  prostate,  prefers  withdrawing  them  both 
together,  keeping  the  two  instruments  firm  one  on  the  other,  as  is  commonly 
done  in  operating  for  fistula  in  ano.  It  is  difficult  to  discover  in  what  respect 
the  cutting  for  stone  is  rendered  less  dangerous  or  more  convenient  by 
either  of  the  above  shades  of  diff'erence  from  the  principal  operation. 

f.  Procedure  of  Lecat.  A  method  of  operating  for  stone,  in  the  oblique  or 
lateralized  way,  which  at  the  time  made  some  impression  on  the  profession, 
is  that  of  Lecat.  The  sound  used  by  this  operator  did  not  terminate  at  its 
straight  end  by  the  usual  flat  surface,  but  by  a  handle.  The  instrument  with 
which  he  laid  bare  and  incised  the  urethra  had  lateral  notches  near  its  back, 
and  was  called  by  the  inventor  his  **  uretrome."  Lecat  conveyed  another 
one,  ending  in  a  blunt  extremity,  to  the  assistance  of  the  former  as  far  as  the 
groove  in  the  staff*  to  cut  through  the  prostate,  very  much  as  was  done  by 
Cheselden  in  his  second  procedure,or  that  described  by  Morand.  However, 
the  edge  of  this  second  instrument,  called  cystotome,  was  never  to  go  beyond 


OPERATIVr.    SURGERY,  75'3 

the  vesical  tubercle  which  exists  at  the  entrance  of  the  urethra,  for  which 
very  reason  the  name  of  cjstotome,  is  most  singularly  inappropriate  to  it. 
Lastly,  the  surgeon  of  Rouen,  for  a  short  space  conceived  the  idea  of  substi- 
tuting a  sheathed  lithotome  in  place  of  his  cystotome,  and  to  wliich  he  gave  the 
appellation  o.  cystotome  gorget.  The  original  which  he  adopted  was  a  large 
incision  externally,  a  small  one  within;  whence  we  see  that  he  foresaw  the 
danger  of  going  beyond  the  limits  of  the  prostate,  and  preferred  rather  to 
dilate  the  entrance  of  the  bladder  than  to  incise  it.  But  to  accomplish  the 
ends  aimed  at  beneath  the  thought,  the  instrumental  apparatus  was  unneces- 
sary, and  his  method,  although  he  derived  indisputable  success  from  it, 
was  not  generally  adopted.  Some  practitioners  indeed  have  continued 
to  pursue  it.  Pouteau  reaped  such  successful  results  from  it  with  a  very 
slight  modification,  that  in  some  of  the  Lyonese  hospitals  it  is  still  frequently 
practised.  A  surgeon  of  Venice,  M.  Paiola,  who  has  increased  its  complex- 
ity, by  adding  a  third  instrument  to  those  of  Lecat,  has  it  is  said  recurred  to 
it  five  hundred  times  and  never  lost  a  single  patient !  This  assertion  is  so 
strange  that  but  for  Langenbeck  speaking  in  eulogistic  terms  of  its  author  it 
would  be  undeserving  the  least  attention.  It  will  be  seen  in  a  thesis  by  M. 
Dumont,  that  in  the  hospital  at  Rouen,  M.  Flaubert,  also  follows  the  axiom 
established  by  Lecat,  and  that  according  to  him  a  small  incision  and  a  free 
dilation,  is  a  maxim  from  which  no  surgeon  should  ever  deviate.  M.  Delpech 
was  equally  of  opinion  that  it  was  safer  to  dilate,  and  even  to  tear  the  neck  of 
the  bladder,  than  to  cut  it  freely,  and  that  the  precept  of  Lecat  on  this  sub- 
ject ought  to  be  law.  Beneath  it  there  is  an  important  truth  which  of  late 
years  only  could  have  been  properly  estimated,  because  until  then  the  anato- 
mical reason  had  not  been  distinctly  shown ;  it  is,  that  lithotomy  confined  to 
the  circle  of  the  prostate  is  infinitely  less  dangerous  than  that  in  which  the 
incisions  exceed  the  limits  of  this  gland. 

g.  Procedure  of  Moreau.  A  surgeon  at  the  Hotel  Dieu,  in  Paris,  M. 
Moreau,  who  died  in  Paris,  1786,  discarded  all  these  complications,  and  per- 
formed the  lateralized  operation  in  the  following  way.  To  a  certain  extent 
his  lithotome  resembled  the  old  one  of  CoUot.  He  cut  very  freely  the  skin 
and  cellular  subcutaneous  tissue ;  opened  the  membranous  portion  of  the 
urethra;  raised  the  staff  behind  the  pubis,  and  at  the  same  time  plunging  his 
bistoury  into  the  bladder ;  strongly  elevated  his  right  wrist  to  cut  the  pro- 
state obliquely,  and  then  depressed  it  to  carry  backwards  the  cutting  edge  of 
his  instrument,  as  he  brought  it  out  at  the  external  opening,  His  idea  was  to 
make  a  large  opening  into  the  neck  of  the  bladder,  so  as  thence  easily  to 
extract  the  stone,  a  still  larger  opening  in  the  integuments  to  avoid  infiltra- 
tion, or  abscess,  and  to  cut  but  very  little  of  the  parts  intermediate ;  to  avoid 
the  arteries  of  the  perineum  which  are  lodged  principally  in  them,  and  likewise 
to  avoid  the  rectum,  so  that  his  wound  must  have  resembled  a  double  triangle 
whose  narrowest  part  was  in  the  centre  of  its  length. 

ii. '  Procedure  of  frere  Come. — A  modification  of  the  lateralized  operation  for 
stone,  which  actively  engaged  professonal  minds,  was  that  which  brother 
Come  proclaimed  himself  the  inventor  in  1748. 

This  monk  contrived  an  instrument,  which  being  introduced  closed  into 
the  bladder  through  the  incision  in  the  urethra,  is  open  by  exerting  pressure 
on  the  bascule  of  its  outer  extremity,  and  as  it  is  withdrawn  cuts  the  pro- 
95 


754  NEW   ELEMENTS  OF 

state  from  within  outwards.  This  instrument  since  known  as  the  sheathed  litho- 
tome,  at  first  appeared  to  oifer  numerous  advantages.  Its  handle  cut  into 
facets,  numbered  5,  7,  9,  11, 13  and  15  is  so  arranged  that  by  bringing  off  the 
numbers  towards  the  side  of  the  bascule,  one  is  sure  of  having  a  correspond- 
ing opening  toward  the  vesical  extremity  of  the  instrument.  Thus  it  is 
known  beforehand,  and  with  great  certainty  that  the  neck  of  the  bladder  will 
be  divided  to  an  extent  of  7,  9, 11,  13  or  15  lines,  according  as  one  or  the  other 
of  these  dimensions  shall  have  been  pitched  upon  before  it  is  introduced. 
Franco  speaks  of  an  instrument  very  much  of  the  same  kind,  and  Bienaise^s 
concealed  bistoury  does  not  diifer  much  from  it.  It  was  objected  to  it,  that 
it  was  liable  to  escape  from  the  groove  in  the  staff;  to  slip  between  the  blad- 
der and  neighboring  parts;  to  wound  the  rectum  whilst  it  was  being  with- 
drawn ;  to  cut  the  pudic  vessels ;  and  lastly,  to  pierce  the  bladder  itself, 
after  it  was  emptied  through  the  wound  in  the  perineum. 

To  do  away  with  the  latter  objection,  its  point  was  blunted  by  Caguet,  a 
surgeon  at  Rheims.  However,  as  it  finally  appears  to  possess  merely  the 
advantage  of  cutting  the  same  parts  always  to  a  determinate  extent,  which 
are  divided  by  other  lithotomes,  it  has  with  some  show  of  reason  been  alter- 
nately lauded  or  condemned.  Surgeons  but  little  accustomed  to  capital  ope- 
rations, and  wlio  are  not  sure  of  their  hand,  who  are  not  very  perfect  in  the 
anatomical  details  of  the  perineum,  but  who  nevertheless  venture  to  cut  for 
stone,  may  and  even  ought  to  give  it  a  preference. 

The  lithotome  gorget  which  Bromfield  wished  to  substitute  for  it,  composed 
of  two  pieces  movable  on  one  another,  is  incomparably  more  defective. 
The  modifications  made  on  it  by  Mr.  Evans  of  London,  and  several  operators 
in  France,  which  are  almost  all  confined  to  its  bascule  and  handle,  are  too 
unimportant,  too  evidently  matters  merely  of  taste,  for  me  to  stop  to  discuss 
them. 

Brother  Come  performed  his  operation  after  the  usual  method  of  lateral- 
ized  cutting  as  far  as  the  division  of  the  membranous  part  of  the  urethra.  The 
lithotome  passed  along  jpn  the  nail  of  the  left  index  finger  into  the  groove  of 
the  staff,  was  then  to  be  engaged  closed  in  the  bladder.  Then  the  surgeon 
himself  took  the  staff  in  his  left  hand  to  depress  its  handle  and  elevate  its 
concavity  behind  the  pubis,  whilst  with  his  right  hand  pushed  on  the  point  of 
the  sheathed  lithotome  in  the  groove,  which  thus  passed  into  the  bladder,  and 
the  staff,  now  no  longer  useful,  was  withdrawn  at  once  from  the  urethra. 
Having  anew  assured  himself  of  the  existence  of  the  stone,  which  can  be  felt 
easily  with  the  end  of  the  lithotome,  the  operator  takes  hold  of  the  shank  of 
the  instrument  with  his  left  forefinger  and  thumb  semiflexed ;  opens  it  by 
pressing  on  its  bascule  with  the  right  hand ;  rests  the  back  of  the  instrument 
firmly  against  the  symphysis  pubis,  a  little  to  the  right  side ;  directs  the  cutting 
edge  of  it  to  the  left  and  backwards ;  draws  it  forth,  raising  its  handle  mode- 
rately until  its  blade  has  cleared  the  prostate  ;  slackens  the  bascule  at  this 
moment ;  allows  it  to  reclose  by  degrees ;  and  lowers  it  more  and  more,  and 
in  such  a  way,  that  from  the  neck  of  the  bladder  to  the  integuments  its  cut- 
ting edge  shall  as  it  were  have  described  a  half  circle,  the  convexity  of  which 
should  be  in  front,  nearly  as  in  the  procedure  of  Moreau. 

i.  Procedure  of  Guerin. — Brother  Come  is  far  from  being  the  only  person 
who  has  proposed  a  particular  instrument  for  lessening  the  dangers  of  litho- 


OPERATIVE    SURGERY.  755 

tomy.  A  host  of  others  have  since  his  been  invented,  tne  object  of  some  of 
which  has  been  to  render  opening  of  the  urethra  more  certain  ;  of  others  to 
divide  the  prostate  neck  of  the  bladder  with  less  hazard.  Among  the  first 
are  many  species  of  staves;  for  example  that  of  Guerin,  so  constructed 
that  when  once  placed,  its  external  extremity  is  sufficiently  depressed  to  be 
directed  opposite  or  to  face  its  most  convex  part,  that  is  to  say,  the  groove  of 
its  urethral  portion.  It  is  besides  ended  by  a  sort  of  perforated  head,  through 
which  may  be  carried  a  long  trocar  canulated  on  its  inferior  surface,  and 
which  passed  upon  the  perineum  necessarily  falls  of  itself  into  the  groove  of 
the  staff.  We  see  thence  that  the  incision  in  the  soft  parts  externally 
becomes  extremely  easy,  and  that  the  opening  in  the  urethra  off*ers  not  the 
least  embarrassment.  In  all  other  respects  the  operator  acts  as  has  been 
described  when  speaking  of  median  cutting.  An  instrument  differing  from 
that  of  Guerin  in  having  two  halves  jointed  externally  by  a  hinge,  has  been 
employed  in  England  by  Mr.  Earle,  with  similar  views  to  those  of  the 
Bordeaux  practitioner.  Deschamps  describes  a  third  also  belonging  to  this 
list. 

Were  the  opening  into  the  urethra  the  really  difficult  point  in  the  opera- 
tion, this  species  of  sound  would  perfectly  answer  the  end  for  which  it 
was  designed.  But  let  a  surgeon  have  ever  so  little  skill  or  knowledge  of 
parts,  it  is  never  at  this  stage  of  lithotomy  that  he  stops  short.  Conse- 
quently the  instrument  of  MM.  Earle  and  Guerin  will  remain  merely  things 
of  caprice  or  individual  usefulness,  as  so  many  others  have  done.  The  com- 
mon staff'  on  which  Sir  C.  Bell  has  caused  the  groove  to  be  put  on  one  side, 
so  as  to  be  able  while  holding  it  in  the  median  line,  to  cut  obliquely  to  the 
left  when  we  reach  the  prostate,  seems  really  only  calculated  to  increase  the 
difficulties  of  the  operation.  As  to  Mr.  Key's  staff",  which  is  straight  or 
scarcely  curved  for  an  extent  of  half  an  inch  towards  its  beak,  it  does  not 
seem  to  me  to  deserve  any  real  importance,  nor  to  possess  any  indisputable 
advantage  over  the  rest. 

The  instruments  contrived  to  facilitate  opening  the  bladder  and  make  it 
more  sure  are  of  two  kinds.  Some  in  fact  nowise  differ  save  by  feeble 
shades  of  distinction  from  common  bistouries,  whilst  others  are  indeed 
instruments  peculiar  in  their  nature.  In  this  way  the  lithotome  of  Cheselden, 
a  little  concave  on  the  back,  has  been  altered  in  the  hands  of  M.  Dubois,  into 
a  little  knife  with  a  solid  handle  scarcely  different  from  the  convex  bistoury. 
In  England,  M.  Blizard  employs  a  long,  narrow  bfstoury,  with  a  firm  handle 
like  that  of  the  French  surgeon,  whose  point  ends  towards  the  back  of  the  blade 
by  a  sort  of  blunt  stylet.  Klein,  Langenbeck,  Kern,  Grasfe,  in  Germany, 
have  each  a  lithotome  which  ranks  like  the  former,  in  the  class  of  simple 
knives  or  of  bistouries  of  varied  forms ;  but  to  whoever  will  look  closely  into 
them  it  is  evident  that  all  this  is  entirely  optional,  and  that  it  is  indifferent 
whether  the  one  or  the  other  be  adopted ;  any  of  which  may  be  replaced 
perhaps  advantageously  by  a  common  bistoury,  or  probe-pointed  one.  It  is 
long  since  M.  Dupuytren,  and  some  English  surgeons  alike  asserted  this 
fact,  that  when  directed  by  an  able  hand,  a  common  straight  bistoury  is  quite 
as  capable  as  the  most  complex  lithotome  of  penetrating  the  bladder  and  of  cut- 
ting the  prostate  on  being  withdrawn  in  a  suitable  direction.  We  see  also, 
by  reference  to  the  work  of  Sabatier,  that  the  surgeon -in -chief  at  the  Hotel 


"<^       .  N^^V    ELEMENTS   OF 

Dieu  has  several  times  operated  for  stone,  by  plunging  the  straight  bistoury 
bj  puncture  as  far  as  the  groove  of  the  staff,  then  into  the  bladder,  so  as  to 
divide  by  its  withdrawal  the  prostate  and  all  the  tissues  which  constitute  the 
perineum  together.  This  procedure,  which  reduces  lithotomy  to  the  simple 
opening  of  an  abscess,  is  easier  than  one  might  imagine.  It  would  appear 
that  in  some  cases  M.  Lisfranc  had  adopted  it;  and  in  teaching  surgical  ope- 
rations to  my  pupils,  I  have  frequently  tried  it  on  the  dead  body.  As  how- 
ever, it  can  have  no  other  advantage  than  that  of  rendering  the  operation 
more  quick  of  performance  by  a  quarter  or  half  a  minute,  I  do  not  think 
that  prudence  justifies  the  establishment  of  a  rule  on  a  like  act  of  dexterity 
and  skill,  so  that  if  a  bistoury  be  used  the  urethra  should  be  incised  as  is 
usual,  and  the  knife  be  then  slipped  along  the  groove  in  the  staff,  as  is  done 
by  all  other  lithotomists. 

The  special  instruments  for  this  purpose  of  which  it  remains  for  me  to 
speak,  are  known  under  the  name  of  gorgets. 

j.  Procedure  of  Haivkins. — The  first  gorgets  employed  in  lithotomy  were 
simple  canals  (gouttieres)  ending  on  one  side  by  a  stylet  or  probe  point,  and 
at  the  other  having  a  sort  of  handle.  They  were  used  to  supersede  staffs, 
and  they  are  so  still  to  facilitate  the  introduction  of  forceps  in  almost  every 
species  of  operation.  When  in  this  form  their  edges  are  round  and  blunt,  so 
as  not  to  endanger  the  parts.  It  was  not  before  the  middle  of  the  last  cen- 
tury, that  an  English  surgeon  named  Hawkins  conceived  the  idea  of  meta- 
morphosing the  gorget  into  a  lithotome,  that  is  to  say,  to  make  it  into  a  cutting 
instrument  by  sharpening  one  edge  near  its  point. 

This  instrument,  which  most  English  surgeons  adopted,  is  used  in  the  fol- 
lowing way.  The  membranous  portion  of  the  urethra  being  once  open,  the 
surgeon  seizes  the  gorget  by  its  handle,  carries  the  knob  at  the  point  into  the 
groove  of  the  staff,  and  pushes  it  into  the  bladder,  being  careful  not  to  let  go 
this  latter  instrument,  which  is  elevated  behind  the  pubis  by  a  swinging  mo- 
tion, as  the  gorget  is  dividing  the  left  side  of  the  prostate.  The  apparent 
simplicity  of  Hawkins's  gorget,  did  not  however  prevent  even  its  admirers 
from  discovering  its  defects.  Mr.  Bell  finding  that  its  blunt  part  was  too 
broad,  had  it  contracted  to  prevent  it  from  bruising  or  tearing  parts.  De- 
sault  who  did  away  its  concavity,  besides  adopting  Bell's  modification,  placed 
the  knob  quite  straight  on  the  blunt  edge.  Blicke,  fearing  that  it  might  stray 
out  of  the  groove  of  the  staff,  and  pass  between  the  rectum  and  bladder  as  Sir 
Ai  Cooper  and  Mr.  S.  Cooper  state  they  have  themselves  often  witnessed,  so 
arranged  the  knob  as  that  it  would  not  escape  before  it  had  reached  nearly  to 
the  end  of  this  staff.  That  of  Mr.  Abernethy  represents  as  it  were,  a  trian- 
gular canal,  as  is  seen  also  in  that  of  Cline,  or  else  a  cylindrical  demi-canal 
like  that  of  Hawkins.  Dorsey  has  given  us  an  engraving  of  one,  the  blade  of 
which  takes  off  easily,  and  is  of  the  same  width  throughout  its  free  extremity 
obliquely  cut  like  the  kystotome  of  Desault,  and  being  the  only  cutting  edge. 
Lastly,  Scarpa  who  declared  himself  a  patron  of  the  instrument,  strove  at 
great  length  to  prove  that  a  gorget  ought  to  have  a  very  narrow  cutting  blade 
two  lines  towards  its  knob,  growing  larger  and  larger  until  it  have  acquired 
a  transverse  diameter  of  about  seven  lines,  aad  that  this  cutting  edge 
ought  to  be  bent  at  an  angle  of  sixty-nine  degrees  on  the  edge  which 
acts  as  its  back,  so  that  in  cutting  the  prostate  it  might  make  a  wound, 


OPERATIVE   SURGERY.  757 

the  angle  of  which  should  also  be  at  an  inclination  of  sixty-nine  degrees,  as 
regards  the  direction  of  the  urethra.  Some  English  surgeons,  apiongst  others 
Messrs.  Dease  and  Mair,  thought  that  using  with  it  the  staff  of  Le  Drangave 
more  certainty  to  its  use.  This  proposition  was  not,  nor  did  it  deserve  to  be 
followed.  In  France,  gorgets  have  found  but  very  few  supporters.  M.  Roux 
is  almost  the  only  man  in  Paris  who  uses  them.  The  least  reflection  serves 
to  show  the  unimportance,  I  had  almost  said  insignificance,  of  the  variations 
in  form  to  which  this  instrument  has  been  subjected.  It  is  the  gorget  as  a 
particular  instrument,  and  not  such  a  form  of  gorget  in  particular,  which  we 
are  to  examine ;  and  I  am  surprised  that  authors  of  such  repute  should  have 
involved  themselves  in  disputes  upon  this  subject.  Certain  it  is,  that  with  a 
gorget  the  rectum  or  pudic  artery  will  never  be  wounded,  unless  some 
anomaly  exist  in  the  anatomical  arrangement ;  that  the  limits  of  the  prostate 
either  can  never  be  passed ;  but  as  the  whole  of  this  advantage  arises  from 
the  small  extent  of  wound  it  makes,  it  is  clear  that  the  same  might  be  obtained 
with  any  lithotome  whatever,  if  a  wound  of  six  or  seven  lines  only  were  to  be 
made.  The  inconveniencies  about  the  instrument  are,  that  whatever  be  the 
size  of  the  stone  it  always  makes  a  passage  of  the  same  length ;  that  it  is  more 
likely  than  any  other  instrument  to  wound  the  posterior  wall  of  the  bladder, 
or  even  to  go  through  the  sac,  as  Mr.  Earle  says  he  has  seen  done,  and  above 
all  to  divide  the  tissues  by  pushing  them  before  it ;  in  separating  the  different 
layers  of  the  perineum  from  one  another,  to  relax  them  in  some  measure 
instead  of  pressing  them  downwards  from  above,  stretching  them  as  does  the 
sheathed  lithotome  for  instance,  and  almost  every  cutting  instrument  em- 
ployed by  different  operators  in  this  second  stage  so  as  to  dilate  and 
even  bruise  as  it  divides  ;  of  obliging  the  operator  to  have  several  gorgets  of 
various  sizes  ;  and  of  never  allowing  of  any  incision  of  more  than  eight  or 
nine  lines.  Perhaps  the  least  disputable  advantage  which  it  has,  although  it 
has  not  been  mentioned,  is  to  be  found  in  the  direction  which  it  gives  to  the 
incision  of  the  prostate,  one  of  a  semilunar  shape  whose  concavity  looks  back- 
wards and  to  the  right,  and  the  arch  of  which  having  a  cord  of  about  seven 
lines  in  length,  ought  to  stretch  two  or  three  lines  at  least  without  tearing, 
when  extended  during  the  extraction  of  the  stone.  Under  this  view  Desault's 
gorget  is  evidently  the  worst  constructed  of  any ;  for  to  attain  this  end  it 
ought,  augmenting  in  width  on  its  cutting  side,  to  preserve  its  primitive  canal 
shape,  or  else  that  of  a  half  canal.  Moreover,  in  this  way  it  would  cease  to 
belong  to  the  performance  of  the  lateral  operation,  or  that  properly  called 
the  oblique.  The  incision  would  be  rather  a  transverse  one,  directed 
towards  the  left  ischium,  whence  arises  a  fresh  inconvenience ;  that  of  acting  on 
a  shorter  radius  of  the  prostate  than  that  which  should  be  cut  in  the  proce- 
dures of  brother  Come,  Cheselden,  or  Garengeot. 

k.  Procedure  of  Thomson, — The  deviation  from  the  line  first  indicated  in 
lateralized  operation  is  not  after  all  the  only  one  that  has  been  suggested.  Dr. 
Thomson,  in  1808,  wishing  to  avoid  cutting  the  rectum  and  perineal  arteries, 
thought  of  making  an  incision  with  a  common  lithotome,  not  downwards,  but 
up  and  outwardly  a  little  when  a  backward  incision  of  some  lines  did  not 
seem  to  him  sufliicient  for  extracting  the  stone.  At  about  the  same  time  M. 
Dupuytren,  desirous  of  avoiding  the  same  parts,  thought  proper  to  conduct  his 
incision  almost  directly  upwards  ;  that  is  to  say,  when  he  reached  the  bladder 


751^  NEW    ELEMENTS    OF  IP(p 

he  turned  the  cutting  edge  of  his  bistoury,  or  of  Gome's  lithotome  up  a  little 
to  the  right,  parallel  to  the  ischio-pubic  ramus,  as  if  to  reach  the  symphysis. 
These  modifications  were  properly  abandoned  by  their  inventors  on  consider- 
ing that  then  the  prostate  is  divided  in  its  least  thick  direction,  that  its  limits 
must  invariably  be  passed,  and  still  further,  because  the  stone  has  to  be  ex- 
tracted tlirough  a  point  of  the  inferior  strait  still  narrower  than  in  the  oblique 
posterior  operation. 

1.  Procedure  of  M.  Boyer, — M.  Boyer,  who  almost  always  uses  the  sheathed 
lithotome  and  who  is  said  to  be  very  happy  in  his  operations  for  stone, 
makes  his  incision  in  none  of  the  directions  which  have  been  pointed  out. 
Instead  of  resting  the  back  of  his  instrument  towards  the  symphysis,  he  holds 
it  firmly  against  the  ramus  of  the  pubis  and  ischium  of  the  right  side  so  as  to 
be  able  to  direct  its  cutting  edge  almost  completely  across,  and  to  the  left 
during  its  withdrawing  to  divide  the  prostate  from  within  outwards  like  every 
one  else.  In  doing  this  the  rectum  and  pudic  artery  are  in  no  danger  any 
more  than  the  transverse  perineal  artery  whose  direction  is  almost  parallel  to 
that  of  the  incision,  whilst  the  superficialis  perinei  is  the  only  one  which  can 
be  injured.  This  is  a  modification  against  which  no  reproach  could  be  urged, 
were  it  not  that  the  prostate  has  to  be  divided  in  the  direction  of  one  of  the 
shortest  radii,  and  that  the  incision  cannot  be  of  more  than  seven  lines  in 
extent  without  going  beyond  the  boundary  of  the  gland.  The  lithotome  thus 
managed  answers  all  the  purposes  of  the  gorget  without  its  objections. 

Remarks. — If  it  be  true  that  the  difficulty  to  be  got  over  in  the  oblique  ope- 
ration is  to  open  the  prostate  as  widely  as  possible,  keeping  at  the  same  time 
within  the  limits  of  its  outline,  evidently  the  only  incision  to  be  adopted  is 
that  which  proceeds  downwards  and  outwards.  With  this  supposition  the 
procedure  of  Dr.  Thomson,  and  that  which  M.  Dupuytren  has  tried  to  bring 
into  use  are  unworthy  of  being  discussed.  The  rule  adopted  by  M.  Boyer  of 
allowing  tlie  cutting  edge  of  the  bistoury  to  lean  a  little  towards  the  ischium 
is  infinitely  a  better  one.  For  the  loss  of  a  breadth  of  one  line  in  the  incision 
into  the  prostate  we  derive  undoubted  advantages  as  regards  the  arteries  and 
the  rectum.  As  to  the  incision  made  after  the  manner  of  Boudou,  of  Garen- 
geot,  of  Morand,  of  Le  Dran,  of  Moreau,  of  Dubois,  and  of  Messrs.  John  and 
Chas.  Bell,  and  of  all  those  who  prefer  the  bistoury  with  more  or  less  modifi- 
cation to  particular  lithotomcs,  and  who  seek  to  open  the  neck  of  the  bladder 
extensively,  it  is  a  matter  of  indifference  whether  the  one  or  the  other  be  fol- 
lowed provided  that  care  is  always  taken  to  extend  sufficiently  the  opening 
into  the  integuments  and  other  constituent  parts  of  the  perineum.  Two  cir- 
cumstances present  themselves  for  consideration  in  the  method  proposed  by 
Lecat ;  1st,  the  instruments  he  uses,  for  which  any  others  may  as  well  be  sub- 
stituted ;  2d,  the  idea  of  only  making  a  small  incision  into  the  neck  of  the 
bladder.  This  is  the  only  distinguishing  point  in  Lecat's  operation.  De  la 
Motte  had  already  maintained  that  there  was  less  danger  in  dilating,  and 
even  in  tearing  the  entrance  into  the  bladder  to  a  certain  extent,  than  in 
incising  it ;  and  we  can  scarcely  be  allowed  to  dispute  the  justness  of  the 
remark.  The  error  into  which  its  defenders  have  fallen  is  that  they  have  not 
understood  the  essential  reason  for  it,  and  have  carried  their  extension  beyond 
moderate  bounds.  In  fact,  the  small  incisions  of  which  Lecat  speaks  are 
better  than  large  ones,  only  as  they  are  confined  within  the  limits  of  the  pro- 


OPERATIVE    SURGERY.  759 

state  gland ;  and  it  follows  therefore  that  no  other  operation  for  stone  will  be 
more  dangerous  which  does  not  extend  beyond  this  boundary.  I  have  in 
some  preceding  pages  expressed  my  opinion  as  to  the  gorget  and  its  various 
forms.  The  instrument  of  brother  Come  remains  for  my  consideration  ;  and 
no  one  can  deny  to  it  the  possession  of  great  certainty,  great  simplicity  of 
mechanical  construction,  and  the  capability  of  being  used  by  most  operators 
more  easily  than  the  bistoury;  only  as  we  shall  see  by  the  sequel  it  may  well 
be  superseded  by  the  probe-pointed  bistoury.  The  principal  dangers  of 
oblique  cutting  originating  in  the  risk  of  wounding  the  rectum,  pudic -artery, 
and  the  transverse  or  superficial  arteries,  all  instruments  except  the  gorget 
^re  in  this  respect  equally  objectionable.  If  one  is  careful  to  examine  the 
state  of  the  rectum  by  the  introduction  of  the  finger  into  it,  and  careful  also 
not  to  make  the  deep  wound  too  large,  and  the  lithotome  be  handled  with  a 
little  dexterity,  the  rectum  will  not  be  perforated.  Tlie  pubic  artery  being 
always  situated  along  the  outline  of  the  pubic  arch,  is  consequently  far  be- 
yond the  prostatic  limits,  and  runs  in  reality  no  risk  of  being  wounded.  The 
seat  of  the  superficial  artery  being  in  the  subcutaneous  layer  would  be  so 
easily  seized,  twisted,  tied,  or  cauterized,  that  opening  it  could  never  be  a 
thing  of  any  importance.  The  transverse  perinei,  usually  a  very  small  vessel , 
can  only  be  avoided  with  certainty  by  making  an  incision  into  the  urethra, 
which  shall  not  begin  too  near  the  bulb  or  too  far  from  the  prostate.  Hap- 
pily the  bleeding  which  follows  its  division  is  seldom  abundant  enough  to 
become  serious.  With  this  view  of  the  case  then  there  can  be  no  danger 
in  practising  the  lateralized  operation  for  stone,  unless  in  case  of  an  anoma- 
lous distribution  of  the  vessels  or  of  their  being  of  excessive  size.  A  much 
more  vexatious  difficulty  is  that  we  cannot  obtain  by  it  an  aperture  of  more 
than  ten  or  twelve  lines  at  most;  too  small  therefore  to  admit  of  the  removal 
of  voluminous  calculi. 

With  a  view  to  obviate  this  objection  of  real  weight,  notwithstanding  all 
procedures,  and  all  operations,  the  following  method  has  been  set  forth. 

4.  Transverse  {bi-lateral  or  bi-oblique)  Cutting  for  Stone, 

A  fresh  interpretation  of  the  passage  in  Celsus  in  latter  years  has  given 
origin  to  a  new  operation  for  stone.  When  speaking  of  the  extraction  of 
calculi,  the  Roman  author  advises  that  there  be  made  '*  juxta  anum,  cutis  plaga 
lunata,  usque  ad  cervicem  vesicae,  cornibus  ad  coxas  spectantibus  paululum ;" 
then,  that  at  the  bottom  of  the  first  wound  the  instrument  be  carried  in  to 
make  another  which  should  be  transverse,  and  open  the  cervix-vesicae  by 
going  down  to  the  stone.  Now  it  is  this  passage,  until  lately  so  construed 
as  to  have  given  rise  to  lateral  cutting,  lateralized  cutting,  and  the  apparatus- 
minor,  formerly  described  by  the  Greeks  and  Arabians,  which  interpreted 
truly  constitutes  the  principle  of  this  new  procedure. 

The  words  plaga  lunata,  and  plaga  transversa,  had,  it  is  true,  more  than 
once  puzzled  commentators  on  Celsus ;  but  by  substituting  the  singular  for 
the  plural,  and  translating  ad  coxas,  by  *  towards  the  thigh,'  th^y  fancied  that 
they  had  got  over  the  difficulty.  In  vain  did  Davier,  in  the  year  1734,  April 
15th,  sustain  at  Cochu,  before  the  faculty  of  Paris,  that  in  Celsus's  apparatus 
a  crescentic  incision  is  made  in  the  skin  near  the  anus,  the  ends  of  which 


760  NEW    ELEMENTS   OF 

crescent  turn  towards  the  thighs  ;  in  vain  did  Heister  cause  lisman  to  repeat 
the  same  thing  in  November,  1744 ;  in  vain  did  Normand  de  Dole  complain 
of  the  slovenly  way  in  which  the  works  of  the  ancients  were  perused,  and 
recalled  the  fact  to  mind  that  in  the  Celsian  operation  the  crescentic-shaped 
incision  ought  to  be  situated  near  the  anus  with  its  horns  turned  rather  to- 
wards the  thighs  of  the  patient ;  in  vain  the  same  interpretation  was  again 
urged  by  Macquert  in  a  thesis  defended  in  April,  1754 ;  by  M.  Portal  in  his 
Precis  de  Chirurgie,  published  in  1768,  and  by  Deschamps  himself  in  his 
Treatise  on  Lithotomy ;  no  one  gave  himself  the  trouble  to  turn  it  to  any 
account.  A  second  ambiguity  which  Bromfield  vainly  endeavored  to  clear 
up  and  remove,  was  to  know  whether  the  words  cornibus  spectantibus  paulu- 
lum  ad  coxas  were  to  be  construed  to  mean  a  semilunar  wound  whose  ends 
were  to  be  turned  forwards  rather  than  backwards.  Every  author  whom  I 
have  cited  has,  it  will  be  seen,  adopted  the  first  version.  Bromfield  alone 
inclined  to  the  second,  which  in  truth  seems  to  be  the  correct  one ;  for  coxas 
among  the  ancients  was  generally  applied  to  the  large  bones  of  the  pelvis, 
and  the  ischium  in  particular.  Be  this  as  it  may,  the  question  has  been  con- 
sidered under  its  proper  light  only  since  the  beginning  of  the  present  cen- 
tury. In  the  year  1805  M.  Morland  of  Dijon  mentioned  in  a  thesis  some 
attempts  made  by  M.  Chaussier  on  this  subject,  whence  it  resulted  that  a 
semilunar  incision  with  its  concavity  looking  backwards  allows  of  an  easy 
entrance  into  the  bladder  and  of  extraction  of  a  stone.  Again  this  was  a 
lost  labor,  and  Chaussier  himself  had  forgotten  his  own  investigations,  when 
they  were  reproduced  in  1813  by  Beclard,  almost  in  M.  Morland's  words, 
and  with  as  little  success.  The  convincing  and  forcible  reasons  urged  by  M. 
Turck  in  1818,  at  Strasburg,  in  favor  of  the  same  principles,  again  failed  to 
awaken  the  spirit  of  inquiry 

But,  in  1824,  M.  Dupuytren  engaged  in  an  attempt  to  render  lithotomy 
less  dangerous,  entertaining  the  same  ideas  as  MM.  Chaussier,  Beclard,  and 
Turck,  immediately  almost  put  them  in  practice  on  a  living  subject,  and  was 
speedily  convinced  that  there  existed  in  it  an  inestimable  way  of  operating 
for  stone.  Beclard,  not  quite  so  sanguine,  but  who  had  never  forgot- 
ten the  subject,  and  who  even,  according  to  M.  Olivier  of  Angers,  had  himself 
some  few  times  performed  it,  recapitulated  anew  its  advantages  to  the  Aca- 
demy, whilst  M.  Dupuytren  at  the  Hotel  Dieu  was  making  its  importance 
be  fully  felt.  Since  that  period  numbers  of  surgeons  have  adopted  it,  and  it 
is  now  considered  as  one  of  the  best  methods,  if  even  it  may  not  be  regarded 
as  absolutely  the  very  best  of  all. 

a.  Procedure  of  Chaussier. — It  is  shown  by  the  essay  of  M.  Morland, 
that  Chaussier,  in  conjunction  with  M.  Ribes,  began  by  incising  all  the  soft 
parts  between  the  anus  and  the  bulb  of  the  urethra  with  the  point  of  a  scalpel ; 
that  he  had  entertained  thoughts  of  having  a  double  grooved  staff,  one  groove 
on  the  right  side  and  one  on  the  left,  so  as  to  be  able  to  divide  the  mem- 
branous and  prostatic  portion  of  the  urethra  only  on  one  side,  or  successively 
on  both,  if  it  seemed  to  be  rendered  necessary  by  the  size  of  the  stone;  tliat 
in  his  opinion  the  staff  might  be  superseded  by  the  grooved  staff  as  advised  by 
Le  Dran,  because  in  carrying  it  by  the  wound  it  was  easy  to  cut  upon  it  to  the 
left  and  then  to  the  right;  that  he  had  thought  besides  of  a  sheathed  lithotome 
with  two  blades,  and  of  the  sheathed  scalpel  of  Louis;  but  that  he  was 


OPERATIVE    SURGERY.  761 

also  cautious  to  observe  that  in  such  a  case,  the  best  of  all  was  intelligence, 
guided  by  exact  knowledge  of  situation  and  nature  of  parts. 

b.  Procedure  of  Beclard. — The  instrument  selected  by  Beclard  was  a  spe- 
cies of  rather  wide  gorget,  scarcely  concave,  cutting  on  both  sides,  and  ending 
in  a  little  tongue  in  its  convex  direction.  He  mentions  likewise  the  double 
litliotome,  leaving  every  one  at  liberty  to  adopt  or  dispense  with  it  at  pleasure. 
He  had  also  constructed  a  knife  whose  blade  was  shaped  like  a  leaf  of  sage, 
very  like  Cheselden's  lithotome  and  for  the  same  object.  He  divided  the 
skin  and  other  tissues  in  the  way  pursued  by  Chaussier. 

c.  Procedure  of  M,  Dupuytren. — The  attempts  of  Chaussier  and  Beclard 
remaining  unheeded,  it  is  to  M.  Dupuytren,  in  fact,  that  transverse  lithotomy 
owes  all  its  importance.  In  its  performance  this  surgeon  employs  two  parti- 
cular instruments,  the  one  is  a  bistoury  with  a  solid  handle,  a  kind  of  scalpel 
cutting  on  both  edges  for  an  extent  of  some  lines  near  its  point ;  the  other  is 
a  double  lithotome,  the  idea  of  which  must  have  been  suggested  by  an  expres- 
sion of  Franco's,  and  which  is  a  very  exact  representation  of  the  incisory 
forceps  of  Tagault,  delineated  in  page  366  of  Joubert's  addenda  to  Guy's 
work,  printed  in  1649,  which  had  been  mentioned  by  Fleurant  in  speaking 
of  operations  on  the  female,  and  of  which  Beclard  and  Chaussier  had  equally 
thought,  but  which  it  was  reserved  for  M.  Dupuytren  to  render  as  simple  as 
possible  and  to  bring  into  general  use. 

According  to  Sabatier,  its  sheath  is  concave  on  one  of  its  surfaces,  instead 
of  its  edge,  as  in  Come's  instrument.    Its  two  blades  are  also  concave,  so  that 
they  may,  by  their  separation,  represent  a  curve,  and  so  avoid  the  extremity 
of  the  rectum.     Its  handle  is  conical,  instead  of  being  simply  square,  and  by 
means  of  a  screw  may  be  made  to  approach  or  separate  for  as  many  lines  as 
are  wished  from  the  union  of  the  sheath  with  the  blades,  and  give  to  the  whole 
a  determinate  degree  of  width  of  opening.    M.  Amussat  thinking  this  too 
complicated  still,  has  proposed  to  substitute  for  it  a  kind  of  scissors  which  cut 
on  their  edges  when  they  are  opened,  and  which  are  a  blunt  instrument  when 
closed ;  but  these  scissors  do  not  fulfill  every  purpose  proposed  by  the  use  of 
the  double  lithotome.     In  fact,  a  simple  transverse  incision  is  not  what  the 
surgeon  seeks  to  effect ;  it  must  also  be  oblique  backwards  and  outwards  on 
either  side,  so  as  at  once  to  include  the  two  largest  radii  of  the  prostate.     M. 
Dupuytren,  who  early  discovered  this  fact,  found  all  that  could  be  asked  for 
in  this  particular  in  the  modifications  effected  in  his  original  instrument  by 
Dr.  La  Serre,  and  that  ingenious  cutler  M.  Charriere  particularly.     From 
the  description  given  in  the  essay  of  M.  Bouille,  the  instrument  of  M.  Char- 
riere is,  I  find,  so  constructed  that  pressure  on  its  only  bascule  which  is 
situated  on  the  handle,  causes  the  two  blades  to  leave  their  sheath  imme- 
diately, and  describe  by  their  separation  a  curved  line  exactly  similar  to  the 
outer  incision,  so  that  they  divide  the  prostate  obliquely  backwards  towards 
the  ischial  ^de,  encircling  the  exteiior  surface  of  the  rectum  to  the  right  and 
to  the  left.     Lastly,  instead  of  the  usual  staff,  M.  Dupuytren  has  contrived 
one  which  is  swelled  at  the  seat  of  its  greatest  convexity,  the  better  to  distend 
the  urethra,  and  whose  groove  is  more  shallow  towards  the  point  than  the 
centre.     The  patient  is  to  be  placed  as  if  for  any  other  species  of  operation 
for  stone.    The  surgeon  seated  in  front  of  the  perineum,  makes  tense  the  in- 
teguments with  his  left  han4.     With  his  right  hand,  holding  the  scalpel,  he 
96 


762  NEW    ELEMENTS   OR 

makes  a  semilunar  incision ;  commences  it  near  the  right  ischium ;  passes  six 
lines  in  front  of  the  anus,  and  ends  it  within  the  left  ischium,  so  tliat  its  horns 
may  fall  towards  tlie  centre  of  the  space  whicli  separates  the  anus  right  and 
left  from  the  tuberosities  of  the  ischia.  Thus  he  successively  divides  the 
several  layers  which  occur,  pressing  most  strongly  on  the  median  line  until 
he  reaches  the  membranous  portion  of  the  urethra,  which  he  cuts  longitudi- 
nally, lays  aside  the  scalpel,  takes  the  litliotome,  whose  handle  has  previously 
been  set  at  a  proper  degree  of  separation,  rests  its  point  upon  the  staff,  its 
concavity  looking  upwards,  and  pushes  it  on  into  the  bladder,  as  is  done  when 
brother  Gome's  instrument  is  used.  Before  it  is  opened,  it  is  made  to 
describe  a  half  circle,  in  order  that  its  concavity  from  looking  upwards  may 
become  lowermost  and  look  towards  the  rectum.  Then  it  is  opened  and 
withdrawn  in  the  direction  of  the  external  wound,  the  operator  having  seized 
it  with  his  left  thumb  and  forefinger  a  little  beyond  the  handle,  whilst  with 
his  right  he  keeps  it  steadily  open  to  divide  the  prostate  from  within  outwards 
as  well  as  the  soft  parts  which  the  scalpel  had  not  encountered.  Undoubtedly 
the  scalpel  may  perfectly  well  be  substituted  for  the  common  bistour}^  in  this 
operation ;  the  lithotome  of  frere  Come,  drawn  from  left  to  right,  will  cut  the 
same  parts;  the  double  cutting  edged  gorget  used  by  Dr.Physick  as  early  as 
1804,  which  Sir  A.  Cooper  sometimes  employs,  and  which  was  proposed  by 
Beciard,  is  very  proper  too  for  effecting  this  double  incision.  In  fact,  the  mere 
probe-pointed  straight  ordinary  bistoury  even,  may  be  used  instead  of  any  one 
of  these  instruments  for  the  division  of  the  prostate.  But  it  is  impossible  to 
refuse  to  the  double  lithotome,  the  immense  advantages  of  completing  the 
operation  at  a  single  stroke  ;  of  stretching  the  parts  more  certainly  whilst  it 
divides  them ;  of  making  a  wound  of  greater  regularity ;  and  above  all  of 
giving  it  a  true  curve,  and  not  merely  making  a  V  shaped  incision,  which  is  all 
that  can  be  reasonably  expected  from  the  use  of  a  bistoury  or  any  other  litho- 
tome. Gorgets  have  the  same  disadvantages  here  as  every  where  else :  that 
of  a  tendency  to  detach  parts  and  crowd  them  back  towards  the  bladder 
tluring  the  incision,  which  thereby  becomes  uneven  and  unequal  in  dimen- 
sion. Reasoning  at  once  detects  the  value  of  this  procedure.  If  each  blade 
of  the  lithotome  is  separated  only  four  lines,  a  wound  is  inflicted  evident  at 
least  eight  lines  long ;  ten  lines  long  if  the  calibre  of  the  urethra  be  included. 
Now,  as  every  oblique  posterior  radius  of  the  prostate  is  nearly  ten  lines  in 
diameter,  it  is  clear  that  an  extent  of  tw^enty  lines  is  thus  afforded  to  the 
wound.  Again,  if  the  incision  is  a  true  curve,  any  traction  made  on  it  to 
straighten  it  will  lengthen  it  still  more  ;  the  posterior  portion  of  the  prostate 
pressed  back  along  with  the  rectum  whilst  we  are  seeking  to  draw  forth  the 
stone,  easily  becomes  a  second  curve  parallel  to  the  first,  to  such  a  degree 
that  a  calculus  twenty  to  twenty -four  lines  in  thickness,  and  five  or  six  inches 
in  circumference,  might  strictly  speaking  pass  through  this  aperture  and  tear 
nothing  in  its  passage. 

In  this  respect,  no  species  of  perineal  cutting  for  the  stone,  can  at  all  com- 
pare with  the  transverse  method.  It  threatens  the  intestine  only  when  it 
is  enormously  distended  on  either  side  of  the  bas-fond  of  the  bladder,  because 
it  cut  the  tissues  outwardly  and  a  little  backwards;  and  even  then  only 
when  it  is  necessary  to  give  the  lithotome  a  very  considerable  width  of  open- 
ing.    The  pudic  artery  is  equally  sheltered  from  injury ;  so  also  is  the  super- 


i 


OPERATIVE    bURGEHY.  763 

ficial  artery  whenever  it  occupies  its  normal  situation.  The  transverse  artery 
can  be  but  seldom  reached,  for  the  most  advanced  point  of  the  incision  must 
be  situated  behind  the  bulb  of  the  urethra,  in  which  it  is  seen  principally  to 
distribute  itself.  The  only  branches  which  could  be  divided  are  the  posterior 
twigs  of  this  latter  vessel,  when  they  are  unusually  large  about  the  anus,  and 
also  the  anterior  divisions  of  the  hemorrhoidal.  The  first  incision  falling 
upon  the  membranous  portion  of  the  urethra,  and  the  two  blades  of  the  instru- 
ment being  obliged  first  to  extend  themselves  outwardly,  the  verumontanum 
and  ejaculatory  ducts  are  necessarily  out  of  the  reach  of  danger. 

Nevertheless,  it  must  not  be  forgotten,  that  in  some  persons  the  lower  dila* 
tation  of  the  rectum  is  continued  on  as  far  as  beneath  the  prostate ;  hence,  if 
the  cut  be  made  too  near  the  anus,  we  might  easily  pierce  this  gut  in  the  first 
stage  of  the  operation,  as  is  said  once  to  have  happened.  A  danger  which 
reasoning  might  have  suggested  is  that  of  urinary  fistula.  It  would  at  first 
sight  appear  that  a  wound  so  extensive  in  the  posterior  and  inferior  wall  of 
the  urethra  would  be  but  little  disposed  to  adhesion,  immediate  or  secondary. 
Experience,  the  only  judge  competent  to  decide  upon  such  subjects  has  not 
confirmed  the  fears  thus  entertained.  Its  tenor  has,  on  the  contrary,  been  to 
show  that  as  a  general  rule  the  urine  assumes  its  natural  course  sooner  after 
the  bilateral  procedure,  than  after  any  other.  It  would  appear  also  that  this 
method  of  operation  has  the  advantage  of  being  seldom  followed  by  infiltra- 
tion or  suppuration  in  the  thickness  of  the  perineum ;  which  may  be  explained 
by  the  remark,  that  the  incision  on  either  side  extends  beyond  the  pelvic  apo- 
neurosis; that  it  cuts  but  very  little  either  of  the  origins  of  the  superficial  or 
horizontal  aponeurosis ;  and  that  it  is  confined  to  the  division  of  the  internal 
layer  of  the  ischio-rectal  aponeurosis. 

Thus  far,  twenty-six  cases  operated  on  by  this  method,  are  counted  at  the 
Hotel  Dieu,  and  not  one  has  died  ;  and  of  a  total  of  seventy  mentioned  by  M. 
Dupuytren  six  only  have  perished.  If  even,  as  regards  accidents  it  be  no 
better  than  any  other  method,  it  must  at  least  be  admitted  to  be  quite  as  good. 
To  derive  from  it  every  possible  advantage,  it  appears  to  me  that  the  incision 
ought  to  fall  upon  the  base  of  the  uretro-anal  triangle,  so  as  to  spare  both  the 
bulb  and  the  anus;  then  to  come  down  upon  the  posterior  part  of  the  mem- 
branous portion  of  the  urethra,  a  little  in  advance  of  the  prostate,  having  cut 
through  integuments — 'Subcutaneous  layer — the  intercrossing  fibres  of  the 
sphincter  ani,  of  the  bulbo  cavernosus,  and  transversus  perinei  muscles,  and 
of  the  aponeuroses  to  the  point  at  which  they  are  lost  in  one  another.  The 
horns  of  the  incision  also  should  be  so  far  extended  in  the  direction  of  the 
ischio-rectal  excavations,  as  to  oppose  no  obstacle  to  the  escape  of  fluids  out- 
wardly. If  bilateral  cutting  did  not  allow  of  as  rapid  a  cicatrization  of  the 
wound,  as  the  incision  on  one  side  only  of  the  prostate,  the  operation  should 
then  certainly,  as  Beclard  thought,  and  as  Scarpa  proposes  in  his  letter  to 
M.  Olivier,  be  a  reserved  method,  useful  only  in  cases  where  the  stone  is  of 
great  bulk  ;  but  since  this  is  not  at  all  the  case,  and  the  contrary  happens,  I 
see  nothing  to  prevent  it  from  becoming  a  method  of  general  adoption. 

Procedure  of  31.  Senn. — M.  Senn,  a  surgeon  of  Geneva,  who  studied  for  a 

long  while  in  the  Parisian  hospitals,  endeavored  to  prove,  in  his  thesis,  that 

instead   of    operating   with   a    double   lij^hotome    it  is   better  at   first  only 

.10  divide  one  of  the  oblique  radii  of  the  prostate,  and  that  if  then  the  stone 


764  NEW    ELEMENTS    OF 

be  too  large  the  gland  should  again  be  cut  transversely  to  the  right  at  a 
second  stroke  with  a  straight  probe-pointed  bistoury.  Proceeding  upon 
geometrical  data,  he  asserts  that  the  triangular  portion,  thus  cut  at  the  expense 
of  the  urethra  and  its  surrounding  gland,  which  has  its  base  backwards  and 
to  tiie  right  side,  creates  when  distented  or  pushed  towards  the  rectum  in 
extracting  the  calculus,  a  larger  orifice  than  the  procedure  of  M.  Dupuytren 
aiFords.  M.  Senn's  method  is  different  from  Dr.  Thompson's,  advised  by  him 
in  cases  of  large  stones,  in  that  one  of  the  incisions  is  to  the  left,  and  another 
to  the  right ;  whereas  in  that  of  the  English  surgeon,  one  was  made  up  and  the 
other  down  on  the  same  side.  To  me  it  is  objectionable  as  being  longer,  and 
not  altogether  as  certain  as  cutting  by  the  double  sheathed  lithotome,  and  pos- 
sessing no  real  advantage  over  the  latter.  It  had  been  established  as  a  prin- 
ciple by  M.  Martineau  of  Norwich,  and  it  had  also  been  advised  by  Louis  himself, 
always  to  introduce  the  finger  into  the  wound,  when  any  difficulty  in  with- 
drawing the  stone  is  experienced,  with  a  view  to  detect  the  seat  of  resistance, 
and  to  enlarge  the  incision  with  a  bistoury,  either  backwards,  upwards,  or 
outwardly,  as  Saucerotte  did  so  successfully  ;  whence  it  follows,  that  by  some 
one  or  other  procedure  of  the  lateralized  cutting,  of  oblique  or  transversal 
cutting  modified  by  Louis,  MM.  Martineau,  Boyer,  Thomson,  Dupuytren, 
and  Senn,  every  radius  of  the  prostate  gland  has  been  divided.  From  this 
circumstance  arose  a  new  method  of  performing  lithotomy. 

5.  Quadrilateral  Cutting. — In  the  year  1825,  M.  Vidal  Cassis,  who  says 
that  he  had  been  engaged  in  researches  in  the  hospital  at  Marseilles,  feeling 
the  necessity  of  not  exceeding  the  limits  of  the  prostate  in  enlarging  the 
entrance  of  the  urethra,  and  still  the  want  of  as  large  an  opening  as  possible, 
was  induced  to  propose  in  a  thesis  to  incise  this  organ  in  its  four  principal 
radii,  viz.  backwards  and  to  the  left — backwards  and  to  the  right — and  ob- 
liquely forward  on  two  sides.  This  quadruple  incision  could  be  made, 
according  to  M.  Vidal,  at  one  stroke  of  a  four  blade  lithotome,  yet  he  prefers 
using  a  simple  bistoury,  carried  successively  in  the  four  directions.  The 
reason  of  this  difference  is,  that  if  it  be  a  small  calculus  only,  it  is  optional 
with  the  surgeon  to  cut  it  only  by  one,  or  two,  or  three  sides.  His  method  has 
been  pursued  at  the  Hospital  at  Aix,  by  M.  Goyrand,  who  speaks  very 
favorably  of  his  trials  of  it.  I  have  myself  had  occasion  to  practice  it  upon 
a  patient  in  whom  there  was  a  stone  of  two  inches  and  a  quarter  in  its  largest 
diameter.  The  man  was  sixty  nine  years  of  age,  and  worn  out  with  long 
continued  suffering.  I  operated  in  the  manner  of  frere  Come;  and  it  was 
not  until  I  ascertained  the  impossibility  of  extracting  the  calculus  without 
lacerating  the  parts,  that  I  had  recourse  to  that  of  M.  Vidal,  modifying  it 
however  in  this  way ;  that  I  might  not  be  obliged  to  let  go  the  stone,  an 
assistant  took  charge  of  the  forceps  which  held  it,  and  raised  them  up  a  little 
on  the  left  side.  With  a  straight  bistoury,  carried  in  on  my  forefinger,  I  was 
aWe  to  incise  the  right  posterior  radius  of  the  prostate,  and  then  did  the  same 
to  its  transverse  radius  a  little  above.  The  operation  completely  succeeded, 
and  the  health  of  my  patient  was  afterwards  perfectly  re-established.  Pur- 
suing this  idea,  each  incision  may  extend  only  two  or  three  lines,  and  yet 
together  give  an  opening  gained  of  nearly  one  inch.  If  they  be  made  to  extend 
to  four  or  five  lines,  we  see  at  once  that  an  orifice  of  fifteen  or  twenty  lines 
results  ;  and  thus  a  passage  may  be  made  for  the  largest  calculi,  without  in- 


OPERATIVE    SURGERY.  765 

curring  the  slightest  risk  of  transgressing  beyond  the  prostatic  bounds  or  of 
wounding  the  rectum,  or  any  of  the  arteries  of  the  perineum.  If  bilateral 
cutting  prove  insufficient,  or  any  fears  are  entertained  about  doing  it,  the  idea 
of  M.  Vidal  offers  us  then  a  resource  vi^hich  ought  not  to  be  despised.  Sup- 
posing it  to  be  at  once  decided  on  to  operate  by  it,  there  would,  in  my  opinion, 
be  found  an  advantage  in  using  the  four  bladed  lithotome  constructed  by  M. 
Colombat,  rather  than  in  making;  successively  four  incisions  with  a  bis- 
toury  of  the  common  kind,  for  the  very  same  reasons  which  make  the  double 
lithotome  preferable,  in  the  simple  bitransversal  cutting.  Besides  which, 
it  is  necessary  to  recollect  that  M.  Vidal  incises  the  prostate  in  the  direction 
of  its  oblique  radii,  and  not  from  before  backwards  or  transversely,  as  is 
erroneously  stated  by  the  recent  editors  of  the  works  of  Sabatier. 

§  3.  Recapitulation  of  tlie  Method  of  Operation  in  different  Species  of  Perineal 

Cutting. 

77ie  Apparatus. — The  surgeon  before  he  begins  the  operation,  is  to  arrange 
such  instruments,  &c.  as  may  be  necessary  during  its  progress,  according 
to  the  procedure  on  which  he  has  determined.  These  thing  are,  1st, 
staffs,  sounds,  and  catheters  of  silver  or  gumelastic,  in  case  of  need ;  2d,  a 
common  straight,  a  convex,  and  a  curved  Pott's  bistoury,  a  straight  probe- 
pointed  bistoury,  one  or  more  cutting  gorgets,  and  if  it  be  intended  to  make 
use  of  it,  one  of  the  lithotome  knives,  previously  mentioned ;  3d,  brother 
Gome's  sheathed  lithotome  opened  for  children  to  No.  5  or  No.  7,  to  No.  9  or  1 1, 
seldom  to  13  or  15,  for  adults;  4th,  the  probe-pointed  scoop  (tige  a  curette), 
having  a  crista  on  its  plane  surface ;  5th,  a  simple  gorget ;  6th,  straight  and 
curved  forceps,  of  various  sizes;  7th,  long  polypus,  dissecting  and  dressing 
forceps,  straight  and  curved  scissors ;  8th,  a  needle  fitted  to  a  handle,  either 
that  of  Petit  or  of  Deschamps,  and  some  common  armed  suture  needles; 
9th,  a  plain  canula  of  silver  or  of  gumelastic,  another  fitted  with  a  sheath 
(chemise).  Pledgets  of  lint  fastened  in  their  centres  by  loops  of  strong  and 
well  waxed  thread;  10th,  fresh  lint,  balls  of  it,  bandages,  compresses,  lacs 
or  lithotomy  fillets,  water,  sponges,  some  styptic  liquor,  a  strong  syringe,  and 
lastly,  several  wax  candles,  if  the  natural  light  be  apparently  not  powerful 
enough  for  all  purposes. 

Of  the  Staff. — Amid  all  these  objects,  one  or  two,  for  example  the  staff  and 
the  forceps,  require  a  particular  choice  to  be  exercised  in  their  selection. 
Cxteris  paribus^  it  is  better  to  have  the  staff  very  large  than  too  small.  The 
larger  it  is  the  better  it  distends  the  urethra,  the  more  easily  is  it  felt  at  the 
bottom  of  the  perineum,  the  better  it  conducts  other  instruments,  and  it 
renders  the  patient  less  liable  to  be  wounded.  The  groove  is  to  be  at  once 
wide  and  deep,  otherwise  it  would  be  difficult  for  the  finger  to  detect  it 
through  the  thickness  of  the  urethra,  nor  would  the  lithotome  receive  a  suit- 
able direction.  After  this,  it  matters  but  little  whether  it  be  semilunar  in  its 
transverse  section  as  they  used  to  be  made,  triangular  as  advised  by  English 
surgeons  generally,  or  square  as  M.  Dupuytren  recommends.  The  cul-de- 
sac  in  which  it  ends  being  at  best  of  but  doubtful  utility,  and  perhaps  liable 
to  impede  the  motion  of  the  point  of  the  lithotome,  had  better  taper  off  in- 
sensibly, to  preserve  the  rounded  and  blunt  form  of  the  staff.     If  the  groove 


766  NEW    ELEMENTS   OF 

were  to  be  extended  as  far  as  to  the  point  of  the  staff,  it  would  be  advantageous 
only  when  the  staff  was  held  stationary  and  not  raised  up  towards  the  pubis 
before  the  division  of  the  prostate,  because  then  the  point  of  the  bistoury  used 
is  more  firmly  kept  in  it.  The  curve  of  this  instrument  need  neither  be 
carried  all  the  way  to  its  point ;  but  this  point,  unless  we  wish  to  see  it  retreat  into 
tlie  urethra,  when  we  suppose  it  still  in  the  bladder,  must  extend  at  least  an 
inch  or  two  beyond  the  axis  of  the  handle.  It  is  scarcely  necessary  to  add, 
tliat  the  shape  of  the  flat  piece  on  the  handle  is  a  matter  of  taste  entirely,  and 
that  it  is  rendered  in  nowise  more  convenient  by  substituting  rings  after  the 
manner  of  Ponteau's,  nor  by  attaching  a  wooden  handle  to  the  stem,  as  in  that 
of  Lecat. 

Of  the  Forceps. — The  forceps  in  ancient  use,  which  were  jointed  like  scis- 
sors very  near  the  grasp,  had  a  double  inconvenience,  that  of  opening  wider 
in  the  wound  than  in  the  bladder,  and  of  seizing  the  stone  badly.  The  mere 
removal  of  the  rings  upon  the  outer  sides  of  the  handle  did  not  suffice  to 
remedy  this  defect,  to  effect  which  the  handles  were  so  arranged  as  to  cross 
one  another  more  or  less  within,  and  thus  before  they  extend  beyond  the  axis 
of  the  instrument  without,  they  allow  of  the  forceps  opening  considerably. 
That  variety  which  has  the  two  blades  parallel  when  separated,  and  not 
divergent,  and  which  has  a  lateral  articulation,  such  as  is  to  be  obtained  at  Mi 
Charriere's,  has  an  additional  advantage  of  letting  go  its  hold  less  easily,  and 
of  better  adapting  itself  to  the  form  of  the  stone. 

Position  of  the  Patient  and  the  Assistants. — A  common  bed  is  too  large,  too 
yielding,  and  generally  too  low,  to  be  substituted  in  private  practice  for  the 
operating  table  which  is  used  in  public  institutions.  However,  I  myself,  am 
not  fond  of  those  mechanical  contrivances  which  some  are  in  the  habit  of 
having  conveyed  to  their  patient's  houses.  Therefore,  M.  Heurteloup's  table, 
and  that  of  MM.  Tanchou,  Rigal,  and  others,  however  ingenious  they  may  be, 
seem  to  me  to  be  no  more  indispensable  than  M.  Rouget's  bed,  or  the  litho- 
tomy table  of  the  ancients.  A  commode,  a  common  table,  or  a  cot,  firmly 
fixed  and  properly  covered,  are  much  less  alarming,  and  always  quite  sufr 
ficient  for  a  surgeon  who  has  no  desire  to  acquire  notoriety  by  the  use  of  any 
particular  means.  What  is  wanted,  is  that  the  patient  should  lie  on  his 
back,  have  his  head  and  chest  flexed,  or  moderately  raised,  so  as  that  his  pelvis 
be  not  sunk  in  the  mattress ;  that  the  perineum  pass  beyond  its  edge ;  and 
that  the  assistants  may  move  easily  around  him.  At  the  present  day,  the 
Celsian  method  of  seating  the  patient  doubled  up  on  the  knees  of  two  strong 
persons,  and  then  of  binding  him  with  ligatures  passed  under  the  armpits, 
roots  of  the  tliighs,  over  the  hands  and  i^^U  as  prescribed  by  mnemonists,  is 
no  longer  thought  of. 

The  list  bandages,  in  a  figure  of  8  form,  employed  by  Ije  Dran,  are 
not  necessary.  When  it  is  remembered  that  no  species  of  confinement 
has  ever  been  advised  in  operations  for  hernia  or  aneurysm,  we  see  no  reason 
why  in  stone  there  can  be  urgent  need  of  any  unless  iht  patients  are 
children  or  lunatics.  I  have  so  far  dispensed  with  it,  without  ever  having 
reason  to  repent  doing  so;  although  in  a  patient  under  my  care  at  La  Pitie, 
from  whom  in  October,  1830;  I  removed  an  immense  stone,  the  operation  was  as 
laborious  a  one  as  possible.  If,  nevertheless,  prudence  or  necessity  induce  one 
to  prefer  it,  we  requiie  a  flannel  bandage,  or  failing  in  this,  a  strip  of  flexible 


OPERATIVE    SURGERY.  767 

linen  of  three  fingers'  breadth  and  two  or  three  yards  long.  With  this  band- 
age, doubled  where  the  loiip  is,  we  make  a  running  knot,  which  is  carried 
over  and  tightened  on  the  patient's  wrist,  who  then  takes  his  heel  into  his 
hand,  leaving  the  thumb  on  the  fibular  side,  the  fingers  below,  and  the  radial 
edge  of  the  hand  forwards.  The  two  ends  of  the  bandage  are  then  taken  by 
the  surgeon,  who  separates  tliem,  carries  one  inwards,  the  other  outwards, 
crosses  them  over  the  ancle,  carries  them  to  the  sole  of  the  foot,  brings  them 
up,  then  backwards,  and  then  lastly  forwards,  where  he  fastens  them  in  a 
bow,  being  careful  to  leave  the  free  extremity  outwards.  The  foot  and  hand 
of  each  side  thus  confined  are  confided  to  two  assistants,  who  stand  on  either 
hand,  on  the  outer  side  of  the  limb,  their  backs  turned  a  little  towards  the 
head  of  the  bed,  performing  the  same  office  exactly  as  if  no  ligatures  were 
used.  Whilst  with  the  hand  which  is  towards  the  pelvis  each  assistant 
seizes  the  corresponding  knee  to  bring  it  from  the  axis  of  the  body,  he  em- 
ploys the  other  in  grasping  the  foot  by  its  inner  edge  and  back,  pronating  it 
outwards ;  if  he  were  to  lay  hold  of  it  below,  the  patient  might  use  this  hand 
as  a  fulcrum  to  elevate  his  pelvis,  which  is  particularly  to  be  guarded  against. 
This  disposition  to  raise  the  pelvis,  which  is  particularly  noticed  among  chil- 
dren, joined  to  a  rotatory  motion  from  right  to  left,  is  so  difficult  of  control, 
as  to  require  the  co-operation  of  a  third  assistant,  who  should  be  tall  and 
strong  if  possible,  and  who  is  to  stand  on  the  left  side.  By  the  application 
of  the  palms  of  his  hands  on  each  crista  of  the  ilia,  with  the  thumb  of  each 
hand  spread  over  in  front  from  the  anterior  superior  spinous  process  into  the 
fold  of  the  groin,  he  manages  every  movement  by  slight  efforts  of  pressure, 
and  in  general  with  but  little  fatigue.  A  fourth  assistant  seated  on  the  table 
or  the  bed  watches  over  the  action  of  the  head,  and  closes  the  patient's  eyes 
with  a  compress.  A  fifth  stands  to  the  right,  opposite  the  side,  to  raise  up  the 
scrotum  and  support  the  stall*.  Lastly,  a  sixth  is  at  hand  to  pass  to  the  sur- 
geon such  instruments  as  he  requires  in  the  course  of  the  operation. 

Introduction,  and  Location  of  the  Staff. — Before  proceeding  to  the  division 
of  parts,  the  operator  introduces  the  staff  into  the  bladder,  and  does  not 
permanently  locate  it  until  he  has  himself  again  recognized  the  presence  of 
the  st(fne,  and  pointed  out  its  existence  to  some  one  or  other  of  liis  assistants. 
It  has  long  been  an  established  rule  to  let  the  flat  handle  lean  towards  the 
right  groin,  so  that  its  convexity  shall  bulge  out  the  perineum  more  or  less 
to  the  left  of  the  median  line,  and  obliquely  backwards  towards  the  ischium ; 
but  it  is  doubtful  how  far  this  rule  is  a  good  one,  or  any  other  force  than  that 
of  long  established  routine,  particularly  when  we  mean  to  open  the  prostate 
with  a  gorget  or  the  sheathed  Uthotome  In  fact,  the  inclination  given  the  staff 
does  not  change  the  direction  of  th«  parietes  of  the  urethra,  as  respects  the 
axis  of  the  canal.  What  matters  it  after  all  that  the  urethra  be  opened  on  the 
side  or  upon  the  median  line,  when  we  have  only  to  do  with  its  membranous 
portion,  or  to  make  a  way  for  the  entrance  of  other  instruments?  The  only 
good  reason  which  can  be  given  for  this  practice  is,  that  perhaps  it  affords  greater 
facility  for  avoiding  the  bulb,  by  the  crowding  back  to  the  left  of  that  portion 
of  the  urethra  which  conceals  this  enlargement,  and  which  consequently  be-r 
comes  no  obstacle  in  the  remainder  of  the  operation.  It  is,  therefore,  nearly 
optional  to  place  the  catheter  to  the  left,  as  is  generally  done,  or  on  the  median 
line,  as  is  preferred  by  MM.  Scarpa  and  Astley  Cooper,  even  in  performing 


7G8  NEW  ELEMENTS  OF 

the  lateralized  operation.  Instead  of  holding  it  ourselves  with  the  left  hand 
with  a  view  to  direct  its  movement  better,  and  alter  its  position  according  to 
circumstances  as  many  do,  following  the  advice  of  Ponteau,  it  is  usual  among 
surgeons  at  the  present  day  to  entrust  the  statF  when  its  situation  is  decided 
on  to  an  intelligent  assistant,  who  ought  to  be  well  acquainted  with  its 
mechanism  and  uses. 

First  Stage.' — The  surgeon  standing  up,  or  if  the  relative  proportions  of  his 
height  with  that  of  the  patient  seem  to  require  it  with  his  right  knee  on  the 
ground,  or  upon  a  stool  if  necessary  to  support  it,  armed  with  the  bistoury  he 
has  selected  in  his  right  hand,  first  cuts  through  the  integuments,  which  he 
makes  tense  with  the  thumb  and  fingers  of  the  other  hand,  not  heeding  the 
scrotum  which  is  gently  upheld  by  the  assistant  who  holds  the  staff  with  the 
right  hand.  This  incision  begins  on  the  left  side  of  the  raphe  about  an  inch 
in  advance  of  the  anus,  is  to  stretch  obliquely  backward,  and  end  midway  in 
the  space  which  separates  the  tuberosity  of  the  ischium  from  the  opening  of 
the  rectum,  its  length  being  about  four  inches.  Made  nearer  the  scrotum  \% 
exposes  to  infiltration,  and  no  object  is  gained.  It  is  useless  to  prolong  i^ 
towards  the  sacro-sciatic  ligament.  Were  it  any  shorter  it  might  interfere 
with  the  extraction  of  the  stone,  and  would  not  favor  sufficiently  the  escape 
of  urine.  Nearer  to  the  median  line  it  would  frequently  fall  upon  the 
rectum;  and  if  it  were  practised  as  Roux  did,  very  near  the  ischio-pubic 
ramus,  it  would  not  preserve  its  parallelism  with  that  in  the  deeper  seated  parts. 

The  bistoury  again  applied  to  its  upper  angle,  divides  the  subcutane- 
ous layer,  the  posterior  edge  of  the  transverse  muscle,  and  successively  all  the 
other  layers  which  intervene  between  the  skin  and  urethra,  carefully  bearing 
most  firmly  on  the  centre  part,  and  not  on  the  two  ends  of  the  solution  of 
continuity. 

Rather  than  to  continue  this  manipulation  until  the  instrument  is  bare  in 
the  urethra,  it  is  better  to  feel  through  the  yet  undivided  tissues  for  the  grove 
in  it  with  the  fore  finger,  and  place  the  right  edge  of  the  fissure  between  the 
nail  and  pulp  of  the  finger,  the  radial  edge  of  which  is  looking  downwards, 
The  surgeon  sliding  the  point  of  the  bistoury  which  he  has  not  laid  aside, 
like  a  pen  upon  the  nail  which  is  kept  motionless,  pierces  the  lower  wall  of 
the  urethra,  a  little  in  advance  of  the  summit  of  the  prostate,  and  strikes  upon 
the  fissure  in  the  staff.  The  forefinger  which  guides  it  is  then  raised  on  the 
back  of  the  bistoury,  pushes  its  point  towards  the  gland  for  an  extent  of  three 
or  four  lines,  whilst  the  operator  with  his  other  hand  raises  the  handle  and 
continues  to  press  it  against  the  groove  in  which  it  is  engaged.  Should  it  slip 
out,  the  rectum  runs  the  risk  of  being  pierced.  Uretro-cutaneous  fistula 
originate  from  this  cause,  of  which  MM.  Dupuytren  and  Begin,  cite  an 
instance,  and  of  which  I  know  myself  another.  The  forefinger  now  resumes 
its  steady  position  at  the  edge  of  the  staff,  and  then  the  right  hand  draws  out 
the  knife,  whilst  at  the  same  time  it  depresses  its  shoulder  so  as  to  divide  yet 
more  largely  the  layers  nearest  the  urethra. 

Second  Stage. — The  period  for  introducing  the  lithotorae,  which  ever  it  may 
be,  lias  now  arrived.  If  it  be  that  of  brother  Come,  the  operator  takes  hold 
of  its  handle,  not  touching  its  bascule,  strikes  its  beak  over  his  nail  into  the 
opening  in  the  urethra,  so  as  to  strike  perpendicularly  on  the  groove  in  the 
staff,  moves  it  along  it  upwards  and  downwards  to  be  sure  of  its  having  en- 


OPERATIVE    SURGERY.  7*69 

tered,  and  when  he  perceives  the  contact  of  the  two  metallic  bodies,  he  rises, 
if  he  has  been  kneeling,  takes  his  fore-finger  out  of  the  wound,  takes  the  staft' 
into  his  own  hands,  lowers  its  flat  handle  and  tilts  up  the  point  with  his  left 
hand,  whilst  with  his  right  he  slides  the  summit  of  the  lithotome  along  the 
groove  into  tlie  bladder,  a  gush  of  urine  from  which  immediately  denotes  its 
having  entered. 

The  same  precautions  are  called  for  by  the  use  of  a  gorget;  nor  does 
prudence  require  less  when  a  tongued  or  probe-pointed  bistoury  is  used : 
small  solid  handled  knives,  straight  or  convex  are  employed.  If  the 
visceral  end  of  the  staft'  were  not  tilted  towards  the  symphysis  pubis  to  make 
way  for  these  instruments,  they  would  equally  cut  the  prostate  it  is  true; 
but  then,  either  their  point  or  their  edge  will  almost  inevitably  strike  tlie 
trigonal  vesical  space  so  as  frequently  to  penetrate  it  from  side  to  side.  By 
following  its  groove,  on  the  contrary,  owing  to  this  elevating  movement,  they 
bring  it  into  correspondence  with  the  vertical  axis  of  the  bladder,  and  pene- 
trate with  impunity  as  deep  as  may  be  required,  so  that  on  withdrawing  them 
we  may  give  the  incision  all  necessary  extension. 

The  staff  having  performed  its  office  is  now  withdrawn.  The  hand  in 
which  the  handle  of  the  lithotome  is  held,  slips  some  fingers  below  its  bascule 
and  opens  it;  the  other  hand  takes  hold  of  its  back  on  the  level  of  the  articu- 
lation of  the  sheath  with  its  blade,  the  thumb  on  the  right  side,  the  forefingei- 
semiflexed  on  the  left  side,  its  radial  edge  being  directed  towards  the  pubis. 
Its  cutting  edge  looking  in  the  direction  of  the  outer  incision,  or  in  any 
other  way  if  it  be  preferred,  both  hands  are  to  unite  their  efforts  to  withdraw 
it.  It  is  the  part  of  the  right  hand  to  prevent  the  sheath  from  leaving,  as  it  ik 
being  withdrawn,  that  point  on  the  arch  of  the  pubis  against  which  its  dorsal 
or  concave  edge  had  at  first  been  applied. 

The  right  hand,  which  has  to  draw  it  forth,  has  two  dangers  to  avoid.  By 
raising  the  wrist  too  high  the  incision  at  its  base  would  be  deeper  than  at  the 
point  of  the  prostate;  too  considerable  a  depression  of  it  would  not  only- 
produce  the  contrary  result^  but  expose  the  rectum  to  the  danger  of  being 
wounded.  If  it  were  not  kept  firmly  pressed  against  the  pubic  arch  there 
would  be  no  fixed  point,  and  the  dimensions  of  the  wound  would  vary 
according  as  the  blade  should  be  brought  down  with  greater  or  less  force : 
one  of  the  inconveniences  attending  the  gorget  and  the  bistoury. 

Whatever  be  the  instrument  with  which  this  separation  of  parts  is  made, 
we  should  find  that  by  saving  the  tissues  situated  immediately  below  the 
prostate,  as  advised  by  Morand,  no  other  advantage  would  be  gained  than 
more. certainly  avoiding  the  rectum,  for  it  is  not  here  that  the  transverse 
artery  of  the  perineum  is  situated ;  but  a  dangerous  obstacle  would  result 
to  the  passage  of  the  urine. 

As  on  the  other  hand  the  intestine  is  sufficiently  well  protected  by  the 
obliquity  of  the  incision,  it  is  unnecessary  to  follow  this  advice.  The 
more  the  axis  of  the  wound  approaches  the  perpendicular,  i.  e.  the  axis  of  the 
body,  the  greater  is  the  chance  that  neither  abscess  nor  infiltration  will  occur. 
On  the  whole,  the  deep  incision  being  intended  to  enlarge  the  entrance  of  the 
urethra  as  much  as  possible  without  going  beyond  the  limits  of  the  prostate, 
ought  to  bear  upon  the  greatest  radius  of  this  gland,  not  only  from  the  centre 
to  the  circumference  but  also  from  before  backward,  and  so  that  the  circle 
97 


770  NEW   ELEMENTS  OF 

of  its  base  only  be  respected.  This  is  a  problem  to  be  solved  in  the  lateral- 
ized  operation.  Now,  the  smallest  reflection  shows  us  that  to  do  this  there  can 
be  no  advantage  in  cutting  the  membranous  portion  of  the  urethra ;  and  that 
it  is  alone  necessary  to  open  this  duct  near  to  the  summit  of  the  prostate,  and 
consequently  back  of  the  horizontal  aponeurosis  of  the  perineum.  For  the 
same  reason,  it  wUl  appear  how  perfectly  useless  it  is  to  continue  the  incision 
of  the  other  tissues  in  front  towards  the  pubis,  because  its  only  object  is  to 
make  a  passage  sufficiently  large  for  the  stone ;  and  that  for  the  sequelae  of  the 
operation,  the  escape  of  urine,  it  is  particularly  necessary  that  its  enlargement 
should  be  made  in  a  backward  direction. 

Third  Stage. — The  lithotome  having  now  become  uselp-^s,  is  now  passed 
to  the  assistant,  and  its  place  instantly  taken  by  the  left  forefinger,  which 
being  introduced  from  below  upwards,  and  from  before  backwards,  serves  to 
ascertain,  1st,  the  internal  condition  of  the  organ ;  2d,  the  position,  sometimes 
the  size,  the  form,  and  even  the  number  of  stone's  which  it  contains ;  Sd,  the 
dimensions  of  the  wound.  Care  must  be  taken  that  the  finger  in  its  passage 
does  not  detach  either  the  intestine  nor  prostate,  by  getting  by  mistake 
between  these  parts.  Before  it  is  withdrawn  the  probe-pointed  bistoury  is 
conducted  in  upon  it  to  enlarge  the  wound  if  too  narrow,  either  prostatic 
or  perineal,  in  one  direction  or  in  the  other;  after  which  it  serves  to  conduct 
the  probe-pointed  scoop,  the  gorget,  or  else  the  forceps.  To  do  this,  it  had 
better  be  placed  with  the  nail  turned  backwards  in  the  inferior  than  in  the 
superior  angle  of  the  wound ;  for  the  reason  that  the  instruments  it  is  to  direct, 
have  a  greater  liability  of  escaping  backwards  between  the  tissues  than  they 
have  forwards.  The  scoop  being  longer  and  thinner  than  the  gorget,  pervades 
the  vesical  cavity  better,  and  reaches  the  stone  more  easily  wherever  it  be 
situated ;  but  is  afterwards  rather  less  convenient  as  a  guide  to  the  forceps. 
In  a  great  majority  of  cases,  however,  both  may  be  dispensed  with  ;  and  the 
forceps  be  passed  in  immediately  upon  the  finger.  As  soon  as  their  duty  as 
exploring  agents  is  finished,  they  are  brought  back  instead  of  the  finger;  so 
as  to  be  able  to  depress  the  posterior  angle  of  the  wound  with  whichever  one 
we  employ.  With  the  right  hand  now  at  liberty,  the  operator  presents  the 
forceps  above,  one  grasp  or  blade  to  the  left  and  one  to  the  right,  and  slipping 
them  in  on  the  gorget,--  or  embracing  the  crista  of  the  scoop  between  their 
half  opQn  edges,  pushes  them  as  he  had  done  for  the  finger,  penetrates  into 
the  bladder  in  this  way,  and  at  the  same  instant  disengages  the  conducting  in- 
strument. Before  we  think  of  seizing  the  calculus,  we  try  again  to  touch  it 
by  various  motions  of  the  instrument.  All  this  makes  the  latter  stage  of  the 
operation  sometimes  the  longest  of  any  and  the  most  difficult,  though  it  is  gen- 
erally the  simplest  and  speediest.  The  surgeon  then  opens  the  forceps  with 
both  hands ;  the  forefinger  and  thumb  of  each  acting  on  the  corresponding 
ring.  When  the  blades  are  far  enough  apart,  he  turns  it  suddenly  round 
on  its  axis,  so  that  it  describes  the  quarter  of  a  circle  from  right  to  left; 
so  that  one  spoon  becomes  quickly  the  lower,  the  other  the  upper;  the  lower 
one  raking  in  a  measure  the  wall  of  the  bladder,  and  slipping  beneath  the 
stone.    If  this  movement  does  not  succeed  the  first  time,  it  is  repeated, 

*  This  gorg'et,  called  «  simple,"  is  not  a  cutting-  instrument,  but  merely  a  grooved  body 
attached  to  a  liandle,  of  varying-  size.  Its  use  is  to  conduct  the  forceps  to  the  stone,  and 
ivence  is  called  **  gorgeret  conducteur.*' 


OPERATIVE    STTRGERY.  771 

eitlier  in  the  same  way  or  from  left  to  right,  or  by  elevating  or  depressing 
the  wrist  a  little  more.  The  stone  when  grasped,  may  separate  the  handles 
of  the  forceps  more  widely  than  it  was  at  first  supposed  it  would;  this  is 
owing  to  its  being  too  near  the  joint,  to  its  not  being  seized  in  its  smallest 
diameter,  or  to  an  erroneous  idea  of  its  size.  In  the  two  former  cases  this  is 
remedied  by  pushing  forward  the  calculus  with  the  scoop,  or  by  moving  it 
about  until  it  presents  by  its  thinnest  part  without  letting  go  of  it  entirely. 
In  the  latter  case  there  is  no  other  resource  than  to  cut  away  the  frenum, 
if  the  prostatic  opening  does  not  appear  large  enough.  It  is  better  to  let  it 
go  and  seize  it  again,  than  to  persevere  in  attempting  to  rectify  its  malposi- 
tion in  the  grasp  of  the  blades  which  hold  it;  understanding  that  if  it  be  not  a 
very  large  one  all  these  precautions  will  be  found  unneeded.  If  the  stone 
should  be  a  flat  one,  and  much  longer  in  one  direction  than  in  the  other, 
although  seized  by  its  smallest  diameter,  it  might  need  relaxing,  and  then  to 
be' seized  again  if  it  came  crosswise  to  the  wound.  The  same  thin";  will  also 
happen  if  it  be  somewhat  elongated,  cylindrical,  or  shaped  like  a  girkin. 
Tbese  peculiarities  are  pointed  out  to  exist,  by  the  insurmountable  resistance 
which  is  all  of  a  sudden  offered  at  the  moment  that  the  forceps  seems  entirely 
to  be  leaving  the  bladder. 

The  forceps,  even  though  they  have  never  been  opened,  having  an  interval 
between  their  blades  that  they  may  not  pinch  the  inner  membrane  of  the 
organ,  may  have  received  the  stone  if  a  small  fiat  one  between  them,  and 
may  contain  it  in  one  of  their  spoons  unknown  to  the  operator.  This  may 
be  suspected,  if  having  touched  or  endeavored  to  lay  hold  of  it  we  no  longer 
feel  it  any  more.  The  forceps  is  in  this  case  to  be  withdrawn  to  examine  as 
to  the  fact.  Besides,  it  is  not  very  uncommon  to  see  small  stones  escape  with 
the  stream  of  urine,  or  stop  for  a  while  in  the  trajet  of  the  wound,  so  that 
their  existence  is  rendered  doubtful. 

Let  us  suppose  now  that  the  stone  is  fairly  seized.  The  forceps  being 
again  placed  horizontally,  the  surgeon  takes  hold  of  the  rings  on  the  handle 
with  his  right  hand,  fastens  them  with  his  left  hand  turned  supine,  as  near  the 
grasp  as  possible ;  the  fingers  being  below,  the  thumb  above.  He  then  begins 
his  traction,  after  being  well  satisfied  that  the  stone  is  free,  and  the  only  thing 
grasped  by  the  forceps.  To  do  this  he  presses  it  down  with  the  thumb  of  one 
hand,  that  it  may  press  principally  against  the  posterior  angle  of  the  wound, 
whilst  the  other  hand  performs  the  necessary  tractive  efforts.  These  are 
made?' from  right  to  left  above  downwards,  rather  than  directly  forwards, 
being  careful  to  make  them  follow  the  direction  of  the  axis  of  the  pelvis  as 
in  extracting  the  head  of  a  foetus. 

Should  the  straight  forceps  pass  constantly  over  the  stone  so  as  not  to  be 
able  to  enclose  it  in  its  spoons ;  in  a  word,  if  the  stone  escapes,  owing  to  its 
having  swerved  from  its  position,  being  too  low  or  situated  in  too  deep  an 
excavation,  curved  forceps  are  indicated.  They  are  introduced  like  the 
others,  and  their  cavity  is  turned  towards  the  direction  of  the  stone  to  .seize 
it;  they  are  drawn  out  in  a  contrary  one  for  its  extraction.  That  species  of 
forceps  resembling  the  obstetrical  instrument  invented  by  F.  Come,  are 
indispensable  only  for  very  large  stones  which  are  accurately  encircled  by 
the  bladder.     The  branches  are  introduced  separately,  sliding  them  between 


772  NEW   ELEMENTS   OF 

the  parietes  of  the  organ  and  the  foreign  body ;  they  are  then  locked,  abso- 
lutely as  in  manipulating  with  midwifery  forceps. 

The  calculus  being  brought  out,  it  is  not  to  be  laid  aside  until  its  appearance 
has  been  inspected.  If  it  is  rounded,  of  an  elliptical,  oval,  elongated,  but 
destitute  of  angles  and  facets,  we  are  entitled  to  believe  that  no  others  exist 
in  the  bladder.  Calculi  covered  with  projecting  roughnesses  induce  the  like 
belief.  Those  which  present  us  with  surfaces  as  smooth  as  if  they  had  been 
chiseled  off,  separated  by  edges  or  by  distinct  angles ;  which  offer  every 
indication  of  being  fragments  or  broken  stones,  of  course  lead  us  to  suspect 
the  reverse.  This  mere  glance  however  gives  mere  presumption  only,  and 
does  not  permit  us. to  dispense  with  other  examination.  We  are  therefore  to 
carry  in  the  scoop  or  the  finger  within  the  cavity  of  the  organ,  to  know 
exactly  hov/  the  case  stands,  and  so  as  to  withdraw  every  tolerably  large 
sized  piece  of  any  foreign  body.  Some  bladders,  in  fact,  contain  a  very  con- 
siderable number.  That  of  a  patient  who  had  been  cut  three  times  contained 
three  hundred  at  the  time  that  M.  Ribes  made  the  examination  of  his  body. 
Recently  the  journals  have  mentioned  a  patient  from  whom  M.  Roux  ex- 
tracted near  a  hundred;  and  in  another  M.  Murat  counted  six  hundred 
and  seventy-eight.  It  is  of  vital  importance  that  none  of  these  calculi  remain 
either  in  the  bladder  or  in  the  trajet  of  the  wound.  As  they  are  usually  very 
small  they  may  very  easily  lose  themselves  amongst  the  parts,  and  that 
unless  the  most  scrupulous  minuteness  of  observation  be  used  the  patient 
will  run  the  risk  of  preserving  about  him  the  nucleus  of  stone  after  the  ope- 
ration. The  size  of  the  stone  may  also  become  a  source  of  embarrassment. 
When  they  exceed  two  inches  in  their  small  diameter,  it  is  often  impossible 
to  extract  them,  even  by  tlie  recto-vesical  cutting.  In  a  case  of  this  kind 
last  year,  M.  Dupuytren  performed  the  operation  of  lateral  cutting,  and 
slit  up  the  anterior  wall  of  the  rectum.  Divers  instruments  have  been  invent- 
ed to  break  them  into  fragments  in  such  a  case.  Tiiat  of  brother  Come  has 
two  pyramidical  teeth  within  the  grasp,  which  is  flat- filed.  The  stone-break- 
ing forceps  of  Benj.  Bell,  are  also  denticulated,  and  a  screw  crosses  the 
handles.  M.  Sirhenry's  forceps  for  breaking  the  stone,  by  penetrating 
per  urethram;  the  **pince  a  virgules"  of  Baron  Heurteloup;  the  friction  for- 
ceps of  M.  Rigaud  ;  the  *'  ansebrise"  of  Jacobson ;  in  a  word,  almost  every 
forceps  used  in  midwifery  will  accomplish  the  object.  The  latter  instru- 
ment would  possess  the  advantage  of  allowing  of  the  perforation  of  the 
stone,  if  their  ordinary  construction  did  not  permit  us  to  break  them,  and 
should  I  think  be  preferred  ;  but  the  stones  which  render  such  manipulation 
indispensable,  are  so  large  and  difficult  to  embrace  that  it  is  generally 
thought  preferable  to  proceed  at  once  to  the  operation  of  hypogastric  cuttingy 
and  extract  them  above  the  pubis.  No  one  is  now  so  fearful  of  seeing  a 
stone  when  friable  break  beneath  the  forceps,  as  to  employ  Broomfield's 
quadruple  forceps,  the  graduated  ones  of  Lecat,  the  horsehair  fillet  of  Huss, 
Home's  circular  development  forceps,  or  the  triple  forceps  with  fenestra  in 
the  grasps  made  by  Cluly,  the  cutler  in  Sheffield.  If  the  thing  occurs  it  is 
found  more  convenient  to  go  successively  in  search  of  all  the  fragments  with 
the  same  instrument,  and  wash  away  the  fragments  with  emollient  injections 
afterwards. 


OPERATIVE    SURGERY.  775 

Hie  state  of  fixedness  of  the  stone  has  been  at  every  period  a  source  of 
more  embarrassment  with  surgeons.  Before  we  lose  ourselves  in  useless 
eiforts  we  should  try  with  the  forefinger  to  detect  the  nature  of  the  difficulty 
which  exists.  If  the  foreign  bodies  seem  to  adhere  by  one  surface  only, 
probably  some  fungous  growths  and  vegetations  have  sprung  up  between  its 
roughnesses.  In  this  case,  the  plan  of  Lapeyronie,  followed  hj  ^larechal,  Le 
Dran,  M.  Boyer,  &c.,  which  consists  in  methOilically  pulling  at  the  stone 
with  forceps  when  once  it  is  seized,  to  tear  it  away ;  is  the  only  one  which 
will  answer  every  time  that  the  finger  or  scoop  fail  to  shake  it  from  its  attach- 
ments. If  it  is  simultaneously  encysted  and  adherent,  rubbing  away  the  cyst 
with  a  staff,  advised  by  Littre,  will  be  of  very  little  service.  Scarcely  better 
would  pounding  it  with  forceps,  which  he  also  advises,  prove  to  be ;  laceration 
here  is  equally  the  only  remedy.  When  simply  stopped  by  a  frenum,  or 
contained  in  a  cyst  more  or  less  largely  open,  and  not  adherent,  a  cutting 
instrument  should  not  always  be  forbidden ;  Garengeot,  Le  Blanc,  and  De- 
sault  have  used  it  with  success.  A  straight,  or  curved  probe-pointed  bis- 
toury, surrounded  with  a  strap  of  linen  round  its  edge,  to  within  five  or  six 
lines  of  the  button,  should  be  very  cautiously  carried  to  the  free  border  of 
the  cyst;  then  introduced  flatwise  between  the  stone  and  the  cyst,  so  that  as 
its  blade  is  withdrawn  it  may  cut  the  adventitious  sac  from  top  to  bottom 
to  a  suitable  extent,  almost  as  if  we  were  relieving  the  stricture  in  a  hernia. 
Nothing  prevents  this  operation  from  being  performed  on  other  points  of  the 
frienum,  if  the  first  does  not  suffice,  or  it  appears  too  dangerous  to  extend  it 
far  enough. 

The  tonsil  kiotome,  or  frenotome,  used  by  Desault,  certainly  is  not  equal 
to  the  bistoury  of  Pott,  and  does  not  deserve  adoption.  The  common  straight 
bistoury  employed  by  Garengeot,  offers  two  inconveniences;  1st,  its  point 
incessantly  threatens  to  cut  the  wall  of  the  bladder;  2d,  it  neither  slides,  nor 
can  be  introduced  as  easily  between  the  cyst  and  the  surface  of  the  stone,  as 
the  bistoury  which  is  probe-pointed.  The  surgeon  should  however  remember, 
that  a  frenum  formed  by  simple  partial  contraction  of  the  urinary  pouch, 
and  that  abnormal  sacs  existing  with  it,  instead  of  projecting  inwardly  will 
not  admit  of  such  incisions  at  all,  or  only  with  the  utmost  reserve  ;  for  as  they 
then  bear  on  the  inner  surface  of  the  bladder  itself,  this  would  seldom  fail  to 
injure  the  peritoneum. 

An  exception  should  still  be  made  in  favor  of  calculi  fastened  by  one  end 
within  the  ureter.  The  orifice  of  this  canal,  which  crosses  the  thickness  of 
the  bas-fond  of  the  bladder  very  obliquely,  might  in  fact  be  incised  separately 
for  an  extent  of  several  lines  without  any  danger. 

It  is  better  to  return  to  force,  shaking  and  tractions  in  various  directions, 
if  a  stone  of  a  gourd-shape  for  instance  be  retained  b}^  one  end  in  the  ureter 
or  in  a  secondary  cavity  of  the  bladder,  and  only  have  recourse  to  incision 
when  in  despair  of  succeeding  in  any  other  wa3'. 

Cutting  at  Two  separate  Times. — The  difficulty  of  seizing,  or  extracting  the 
stone,  the  dread  of  exhausting  the  patient  by  fatigue  from  long  searches,  have 
led  to  this  idea  of  practising  the  operation  at  distinct  intervals ;  that  is  to 
say,  at  one  to  confine  oneself  to  merely  opening  the  bladder;  to  put  off  the 
other  till  tiie  extraction  of  the  stone.  The  same  idea  had  been  set  forth  by 
the  Arabs,  for  which  Albucasis  says,  that  if  the  hemorrhage  comes  on,  the 


774  KEM  ELEMENTS  OF 

surgeon  is  to  touch  the  wound  with  vitriol  and  wait^  F^-anco,  who  re-e&tab- 
lished  it,  waited  for  three  or  four  days.  Maret,  of  Dyon,  nevertheless, 
is  the  first  who  endeavored  to  render  it  general.  Since  then  it  has 
received  the  support  of  Camper,  of  T.  Haaf,  who  returned  to  the  search 
after  a  lapse  of  eight  days,  and  more  lately  of  M.  Guerin  of  Bordeaux.  It 
is  doubtless  to  be  expected  after  its  adoption,  that  at  least  the  foreign  body 
will  approach  the  passage  made  for  it  and  be  reached  with  less  difficulty ;  and 
even,  that  it  will  escape  by  the  wound,  and  fall  into  the  dressings.  But  in 
spite  of  these  advantages,  there  is  to  be  endured  the  restlessness  of  the 
patient,  the  ceaseless  irritation  of  the  stone,  the  acute  pain  produced  by  the 
passage  of  the  forceps  through  a  wound  more  or  less  inflamed  ;  in  a  word, 
two  operations  instead  of  one.  Consequently  modern  practitioners  have 
rejected  this  form  of  operation,  and  never,  unless  it  is  impossible  for  them  to  do 
otherwise,  leave  a  stone  in  the  bladder  after  having  once  divided  the  soft  parts. 

Injections. — For  fear  that  some  gravelly  fragments  may  still  remain  behind 
in  the  bladder,  most  surgeons  are  in  the  habit  of  washing  it  out  by  large  injec- 
tions of  warm  water  or  emollient  decoctions.  When  carefully  effected, 
injections  can  never  do  harm.  Nor  do  v,  e  see  how  they  can  be  dispensed 
with,  for  they  have  the  undoubted  advantage  of  bringing  with  them  clots  of 
blood,  flocculi  of  mucus,  as  well  as  fragments  of  stone,  which  often  evade  the 
most  attentive  scrutiny.  To  exhibit  them  we  require  a  large  syringe,  a  common 
glyster  syringe,  which  will  contain  a  quart  or  more  of  fluid.  With  less  the  gush 
of  the  injection  would  not  be  forcible  enough  to  expel  the  matters  which  we  are 
anxious  to  expel.  Not  to  wound  the  organ  we  may  use  a  syphon  ending  like  the 
top  of  a  watering  pot,  either  of  tin  or  of  gumelastic.  However,  with  a  little  dex- 
terity and  an  unrefractory  patient  the  common  pipe  exposes  him  to  no  risk. 
After  the  first  injection  a  second,  and  then  a  third,  are  made  so  as  to  be  yet 
more  sure  of  detecting  heterogeneous  matters.  We  are  then  to  wipe  off  the 
patient  with  a  sponge  and  some  warm  water,  and  remove  the  ligatures 
and  other  fetters  which  the  operation  may  have  rendered  necessary.  The 
patient  is  then  placed  in  bed  upon  his  back,  his  head  and  chest  moderately 
elevated,  the  lower  limbs  close  together,  semiflexed,  and  kept  so  by  a  sheet 
folded  cylindrically  and  placed  under  the  hams.  Tying  the  legs  and  thighs 
of  the  patient  to  prevent  them  from  separating,  as  was  done  only  as  late  as 
the  last  century,  is  a  useless  proceeding.  Even  the  supine  position  need 
not  be  permanently  maintained.  The  patient  must  be  allowed  to  lean  on 
either  side,  and  confine  himself  to  his  back  only  so  long  as  it  is  not  incon- 
venient or  attended  with  fatigue. 

The  Cannia  in  the  Wound. — The  practice  of  placing  a  catheter  in  the 
bladder,  the  more  quickly  to  re-establish  the  natural  route  of  the  urine, 
has  long  been  discontinued.  The  same  is  nearly  the  case  witli  the 
canula,  which  many  operators  once  thought  it  necessary  to  leave  in  the 
wound  for  a  certain  number  of  days  after  the  operation,  and  which  was 
intended  to  prevent  infiltrations  by  conducting  out  the  efiused  fluids.  This 
tube,  which  some  practitioners  are  still  in  the  habit  of  using  under  certain 
particular  circumstances,  irritates  the  wound,  the  neck  of  the  bladder,  and 
also  its  lining  membrane.  It  is  a  foreign  body  thwarting  the  restorative  efforts 
of  tiie  organization,  a  greater  or  less  annoyance  to  the  patient,  and  which 
alone  may  give  rise  to  fearful  symptoms.     I  once  saw  it  used  in  an  old  man 


OPERATIVE    SURGERY.  775 

eighty-four  years  of  age  who  was  soon  attacked  with  adynamic  symptoms, 
and  who  died  at  the  end  of  eleven  days.  The  whole  length  of  the  wound 
was  covered  with  a  grayish  concretion ;  pus  was  poured  out  round  about  it, 
and  traces  of  purulent  inflammation  were  discernible  even  within  the  pelvis. 
Thus  it  is  an  instrument  more  hurtful  than  useful ;  and  if  it  should  ever  be 
an  object  to  guard  against  approximation  of  the  edges  of  the  incision,  it  would 
be  better  to  place  a  tent  or  pledget  of  lint  between  them. 

Untoward  Occurrences, — The  first  accident  to  be  feared  m  lateralized  cut- 
ting in  general  perineal  lithotomy  is  hemorrhage.  This  may  occur  under 
three  circumstances ;  during  the  division  of  the  tissues,  in  the  four  and 
twenty  hours  subsequent  to  the  operation,  and  after  a  lapse  of  several  days. 
In  the  first  case  it  must  be  owing  to  lesion  of  the  arteria  superficialis,  the 
arteria  transversa,  the  hemorrhoidal,  or  trunk  of  the  pudic  artery  of  the  pros- 
tatic plexus  of  veins,  or  else  of  some  anomalous  artery.  It  comes  from  the 
.superficial  when  the  blood  springs  from  the  upper  angle  of  the  wound  and 
•subcutaneous  layer;  from  the  transverse  on  the  contrary  if  it  can  be  stopped 
,Lby  pressure  with  the  finger  some  way  dov.n  on  the  outer  lip  of  the  wound 
^opposite  the  bulb  and  membranous  portion.  It  is  caused  by  the  hemorrhoidal 
i4f  the  stream  comes  from  the  lower  angle  of  the  solution  of  continuity.  It  is 
'•likewise backward  and  outwards  when  the  pudic  has  been  cut,  but  its  source 
will  be  perceived  at  a  great  depth.  That  bleeding  which  results  from  dividing 
a  vein,  or  which  is  caused  by  the  section  of  some  artery  around  the  prostate 
being  more  deep-seated  than  any  other,  will  in  the  former  event  be  known  by 
the  color  of  the  blood,  and  in  the  second  by  the  circumstance  that  no  pressure 
on  any  part  of  the  perineal  wound  with  the  finger  will  arrest  it  even  for  a 
moment.  When  the  blood  does  not  flow  per  saltern,  and  is  not  in  sufficient 
abundance  to  weaken  the  patient  much,  no  obstacle  should  be  offered  to  it- 
It  is  frequently  a  salutary  loss,  and  capable  of  warding  off  serious  evils.  On 
the  other  hand,  if  threatening  to  be  abundant,  to  be  lasting,  when  the  patient 
is  already  much  weakened,  or  very  aged,  it  is  proper  to  check  it  at  once. 
When  it  can  be  applied,  ligature  is  the  best  and  most  simple  means  for  the 
purpose.  W^hen  the  divided  trunk  can  be  seen  in  the  wound  it  is  to  be  seized 
\vith  a  pair  of  dissecting  forceps,  or  if  not  sufficiently  isolated  with  a  tenacu- 
lum and  a  thread  immediately  passed  around  it.  If  it  were  the  pudic  we  had 
to  tie,  and  its  extremity  difficult  to  seize,  we  should,  I  think,  imitate  Dr. 
Physick,  who  cut  it  in  his  first  operation  for  stone,  and  pass  between  it  and 
the  ischio-pubic  ramus  a  double  thread  by  the  assistance  of  a  curved  needle 
in  the  handle  contrived  by  J.  L.  Petit.  This  needle  should  be  buried  in  the 
interior  of  the  wound,  would  pass  on  the  outerside  of  the  artery  behind  its 
division  to  re-enter  the  solution  of  continuity,  where  the  thread  is  to  be  dis- 
engaged from  its  point  so  that  it  may  be  withdrawn,  and  immediately  be 
knotted  over  the  tissues.  I  do  not  think  that  the  advice  given  by  Mr.  Tra- 
vers  of  carrying  in  such  a  case  a  ligature  round  the  vessel  as  it  passes  between 
the  sciatic  ligaments  can  ever  be  thought  of.  Besides,  this  wound  is  so  un- 
common, so  difficult  to  inflict,  unless  we  depart  widely  from  the  rules  of 
scientific  surgery,  that  the  means  of  guarding  against  the  danger  from  it  are 
of  minor  importance.  It  is  also  probable  that  persons  have  been  frequently 
misled  as  to  its  existence  by  bleeding  from  anomalous  branches,  or  from  some 
cf  its  secondary  branches  rather  larger  than  common. 


776  NEW  ELEMENTS    OF 

Supposing  it  were  easy  to  isolate  and  seize  the  vessel,  but  that  it  was  too 
high  up  for  us  to  surround  it  with  a  ligature  easily,  we  should  not  hesitate  to 
twist  it  by  means  of  the  forceps  which  have  hold  of  it.  Lastly,  if  neither 
torsion  nor  ligature  can  be  applied,  or  entirely  fail  to  arrest  the  hemorrhage, 
several  other  means  are  to  be  tried.  The  large  canula,  so  arranged  as  to 
fill  and  press  upon  all  the  extent  of  the  wound,  in  use  not  half  a  century 
ago,  was  inconvenient  from  compressing  more  strongly  towards  the  skin  than 
the  prostate,  and  frequently  causing  effusion  of  fluids  into  the  bladder.  It 
appears  that  M.  Boyer  has  frequently  advantageously  used  a  strong  roll  of 
lint  carried  within  the  bladder  itself  and  fastened  by  a  sti'ing,  the  two  ends  of 
which  are  then  knotted  to  another  roll  which  is  passed  down  as  deeply  as 
possible  on  the  same  side  as  the  urethra ;  but  the  little  contrivance  of  M. 
Diipuytren  is  here  evidently  the  preferable  one.  It  consists  of  a  tube  open 
at  top  and  on  the  sides,  around  which  is  attached  a  sort  of  shirt  made  of  fine 
linen.  It  is  introduced  in  beyond  the  neck,  and  then  we  are  to  slip  between 
it  and  its  linen  covering  some  lint  with  a  pair  of  dressing  forceps  until  the 
wound  is  quite  full,  so  as  to  compress  all  the  circumference  suitably,  rather 
more  strongly  towards  the  bottom  than  near  the  skin.  All  this  being  retained 
by  a  T  bandage,  offers  no  impediment  to  the  flow  of  urine,  and  moreover 
hIIows  us  to  increase  or  diminish  the  pressure  in  one  or  another  direction  as 
may  be  requisite.  In  two  or  three  days  the  surgeon  gradually  takes  out  the 
lint,  and  soon  afterwards  the  rest  of  the  apparatus. 

If  the  bleeding  does  not  show  itself  for  some  hours,  it  is  seldom  a  source 
of  so  much  uneasiness  as  to  require  instrumental  attention.  The  blood  which 
now  appears  had  not  appeared  at  an  earlier  period,  not  because  the  contact 
of  the  air  had  for  a  moment  constricted  the  vessels,  nor  because  of  any  spasms 
of  these  canals,  but  because  the  general  circulation  usually  very  slow  in  the 
patient  when  stretched  on  a  bed  of  pain,  experiences  a  lively  reaction,  a  re- 
newal of  power  in  its  impulsive  efforts ;  and  therefore  it  is  that  the  evil  often 
cures  itself,  and  that  this  hemorrhage  is  easily  suspended  by  the  application 
of  cold  or  revulsives,  which  tend  to  draw  the  fluids  into  another  direction. 
In  such  a  case  we  might  begin  by  applying  cold  to  the  hypogastrium,  the 
upper  part  of  the  thighs  and  perineum,  and  even  by  injecting  it  into  the 
wound.  If  there  be  fever  and  a  hard  pulse,  a  small  bleeding  from  the  arm 
is  evidently  indicated.  In  a  contrary  condition  of  system,  manuluvia  of 
mustard,  dry  cupping,  scarifying  between  the  shoulders,  mustard  plasters  to 
the  same  regions  should  be  tried  before  tamponning  or  the  ligature,  unless  the 
hemorrhage  was  profuse  in  the  extreme. 

When  it  does  not  appear  for  some  days  we  may  be  pretty  certain  that  it 
results  from  no  opening  of  an  artery,  but  from  pure  exhalation  either  from 
the  wound  or  vesical  cavity.  To  account  for  it  on  a  contrary  opinion  we 
must  suppose  the  separation  of  some  eschar  from  the  vesical  parietes,  or,  as 
in  fact  is  sometimes  seen,  general  debility,  decided  dissolution  of  the  fluids 
which  has  softened  all  the  sanguineous  clots,  and  broken  down  every  barrier 
opposed  to  the  exit  of  the  separative  fluid.  It  is  therefore  to  be  considered 
as  the  most  dangerous.  It  admits  of  no  other  treatment  than  that  advised 
for  the  preceding  ones. 

Wowids  of  the  Intestine. — If  the  rectum  is  wounded  in  the  first  stage  of 
the  operation,  or  in  any  way  before  the  bistoury  has  cut  the  neck  of  the  blad- 


OPERATIVE  SURGERY.  7 ft 

der,  the  wound  is  always  found  beneath  the  prostate  gland.  It  most  frequently 
occurs  in  withdrawing  the  lithotome,  and  then  the  perforation  has  its  seat  at 
a  more  elevated  point  above  the  sphincter.  Frequently  it  is  not  first  per- 
ceived. It  may  even  happen  that  at  first  the  perforation  was  not  complete,  bu£ 
that  the  wall  of  the  rectum,  previously  much  thinned  by  the  tutting  instru- 
ment, is  bruised,  and  irritated  during  the  extraction  of  the  stone,  and  that 
the  fall  of  the  slough  completes  the  misfortune.  This  at  least  seemed  to  be 
the  case  with  a  patient  whom  I  saw  operated  on  at  the  hospital  St.  Louis,  in 
1822.  In  the  first  of  these  events,  i.  e.  when  it  is  known  directly,  either  by 
the  escape  of  gas,  or  the  passage  of  fecal  matters  or  urine,  that  the  rectum  is 
wounded,  and  the  division  is  extensive  enough  to  induce  the  belief  that  it  will 
end  in  fistula,  the  best  way  to  prevent  its  occurrence  is  to  slit  the  end  of  the 
perineum  and  of  the  intestine  to  the  anus.  Contraction  of  the  sphincter  being 
no  obstacle  to  the  free  passage  of  the  matters,  the  wound  generally  heals  up 
kindly,  and  almost  as  quickly  as  if  nothing  uncommon  had  happened. 

In  the  second  event — that  is,  when  some  days  elapse,  and  there  be  or  be 
not  any  loss  of  substance,  vesico-rectal  fistula  is  already  formed,  and  it  is 
not  impossible  that  it  may  disappear  spontaneously — we  should  wait  the  ordi- 
nary term  of  the  cure,  and  afterwards  treat  it  as  if  it  had  resulted  from  any 
other  cause.  Urethral  fistulae,  properly  so  called,  are  now  very  rare,  though 
still  sometimes  seen ;  but  whether  they  extend  directly  outwards,  or  only 
communicate  externally  by  the  intervention  of  the  anus,  their  treatment  is 
the  same  as  that  of  urinary  fistula,  which  will  be  discussed  in  a  separate 
article. 

Paralysis  of  the  Bladder. — Retention  of  urine,  caused  sometimes  by  clots 
of  blood,  swelling  of  the  wound,  inflammation  of  the  cervix  vesicae,  or  of  the 
prostate  syncope,  convulsions,  incontinence  of  urine,  inflammation  of  every 
sort  which  may  show  itself  during  or  after  cutting  for  stone,  require  no  fur- 
ther ti'eatment  than  that  generally  known  and  followed  in  the  case  of  these 
diseases.  The  wound  is  a  longer  or  shorter  time  in  closing.  The  urine  flows 
through  it  entirely  for  two,  three,  four,  or  five  days ;  and  then  the  patient, 
from  time  to  time,  experiences  the  inclination  to  void  it.  At  length  some 
drops  pass  through  the  urethra.  More  then  comes  through  it,  and  ultimately 
it  passes  entirely  by  the  natural  outlet  from  the  fifteenth  to  the  thirtieth  day. 
From  that  time,  the  perineal  opening  has  entirely  healed.  However,  it  is  not 
uncommon  to  find  them  follow  other  routes  in  tlieir  exit.  In  some  they  con- 
tinue to  escape  by  the  wound  for  two,  three,  four,  even  five  and  six  months,  so 
that  the  wound  may  in  reality  be  considered  as  a  fistula.  In  others, 
again,  the  wound  in  the  perineum  closes  directly,  or  in  eight  or  twelve  days. 
In  America,  Drs.  Physick,  Dorsey,  and  Copeland  have  each  seen  an  example 
of  this  occurrence.  Beclard  has  seen  several,  following  the  bilateral  cutting. 
Few  experienced  operators  have  not  seen  cases,  but  few  have  mentioned  so 
large  a  proportion  as  M.  Clot  d'Abou  Zabel,  either  after  lateralized  cutting, 
or  the  median  cutting  of  Vacca,  of  which  he  quotes  eleven  cases. 

Art.  2. — Recto-vesical  Operation  for  Stone  [Posterior  or  inferior). 

The  pains  which  surgeons  in  all  ages  have  taken  to  avoid  wounding  the  in- 
testinum  rectum,  in  the  performance  of  lithotomy,  is  of  itself  suflicient  to 
98 


77S  '  NEW   ELEMENTS   OF 

prove  how  very  far  they  were  from  wishing  to  establish  this  method  as  a  prin- 
ciple. It  is  accordingly  but  of  late  years  that  the  idea  has  suggested  itself 
to  practitioners,  and  M.  Sanson,  who  first  ventured  to  promulgate  it  in  1816, 
found  in  this  time-hallowed  prejudice,  one  of  the  most  powerful  opponents  to 
the  adoption  of  his  w^ay  of  thinking.  It  is  now  found  out,  that  the  extraction 
of  stones  by  the  rectum  is  not  an  entirely  new  practice.  M.  Jourdan,  amongst 
others,  has  noticed  that  Vegetius,  a  veterinary  surgeon  mentioned  by  Mai- 
ler, had  said  in  a  work  published  a  century  before  at  Basle,  "  jubet  per  vulnus 
recti  intestini  et  vesicas  aculeo  lapidem  ejicere."  A  mention  made  by  frere 
Come,  of  a  patient  who  had  a  recto-vesical  fistula  caused  by  stone,  and  who 
recovered  after  the  foreign  body  was  extracted  through  the  gut,  may  alsp  have 
served  as  the  basis  of  M.  Sanson's  theory.  The  splinter  taken  out  of  the 
bladder  by  enlarging  the  fistula  in  the  rectum  by  Camper,  is  a  new  proof 
which  might  have  been  made  available.  It  is,  moreover,  very  well  known, 
that  Desault  at  the  Hotel  Dieu  very  frequently  cured  recto-vesical  fistulas 
by  cutting  the  sphincter  ani  through,  so  as  to  create  a  wound  which  should 
extend  all  the  way  to  the  perineum.  It  must  be  added  that,  according  to  the 
statements  of  Dr.  Clot,  recto-vesical  cutting  has  been  practised  in  Egypt  from 
time  immemorial ;  he  has  seen  it  performed  by  empirics  who  are  very  numerous 
in  that  country,'  and  whose  knowledge  had  been  handed  down  from  father  to 
son  like  a  family  estate.  However,  as  no  one  among  us  had  established  the 
procedure  as  a  regular  one,  of  going  through  the  rectum  in  search  of  calculi 
ia  the  bladder,  M.  Sanson  deserves  to  be  fairly  considered  as  the  inventor  of 
"  recto-vesicaP^  cutting.  His  method,  which  was  never  much  advocated  in 
France>  England,  or  Germany,  was  in  Italy  almost  at  once  adopted  by  several 
surgeons  of  distinction,  among  others  by  Vacca,  Barbantini,  Farnese,  Giorgi, 
Guidetti,  Giuseppe,  Lancisi,  &c.  The  advantages  ascribed  to  it  by  its  in- 
ventor, are  those  of  being  more  easy,  less  painful,  of  opening  the  bladder  in 
the  largest  direction  of  the  pelvic  strait;  of  exposing  no  artery  to  be  wounded, 
and  of  allowing  of  the  extraction  of  the  very  largest  calculi.  But  with  us, 
the  dread  of  being  unable  to  close  up  the  communication  between  the  gut  and 
the  bladder  after  the  cure,  has  weighed  against  every  other  probable  advan- 
tage. Indeed,  up  to  this  period  this  operation  for  stone  has  not  been  per- 
formed in  our  country  above  some  thirty  times  by  MM.  Sanson,  Dupuytren, 
Peserat,  Castara,  Willaume,  Cazenave,  Dumont,  Taxil,  and  some  others. 
We  shall  be  enabled,  after  a  survey  of  the  parts  which  the  insti'ument  must 
encounter,  to  judge  of  what  hopes  may  reasonably  be  founded  upon  it. 

§  1.  Anatomical  Remarks. 

In  all  the  different  procedures  thus  far  advised,  the  cutting  instrument  acts 
only  in  the  interspace  which  separates  the  body  of  the  bladder  of  urine  from 
the  membranous  portion  of  the  urethra  as  it  enters  the  horizontal  aponeurosis 
of  the  pelvis.  It  is  therefore  this  part  of  the  urinary  passages,  and  that  part 
of  the  rectum  which  answers  to  them,  which  it  is  particularly  necessary  for  a 
surgeon  to  know. 

The  Bladder  considered  in  its  posterior  wall,  offers  its  trigonal  space  whose 
base  usually  looks  towards  the  recto-vesical  cul-de-sac  in  the  peritoneum, 
and  at  its  lateral  angles  receives  the  terminations  of  the  ureters.    The  length 


OPERATIVE  SURGERY.  779 

of  this  trigone  vesical  is  from  twelve  to  fifteen,  or  eighteen  lines  from  before 
backwards,  and  usually  two  inches  across.  On  the  median  line,  it  is  only 
separated  from  the  rectum  by  a  dense  lamellar  tissue,  which  expands  as  it 
goes  towards  the  sides,  where  the  vesiculae  seminales,  having  the  vas-deferens 
on  their  inner  edge,  come,  converging  towards  its  anterior  angle  to  divide  it 
from  the  rectum,  and  push  it  a  little  forward.  Its  anterior  angle,  which  forms 
the  entrance  of  the  urethra,  at  the  instant  of  its  engaging  in  the  prostatic 
cone,  give  origin  to  the  uvula  vesicae,  or  luete  vesicale,  which  continues  for- 
wards under  the  appellation  of  crista  urethraliSy  and  afterwards  under  that  of 
verumontanwn. 

That  portion  of  the  urethra  which  follows  it,  is  especially  remarkable  as 
connected  with  the  seminiferous  tubes  and  the  prostate  itself.  These  canals, 
which  open  sometimes  nearer,  and  sometimes  rather  further  from  the  median 
line,  but  in  such  a  way  as  never  to  be  more  than  a  line  apart  from  each  other 
in  a  natural  state  of  parts,  and  often  blending,  as  it  were,  upon  the  free  edge 
idf  tiie  verumontannm,  diverge  thence  and  insensibly  separate  as  they 
approach  the  termination  of  the  vesiculae  seminales;  that  is  to  say,  as  they 
come  towards  the  inferior  and  somewhat  lateral  surface  of  the  point  of  the 
trigonal  space,  where  they  are  four  or  five  lines  apart.  The  prostate  gland  just 
here  presents  frequently  at  its  inferior  surface  a  sort  of  groove  which  em- 
braces the  front  of  the  rectum.  The  ejaculatory  canals  cross  the  prostate 
from  behind  forwards,  from  within  outwards,  and  a  little  downwards  from 
above.  Its  thickness  upon  the  median  line,  is  only,  as  we  have  seen  already, 
from  five  to  seven  or  eight  lines,  and  sometimes  less.  Lastly,  its  posterior 
edge  extends,  in  certain  persons,  from  three  to  four  lines  back  of  the  urethra 
under  the  trigone,  so  as  to  form  a  knob  there,  the  importance  of  which  will 
hereafter  appear. 

The  rectum,  which  is  movable,  and  maintained  in  front  of  the  os  sacrum 
by  its  peritoneal  reflection,  a  little  to  its  left  in  the  upper  part,  presents  no 
interest  until  it  descends  far  enough  to  apply  itself  to  the  anterior  surface  of 
the  coccyx.  There  the  peritoneum  leaves  it,  to  mount  up  behind  the  blad- 
der, and  to  line  the  recto-vesical  excavation.  The  intestine  continuing  to 
advance  obliquely  and  downwards,  enters  into  contact  with  the  vesical  tri- 
gonal space,  with  the  ends  of  the  ureters,  with  the  vesiculae  seminales,  and 
with  the  vasa  deferentia.  When  it  has  got  beneath  the  prostate,  and  upon 
the  point  of  the  coccyx  it  is  enveloped  in  the  ring  of  the  sphincters,  of  the 
levator  ani  and  coccygeus  muscles;  it  changes  its  oblique  direction  to 
become  vertical,  and  end  in  the  anus.  As,  on  the  contrary,  the  urethra  at 
this  point  leaves  the  axis  of  the  body  to  pass  forward,  so  there  naturally 
results  a  larger  or  smaller  interspace  between  this  canal  and  the  rectum;  that 
interspace  of  which  we  took  notice  above;  and  which  after  its  two  principal 
limits — I  have  thought  might  be  called  redo-uretral  or  bulho-anal  triangle. 
There  are  eight  or  twelve  lines  from  the  opening  of  the  anus  to  the  top  of  the 
prostate.  Before  we  reach  the  tubercle  on  the  uppermost  edge  of  this  gland, 
is  a  distance  of  an  inch  and  a  half  to  two  inches  :  the  peritoneal  cul-de-sac 
being  separated  from  it  only  by  an  interval  of  twelve  to  fifteen  lines,  some- 
times of  six  or  eight  lines  merely,  as  I  have  seen  in  two  subjects,  as  M .  Senn 
has  seen  it  only  two  or  three  lines  in  width.  In  a  normal  state  in  the  young 
subject,  the  rectum  begins  to  contract  at  the  moment  it  passes  behind  the  neck 


Tffd  NEW   ELEMENTS  Or 

df  the  bladder,  and  above  this  point  forms  merely  a  cylindrical  canal  of 
gi'eater  or  less  size.  In  advanced  age,  or  in  persons  of  a  habitually  costive 
habit,  a  different  disposition  is  frequently  remarked 

In  the  first  place  this  intestine  may  oiFer  a  large  excavation,  -which  has 
more  than  once  been  seen  to  extend  on  either  side  of  the  prostate  and  trigone 
vesical,  so  as  almost  to  come  under  the  edge  of  the  knife  in  cutting  for  stone, 
either  lateralized  transversal  or  even  completely  lateral.  In  the  second 
place  it  may  also  enlarge  anew  after  it  has  passed  beyond  the  posterior  edge 
of  the  prostate  before  it  clears  the  sphincter  externus,  as  if  to  form  between^ 
the  anus  and  urethra  a  cul-de-sac,  which  in  traversing  the  recto -urethral 
triangle  in  bilateral  cutting  it  may  be  difficult  to  avoid. 

The  parts,  though  few,  which  exist  between  the  bladder  and  intestine, 
deserve  perhaps  a  passing  mention.  There  are  no  vessels  on  the  median 
line,  and  the  cellular  tissue  at  that  spot  is  almost  always  destitute  of  fat. 
Laterally  these  two  organs  being,  by  their  rounded  form,  drawn  in  opposite 
directions  must  leave  two  sorts  of  furrows,  larger  as  we  approach  nearer  the 
parietes  of  the  pelvis.  These  furrows  contain,  besides  the  vesiculss  seminales, 
vasa  deferentia,  and  ends  of  the  ureters,  and  below  the  posterior  angles  of 
the  prostate,  an  exceedingly  lax  lamellar  tissue,  particularly  outwardly,  where 
it  is  continuous  with  the  rest  of  the  pelvic  cellular  tissues ;  oftentimes  some 
fat,  some  arteriolse  and  vesicles  which  pass  upon  the  sides  of  the  neck  of  the 
bladder  and  the  forepart  of  the  intestine. 

§  2.  Methods  of  Operation. 

Upon  this  principle,  M.  Sanson  ascertained  that  recto-vesical  cutting  might 
be  performed  in  two  distinct  ways ;  one  in  which  the  prostate,  urethra,  and 
inferior  extremity  of  the  rectum  alone  are  divided  ;  another,  in  which  at  the 
same  time  the  bas-fond,  or  rather  the  trigone  vesical,  and  the  intestine  are 
attacked,  so  as  to  save  the  two  anterior  thirds  of  tlie  gland.  In  Italy,  Vacca 
and  M.  Barbantini  decided  at  once  upon  the  former,  so  as  in  a  measure  to 
'  appropriate  it  to  themselves.  Geri,  Guidette,  &c.  attached  themselves  to 
the  second  way,  on  which  M.  Sanson  himself  had  laid  most  stress.  Upon 
the  whole,  there  is  no  great  difference  in  performing  them. 

Procedure  the  first. — The  staff  held  by  an  assistant  is  to  press  accurately 
upon  the  median  line,  so  as  to  depress  the  anterior  face  of  the  rectum.  The 
surgeon  introduces  the  left  forefinger  to  a  depth  of  ten  lines  into  the  anus; 
turns  the  pulp  forwards  and  the  nail  backwards;  slips  in  flatwise  upon  this 
finger  a  sharp  bistoury  two  inches  long;  plunges  its  point  into  the  groove  of 
the  staff,  having  first  turned  its  cutting  edge  upwards ;  then  he  raises  his  right 
wrist  and  cuts  from  behind  forwards,  that  is  to  say  from  anus  to  urethra,  the 
lower  part  of  the  sphincter  externus,  and  also  all  the  parts  contained  in  the 
recto-urethral  triangle,  drawing  his  bistoury  with  strength  towards  the  bulb. 
He  then  seeks  to  recognize  at  the  bottom  of  the  wound  the  point  of  the 
prostate,  and  places  his  finger  upon  the  groove  of  the  staff*  through  the  mem- 
branous portion  of  the  urethra,  its  cubital  edge  being  towards  tlie  symphysis 
pubis,  the  nail  towards  the  left  ischion.  The  same  bistoury,  held  like  a  pen, 
18  then  plunged  into  the  groove  of  the  staff,  and  slid  along  it  into  the  bladder. 
It  is  then  withdrawn,  lowering  the  hand  a  little,  so  as  to  divide  almost  the 


OPERATIVE   SURGERY.  T9t 

whole  of  the  prostate,  and  such  soft  parts  as  may  have  escaped  in  the  first 
incision.  By  this  means  the  sphincter  externus,  the  interlacing  of  the  fibres 
of  the  transversi  and  bulbo  cavernosus  muscles,  the  seat  of  junction  of  the 
fibrous  laminae  of  the  perineum,  the  membranous  portion  of  the  urethra,  the 
prostate  from  top  to  bottom  on  its  lower  surface,  and  the  forepart  of  the 
rectum  beneath  the  trigonal  space,  are  divided.  One  ejaculatory  duct  also  is 
likewise  comprehended  in  the  incision,  for  chance  alone  would  so  unerringly 
direct  a  bistoury  on  the  median  line  as  that  it  should  pass  directly  between 
them.  If,  as  is  easy  enough  to  happen,  the  incision  deviate  to  one  side,  it 
will  soon  strike  upon  a  distant  part  of  this  canal,  and  might  even  touch  the 
end  of  the  vas  deferens,  or  even  on  the  inferior  end  of  the  vesiculae  seminales 
of  the  same  side.  No  considerable  artery  presents  itself,  not  even  the 
abnormal  branches  indicated  when  speak'ng  of  cutting  through  the  perineum. 

The  Italian  professor  advises  instead  of  the  procedure  of  M.  Sanson,  that' 
the  index  finger  be  so  applied  upon  one  surface  of  the  bistoury,  the  handle  of 
which  is  enclosed  in  the  hand,  as  that  its  fleshy  part  pressing  a  little  upon  the 
instrument  may  entirely  cover  its  point;  that  it  be  carried  in  this  way  to  the 
required  depth ;  that  when  this  is  done,  the  cutting  edge  of  the  bistoury  be 
turne^^orwards,  so  that  the  finger  may  be  placed  on  the  back  of  the  blade, 
and  the  section  of  tissues  performed  at  one  stroke,  as  was  before  stated.  The 
left  fore-finger  remaining  unengaged  feels  for  the  groove  in  the  staff,  in  order 
that  the  bistoury,  whose  cutting  edge  must  then  look  downwards,  may  be 
directed  on  the  membranous  portion  of  the  urethra,  and  from  before  back- 
wards; that  is  to  say,  in  an  opposite  direction  to  that  which  until  then  it  had 
pursued  to  cut  the  prostate  and  tubercle  at  the  vesical  orifice. 

Procedure  tlte  Second. — The  first  incision,  which  is  commenced  rather  higher 
up,  does  not  end  as  near  the  bulb  of  the  urethra  as  in  the  first  procedure. 
The  left  fore-finger  pressed  into  the  wound  no  longer  seeks  to  recognize  the 
point  of  the  prostate  but  its  "base;  and  the  bistoury  to  strike  the  groove  of 
the  staff  is  to  be  passed  in  on  a  level  with  its  posterior  edge,  or  at  most  of  its 
two  lower  with  its  upper  third.  It  is  then  pushed  on  into  the  bladder,  so  as 
to  open  the  inferior  wall  for  about  an  inch  by  withdrawing  it  from  before 
backwards  and  rather  downwards  from  above.  The  solution  of  continuity 
involves,  when  this  method  is  adopted,  the  same  parts  as  the  preceding,  so 
far  as  the  first  incision  is  concerned.  The  second  stage  of  the  ope- 
ration on  the  contrary  saves  a  portion  of  the  urethra  and  of  the  prostate 
at  the  place  where  the  seminal  canals  touch,  and  which  they  cross,  wounds 
instead  the  trigonal  space,  and  approximates  nearer  the  recto-vesical  excava- 
tion. Should  the  incision  not  be  exactly  in  the  median  line,  it  .may  involve 
the  ejaculatory  ducts,  the  seminal  vessels,  the  vasa  deferentid,  and  even  if 
tiie  deviation  is  very  great,  the  ureter.  It  is  evident  also  that  the  peritoneum 
runs  great  risk,  and  that  if  it  dips  down  lower  than  common  it  will  not 
escape.  It  must  be  remarked  also,  that  according  to  the  direction  given  the 
bistoury  as  it  is  withdrawn,  the  wound  should  be  more  of  the  bladder  than  of 
the  rectum ;  be  much  longer  consequently  above  the  inner  surface  of  the  first 
than  the  second  of  these  organs ;  so  tliat  the  mucous  membrane,  and  a  large 
part  of  the  fleshy  membrane  even  of  the  rectum,  comes  down  in  the  form  of  a 
valve  several  lines  beneath  the  wound  in  the  bladder.  Some  Italian  surgeons 
endeavored  to  perfect  M.  Sanson's  operation  by  placing  some  dilating  instru- 


782*  NEW  Elemi:nts  of 

ment  within  the  rectum.  M.  Geri,  for  example,  had  contrived  a  large  gorget 
for  this  purpose.  At  first,  this  modification  did  seem  to  fulfill  the  end  of 
guarding  against  this  movableness  of  tissues^  against  which  M.  Pezerat  had 
so  much  difficulty  in  struggling  in  the  recto-vesical  cutting  which  he  per- 
formed, and  to  render  its  incision  nearly  less  difficult.  However,  Vacca 
opposed  it  very  violently,  and  it  is  indeed  soon  seen  by  reflection  that  it 
must  needs  augment  the  difficulty  of  the  operation. 

But  lithotomy  per  rectum  is  not  alone  to  be  objected  to  on  account  of  the 
difficulty  of  its  execution;  and  no  amelioration  proposed  in  this  respect  deserves 
any  very  great  attention. 

We  can,  I  think  if  it  is  wished,  estimate  the  value  of  the  recto-vesical 
operation  for  stone  without  difficulty.  Its  greatest  and  most  indisputable 
advantage  is  that  it  guards  wholly  against  hemorrhage  :  first,  because  there 
are  no  vessels  naturally  located  between  the  parts  which  are  divided  :  secondly, 
because  no  vessels  springing  from  anatomical  anomalies,  have  ever  been  de- 
tected in  them.  The  second  advantage  is,  that  it  is  extremely  simple.  But'. 
upon  this  point  let  us  not  be  deceived.  Division  of  the  mucous  membrane 
of  the  anus,  rectum,  and  posterior  portion  of  the  perineum,  is  in  certain 
persons  attended  with  all  the  difficulty  of  which  M.  Pezerat  speaks,  whatever 
precautions  may  have  been  taken  to  make  tense  the  tissues. 

In  the  third  place,  it  may  be  urged  as  an  objection  to  those  who  attribute  to 
it  the  making  of  so  easy  an  exit  for  the  urine,  as  that  infiltration  is  never  to 
be  feared ;  that  the  recto-vesical  septum  being  pulled  about  by  the  instruments 
or  the  stone  during  the  operation,  is  of  such  a  nature  as  softietimes  to  detach 
itself,  and  then  we  can  see  nothing  to  render  infiltration  of  some  drops  of 
urine  into  the  surrounding  cellular  tissue  impossible.  Besides  which,  this 
infiltration  almost  necessarily  occurring  above  the  pelvic  aponeurosis  will 
very  soon  spread  to  all  the  sub-peritoneal  cellular  tissue  of  the  organ. 

Its  advantages  of  allowing  passage  to  enormo,us  calculi,  and  of  admitting  of 
a  very  extensive  incision,  may  with  equal  propriety  be  disputed.  In  my 
opinion  it  is  a  serious  error  to  attribute  this  difficulty  to  the  degree  of  separation 
between  the  bones.  No  more  than  Scarpa  can  I  conceive  how,  in  any  method 
of  cutting  the  inferior  strait  when  of  regular  formation  can  impede  the 
extraction  of  a  stone.  The  difficulty  always  arises  from  the  opening  into  the 
bladder.  When  this  is  made  only  upon  the  bas-fond,  it  is  not  possible  to  give 
it  an  extent  of  more  than  twelve  or  fifteen  lines,  because  there  is  this  distance 
only  between  the  prostate  and  the  peritoneal  cul-de-sac.  What,  then,  is  the  ad- 
vantage, when  we  can  obtain,  in  bilateral  cutting  for  example,  an  opening  of 
from  fifteen  to  twenty  lines  ?  If  the  incision  is  confined  to  the  prostate  with 
the  hope  of  exceeding  its  bounds,  the  division,  supposing  it  at  its  extreme 
length,  can  be  only  eight  or  twelve  lines.  If  we  go  beyond  this,  necessarily 
we  exceed  and  cut  the  edge  of  the  gland,  since  in  this  direction  its  radius  is 
but  six  or  seven  lines.  Were  the  two  procedures  to  be  combined,  the  opening 
might  be  of  an  extent  of  an  inch  and  a  half  or  a  couple  of  inches.  Thus  far, 
this  has  not  been  proposed  by  any  one ;  and  besides,  the  bilateral  cutting 
again  is  calculated  to  produce  a  very  extensive  division.  Finally,  if  the  rule 
be  po  longer  adopted  which  advises  us  to  confine  the  incision  to  the  circle  of  the 
prostate,  it  is  evident  that  by  the  bilateral  method  we  can  cut  the  neck  of  the 
bladder  on  either  side,  and  so  produce  a  wound  of  two  inches  or  two  inches 


OPERATIVE   SURGERY.  785 

and  a  half  wide ;  which  it  would  be  impossible  to  do  on  recto-vesical  cutting, 
unless  bj  a  voluntary  exposure  of  the  peritoneum. 

It  appears  that  in  speaking  of  this  operation  something  has  been  attributed 
to  the  division  of  the  perineum  and  membranous  portion  of  the  urethra. 

The  same  error,  moreover,  occurs  in  almost  ever  j  discussion  relative  to  the 
other  methods  of  cystotomy.  But  it  is  easy  to  satisfy  oneself,  that  the  enlarge- 
ment of  the  posterior  opening  of  this  canal  alone  can  enter  into  the  account* 
Enlarge  it  directly  backward,  and  you  never  will  obtain  more  than  an  opening 
of  seven  or  eight  lines  without  going  beyond  the  prostate,  whether  your  ex- 
ternal incision  is  confined  to  the  perineum  or  whether  it  at  the  same  time 
comprises  the  extremity  of  the  rectum.  If  you  prolong  it  an  inch  or  an  inch 
and  a  half,  you  will  cross  the  whole  length  of  the  trigone  vesicale,  and  give 
your  wound  only  an  extent  of  two  inches,  while  you  incur  the  utmost  risk  of 
cutting  the  peritoneum.  On  the  contrary,  the  double  oblique  incision  allows 
of  our  going  as  far  as  twenty  and  some  lines  over  without  encroaching  on  the 
summit  of  the  bladder,  and  if  we  are  not  afraid  to  exceed  the  prostatic  limits, 
it  may  be  yet  much  further  increased  evidently  than  by  the  posterior  method. 

As  to  injury  of  arteries,  it  is  well  to  inquire  if  it  can  counterbalance  the 
danger  of  recto-vesical  fistulae. 

In  transverse  cutting,  it  is  almost  certain  that  bleeding  will  not  occur 
once  in  a  hundred  times.  Recto-vesical  cutting  is  followed  by  fistula  urinaria 
at  least  once  in  four  or  five  times. 

The  hemorrhage  is  far  from  proving  always  fatal.  Fistula  is  a  disgusting 
infirmity ;  for  the  most  part  an  incurable  one. 

So  far  recto-vesical  cutting  has  been  followed  by  almost  as  great  a  propor- 
tion of  deaths  as  the  operations  performed  upon  the  perineum. 

It  has  the  special  disadvantage  of  inevitably  cutting  one  of  the  ejaculatory 
ducts.  Experience  proves  that  it  is  often  succeeded  by  swelling  and  other 
serious  disease  of  the  testicles.  The  peritoneal  reflexion  had  been  opened 
into  in  one  of  M.  Geri's  patients.  Out  of  six,  M.  Janson  of  Lyons  lost 
two ;  in  whom  the  intestine  was  acutely  inflamed.  It  is  stated  by  authors 
that  the  bladder  is  often  inflamed  owing  to  the  entrance  of  stercoraceous  mat- 
ter into  it.  Scarpa  states  that  in  two  patients  seen  by  him,  it  was  gangrenous. 
The  vesiculae  seminales  have  also  been  opened  into.  Abscesses  ^vithin  the 
pelvis  have  many  times  been  met  with.  In  short,  out  of  one  hundred  opera- 
tions performed  in  this  way  up  to  the  present  time  by  MM.  Sanson,  Dupuy- 
tren,  Camoin,  Pezerat,  Willaume,  Cazenave,  Dumont,Urbain,  Sanson,  Taxil, 
Barbantini,  Vacca,  Geri,  Guidetti,  Farnese,  Giorgi,  Giuseppe,  Cittadini,  Mori, 
Lancisi,  Castaldi,  Cavarra,  Regnoli,  Baiidiere,  Sleihg,  Clot,  and  Wenzel, 
twenty  deaths  are  enumerated,  as  many  fistulas,  and  other  occurrences  which 
have  endangered  the  lives  of  some  of  the  patients. 

Upon  the  whole,  recto-vesical  cutting  seems  to  have  no  real  advantages  over 
bilatei-al  cutting;  so  much  so,  that  if  it  were  decided  that  the  latter  was  in- 
sufficient, it  would  perhaps  be  better  to  cut  above  the  pubis  than  through  the 
rectum.* 

*  I  have  been  equally  unsuccessful  with  M.  Civiale  in  ascertaining  whether  it  be  true,  as  M. 
Wessely  assured  me  it  was,  that  vesico-rcctal  cutting  had  been  invented  in  Germany  in 
1813. 


784  NEW  ELEMENTS  Of 


Art.  3. — Hypogastric  Operation  for  Stone. 

The  idea  of  opening  into  the  bladder  above  the  pubis,  for  the  purpose  of 
removing  calculi  from  it,  is  not  formally  expressed  by  any  ancient  author.    It 
appears  certain  that  Philagrius  of  Thessalonica,  in  advising  an  incision  '^sm- 
perne  juxta  glandis  magnitudinem/^  meant  merely  to  speak  of  calculi  which 
were  stopped  in  the  urethra,  and  that  his  only  object  in  opening  the  back  of 
the  penis  was  to  prevent  fistulae,  which  were  much  more  to  be  feared  from 
cutting  into  the  inferior  wall  of  the  excretory  duct  of  the  urine.    On  the 
other  side,  I  do  not  see  upon  what  authority  Mr.  Samuel  Cooper  thinks  that 
the  operation  performed  by  M.  CoUot,  1475,  has  any  reference  to  hypogastric 
cutting  rather  than  to  nephrotomy,  or  to  any  thing  else  which  he  pleases.  The 
merit  of  it  incontestably  belongs  to  Franco ;  however,  this  surgeon  was  induced 
to  do  it  from  necessity  in  spite  of  himself,  and  sedulously  forbids  others  to  fol- 
low his  example.    Rousset  or  Rosset,  in  1581,  who  gave  a  labored  description 
of  it  twenty  years  after  the  publication  of  Franco's  book  on  the  subject,  is 
consequently  the  first  person  who  positively  recommended  and  endeavored  to 
establish  its  general  adoption  as  an  operation.     Still,  from  what  he  says,  it 
might  almost  be  supposed  that  other  practitioners  cotemporary  with  him  had 
likewise  alluded  to  it.    Be  this  as  it  may,  Henry  III,  who  had  promised  to 
give  into  his  hands  three  or  four  criminals  as  an  experiment,  having  died, 
Rousset  could  never  perform  it  on  the  living  subject ;  and  since  him  no  one 
seems  to  have  thought  of  it,  until  1635,  in  which  year  Mercier  defended  it 
before  the  Faculty  of  Paris,  in  a  thesis   by  Nicolas  Pietre.     At  length 
some  surgeons  adopted  it,  and  Collot  relates  that  in  1681  Bonnet  performed 
it  before  Petit  at  the  Hotel  Dieu  with  entire  success.  Proby,  failing  to  extract 
a  stone  by  the  usuai  methods,  had  likewise  recourse  to  it  some  years  after- 
wards ;  and  Groenvelt  publicly  advocated  it  in  a  work  published  in  London 
in  1710.     So  little  was  it  generally  known,  however,  that  Douglas  of  Dublin, 
in  1718,  for  a  short  time  considered  himself  as  its  discoverer.    The  success 
derived  from  it  by  the  last  named  surgeon,  having  opened  the  eyes  of  the 
profession,  and  forthwith  engaged  the  attention  of  Cheselden,  Macgill,  Thorn- 
hill,  Middleton,  Bamber,  and  Pye,  in  England ;  and  of  Morand,  who  per- 
formed it  at  the  Hospital  of  Invalids,  May  27,  1727,  on  an  officer  sixty-eight 
years  old,  and  saw  it  done  on  the  10th  of  December  following  at  St.  Germain 
en  Laye  by  Berier  on  a  child  named  L.  Amon,  four  years  of  age.    It  was 
likewise  practised  by  J.  Robert,  Sermes,  Kulmus,  Heuermann,  and  particu- 
larly by  Heister,  who  caused  it  to  be  defended  in  a  thesis  sustained  by  Weise 
at  Helmstadt  on  the  8tli  of  December,  1728,  and  who  obtained  reports  of 
cases  of  it  from  Runge  and  Praebisch,  so  that  it  seemed  almost  about  to  meet 
with  general  adoption.     Cheselden,  in   1727,  had'  performed  it  upon  six 
patients  with  the  loss  of  only  one ;  Douglas,  with  a  similar  loss  out  of  nine 
persons  who  underwent  it ;  Thornhill  lost  tv/o  persons  out  of  twelve ;  Mac- 
gill  one  in  four.    Notwithstanding  the  numerous  eftbrts  excited  by  the 
appearance  of  frere  Jacques's  method,  this  operation  was  soon  abandoned 
and  it  had  almost  ceased  to  be  thought  of  when  frere  Come  in  turn  un- 
dertook its  readoption  in  1775.  Since  then  it  has  been  advocated  by  Leblanc 


*  OPJERATIVE    SURGERY.  f^S 

of  Orleans,  and  Bazeilhac,  and  Lassus,  and  also  MM.  Deschamps,  Dupuy- 
tren,  Roux,  Boyer,  de  Guise,  and  several  others  have  performed  it,  but 
merely  as  an  exception  and  not  as  a  general  rule.  Notwithstanding  every 
defence  made  for  it,  and  the  numerous  instances  of  success  obtained  in  France 
by  M.  Souberbielle,  tlie  inheritor  of  the  principles  of  Come  and  Barzeilhac, 
the  high  apparatus  relapsed  into  dis-use,  until,  ovv^ing  to  some  proposed  im- 
provements  by  MM.  Scarpa,  Dupuytren,  Sir  Edward  Home,  and  Gelher  it 
has  a  third  time  been  attempted  to  set  forth  its  advantages,  and  to  substi- 
tute it  for  the  perineal  methods  of  operating.  It  consists  in  an  incision  of  the 
anterior  surface  of  the  bladder  through  the  wall  of  the  abdomen. 

§  1.  Anatomical  Remarks. 

In  all  the  operations  for  stone  done  by  the  lower  apparatus,  the  instrument 
can  arrive  at  the  bladder  only  by  exposing  very  important  organs  to  injury ; 
and  such  is  the  distribution  of  parts,  that  tliey  will  not  always  allow  of  an 
opening  large  enough  to  permit  the  passage  of  bulky  stones.  On  the  contrary. 
It  seems  that  by  opening  into  the  bladder  through  the  hypogastrium,  there  is 
scarcely  any  risk  to  be  apprehended,  and  that  it  will  always  be  practicable  to 
make  the  Incision  of  the  tissues  of  any  required  dimensions. 

The  empty  bladder,  taken  together,  forms  in  the  adult  male  a  conoidal 
pouch,  whose  summit  extends  through  the  medium  of  the  urachus  tov/ards 
the  umbilicus ;  and  whose  base  descends  upon  the  rectum,  forming  a  curve 
below  the  pubis  to  give  origin  to  the  urethra.  It  has  often  since  the  time 
of  Celsus  been  repeated  that  it  inclines  a  little  to  the  right.  The  ancient 
latin  dogmatist  having  confined  himself  to  this  simple  assertion  on  the  subject, 
some  of  his  commentators  suppose  that  the  summit,  and  others  that  the  fundus 
is  to  lean  towards  the  left.  I,  like  my  predecessors  adopted  this  same  idea 
of  the  inclination  of  the  bladder  in  an  earlier  work ;  but  I  have  since  satisfied 
myself  that  the  appearance  has  been  taken  for  the  reality.  The  urachuf* 
invariably  terminates  its  summit,  and  the  urachus  is  invariably  placed  behind 
the  median  line.  Again,  the  urethra  is  placed  exactly  in  the  direction  of  the 
axis  which  separates  the  body  into  two  halves,  and  never  in  a  natural  state 
leans  more  towards  the  right  than  towards  the  left.  The  bladder  then 
stretched  between  the  urethra  and  the  urachus  inclines  neither  from  above 
downwards,  nor  from  below  upwards,  nor  from  right  to  left.  The  errors  on 
this  subject  may  ahme  have  been  caused  by  its  connection  with  the  rectum. 
In  fact  the  defecator  organ  does  push  it  more  sometimes  in  one  direction 
than  in  the  other,  whence  it  happens  that  it  appears  more  dilated,  wider, 
more  inclined  in  short  in  that  direction  in  which  it  is  least-frequentiy  and 
least  powerfully  depressed.  Now,  as  the  rectum  is  generally  to  the  left  before 
it  engages  beneath  the  prostate,  it  clearly  appears  why  the  body  of  the  bladder, 
naturally  in  relation  with  this  part  of  the  digestive  tube,  should  seem  to  lean 
a  little  from  left  to  right  in  a  line  from  the  urachus  to  the  prostate. 

From  these  remarks  it  follows  that  as  it  respects  the  position  of  the  reservoir 
of  urine,  perineal  operations  for  stone  may  indifferently  be  excuted  on  either 
the  right  or  left  sides  ;  and  that  in  the  other  niethods  an  incision  along  the 
median  line  of  the  body  is  sure  to  discover  its  vertical  axis. 

The  peritoneum,  by  which  the  bladder  is  partiallv  enveloped,  deserves  here 
99 


786  NEW  ELEMENTS  OP 

our  most  serious  consideration.  After  having  covered  its  entire  posterior 
region,  and  its  summit  (which  is  its  fundus  when  distended),  it  separates  from  it 
on  a  level  with  the  upper  strait  to  spread  over  the  hypogastric  portion  of  the 
parietes  of  the  abdomen.  During  its  distension,  as  it  fills  the  bladder  crowds 
back  this  membrane  gradually,  so  as  to  leave  it  at  a  distance  of  an  inch,  or 
even  two  inches  from  the  upper  edge  of  the  pubis;  hence  its  adhesions  at 
this  spot  are  very  feeble.  The  peritoneum  is  separated  from  the  symphysis 
pubis,  in  the  hypogastric  region,  by  an  interval  so  much  the  larger  as  it  is 
examined  nearer  to  the  neck  of  the  bladder;  which  interval  is  filled  by  an 
extremely  distensible  lamellar  cellular  tissue,  which  is  habitually  much  loaded 
with  fat.  This  tissue  which  is  no  other  than  a  portion  of  the  general  fascia 
propria,  presents  about  the  same  character  as  it  does  in  the  fossa  iliaca  and 
behind  the  attached  edges  of  all  the  folds  of  the  mesentery. 

In  most  subjects,  it  terminates  in  giving  strong  adhesions  to  the  peritoneum ; 
particularly  as  we  approach  the  junction  of  the  two  upper  thirds  with  the 
lower  third  of  the  space  which  divides  the  pubis  from  the  umbilicus.  These 
adhesions  more  speedily  contract  outwardly  toward  the  iliac  regions  than 
upon  the  median  line.  Thus  the  anterior  face  of  the  bladder  is  separated  from 
the  symphysis  pubis  merely  by  the  lamellar  adipose  tissue  of  which  I  have 
just  spoken.  This  pouch,  when  it  rises  above  the  upper  strait  is  at  once  in 
contact  with  the  posterior  surfaces  of  the  recto  muscles,  or  of  their  aponeurosis, 
without  any  interposition  of  the  peritoneum;  and  it  is  consequently  possible 
to  open  into  it  through  this  spot,  without  cutting  its  serous  covering.  Be  it 
observed,  that  between  the  symphysis  and  it  there  are  neither  arteries  nor 
veins,  nor  other  important  parts  to  be  avoided ;  but  let  it  be  remarked  also 
that  the  slightest  traction  or  effort  is  sufficient  to  detach  it,  and  thus  to  create 
a  cavity  more  or  less  wide  and  deep  between  the  bladder  and  outline  of  the 
pelvis. 

JTie  Walls  of  the  Belly  consist  in  the  region  now  under  consideration,  of 
parts  which  it  is  easy  to  remember.  The  skin  here  is  covered  with  hairs,  is 
not  very  movable,  and  of  considerable  density,  especially  at  its  lower  part, 
at  which  it  would  be  difficult  to  follow  Middleton's  advice,  of  pinching  it  up 
into  a  fold  before  cutting  it.  The  cellular  layer  here  becomes  a  fatty  puni- 
cuius  or  membrane  which  often  acquires  a  thickness  of  an  inch  or  more.  In 
it  we  find  sometimes  veins  of  some  size,  and  some  twigs  from  the  cutaneous 
arteries,  and  from  the  superior  pudica  externa.  The  aponeurosis  from  the 
external  oblique,  joined  to  the  anterior  lamina  of  the  internal  oblique,  ter- 
minates in  it,  as  in  the  remainder  of  its  extent  upon  the  linea  alba. 

The  muscles  which  are  found  here  are  the  pyramidales,  the  terminations  of 
the  sterno-pubic,  and  much  more  outwardly  a  slender  portion  of  the  abdominal 
oblique  muscles,  which  are  not  at  present  to  engage  our  attention.  The  recti 
muscles  which  are  divided  from  each  other  by  the  linea  alba  are  in  more  than 
one  respect  remarkable.  Their  tendon  growing  more  flat  contracts  more  and 
more,  is  much  thinner  outwardly  than  within,  in  such  a  way  as  that  as  it 
comes  to  be  inserted  upon  the  edges  of  the  ossa-pubis  near  the  skin,  it  leaves 
a  portion  of  these  bones  uncovered  behind,  and  inwardly  projecting.  The 
outer  edge  of  this  tendon  being  very  thin,  and  continuous  with  the  aponeurosis 
oblique  muscles,  the  parietes  of  the  abdomen  are  infinitely  less  thick  at  a 
distance  of  two  inches  outwards  from  the  symphysis  than  on  a  level  even 


OPERATIVE  SURGERY.  78" 

with  the  recti  muscles,  and  it  has  been  thought  possible  to  arrive  at  the 
bladder,  by  penetrating  them  just  at  this  spot.  Their  posterior  surface  is 
covered  by  a  layer  of  adherent  cellular  tissue  to  a  certain  point  analagous  to 
the  deeper  lamellas  of  the  fascia-superficial  is  in  general.  On  the  median  line 
they  are  divided  from  each  other  by  a  fissure  which  deepens  more  and  more 
in  proportion  as  we  descend  towards  the  strait.  When  it  has  reached  the 
pubis,  the  fissure  becomes  a  triangle  whose  base  is  downwards,  in  which  exists 
abundance  of  cellular  tissue  and  fatty  flakes,  such  as  were  spoken  of  a  sKort 
time  previously. 

The  epigastric  artery,  the  only  important  vessel  which  is  observed  in  the 
thickness  of  the  layers,  reaches  the  edge  of  the  recti  muscles  to  penetrate  the 
fibres  on  a  level  with  a  line  drawn  transversely  from  one  external  superior 
spine  of  the  ileum  to  the  other.  As  it  gives  off  no  branch  of  any  size  which 
goes  towards  the  median  line,  we  need  not  fear  to  wound  it  in  cutting  through 
the  hypogastrium,  unless  that  in  the  desire  to  penetrate  into  the  little  aponeu- 
rotic space,  which  is  bounded  within  by  the  tendon  of  the  rectus  muscle, 
below  by  the  ligament  of  Fallopius,  and  outwardly  by  an  imaginary  line 
which  the  artery  would  represent,  the  incision  had  been  made  a  good  deal  too 
much  towards  the  fossa-ilraca. 

The  spermatic  cord  passing  in  an  opposite  direction  and  lying  at  a  still 
greater  distance  is  equally  shielded  from  danger.  In  going  regularly  through 
the  different  layers  of  the  wall  of  the  abdomen,  we  shall  encounter  beneath 
the  common  integuments  upon  the  median  line,  1st,  the  cellulo-adipose 
cushion ;  2d,  the  linea alba, three  or  four  lines  thick,  the  pubio-vesical  triangle ; 
Sd,  the  cellular  tissue,  which  in  this  region  is  very  abundant ;  4th,  the  anterior 
surface  of  the  bladder. 

A  little  to  one  side  we  meet  with,  1st,  the  very  thick  external  aponeurosis; 
2d,  the  pyramidalis  muscles ;  3d,  a  thinner  fibrous  layer  separating  these 
muscles  from  the  recti;  4th,  these  last  named  muscular  masses,  sheathed 
behind  by  a  very  thin  fascia ;  5th,  the  fascia-propria,  or  lamellar  tissue  as  above 
described.  More  outwardly  still,  the  united  aponeurosis  of  the  three  wide 
muscles  of  the  abdomen  alone  offer  for  division  before  we  come  to  the  sub- 
peritoneal cellular  tissue. 

The  arrangement  of  the  pubis  is  another  point  which  tlie  operator  must  ever 
bear  in  mind.  At  the  symphysis,  they  are  in  general  not  more  than  an  inch 
and  a  half  or  two  inches  high ;  so  that  unless  they  be  extremely  short,  the 
anterior  surface  of  the  reservoir  of  urine  may  easily  be  brought  to  their  upper 
edge.  The  convexity  of  the  form  of  the  ossa-pubis  from  above  downwards 
is  the  reason,  consequently,  why  it  is  easy  to  make  a  stone  slip  in  a  contrary 
direction  from  the  bladder  outwards,  and  why  it  is  advantageously  employed 
as  a  fulcrum  for  lithotomic  instruments,  and  why  the  wall  of  the  bladder 
may  without  difficulty  be  cut  as  far  as  their  lower  edge,  that  is,  from  the 
cervix  vesicse  or  to  the  prostate.  Their  body  increasing  in  thickness, 
becoming  larger  and  larger  as  we  retreat  from  the  median  line,  it  results 
contrary  to  what  M.  Drivon  asserts,  that  the  bladder  is  furtlier  from  the 
integuments  as  we  approach  the  fossa-iliaca  of  either  side,  and  that  if  the 
converse  can  be  admitted,  we  should  act  upon  the  sort  of  vacuum  apparently 
|.  created  by  the  vesico-pubal  triangle.  Sex  and  age  induce  some  changes  of 
structure  in  the  arrangement  of  parts  which  we  have  now  described.    In  the 


^88 


NEW  ELEMENTS  OF 


female  the  symphysis  being  shorter,  and  the  bladder  naturally  raised  up  by 
the  vagina  and  matrix,  it  is  usually  higher  above  the  pubis  than  in  the  male. 

It  happens  besides,  as  a  consequence  of  frequent  deliveries,  that  it  enlarges 
transversely,  so  as  that  almost  it  may  be  said  it  divider  into  lateral  portions, 
and  that  it  might  be  opened  on  the  side  with  less  danger  than  in  the  other 
sex.  To  these  shades  of  difference  has  been  attributed  the  greater  success 
obtained  in  women  from  this  operation  than  in  men.  In  youth  the  narrow- 
ness of  the  pelvis,  the  lowness  of  the  symphysis,  the  smallness  of  curve  in  the 
sacrum,  the  relatively  great  bulk  of  the  rectum,  the  considerable  length  of  the 
bladder  conspire  to  raise  this  latter  organ  very  high  above  the  superior  strait 
generally,  and  so  its  anterior  face  may  be  widely  opened  into,  without  any 
danger  of  dividing  the  serous  membrane.  It  will  be  conceded  nevertheless, 
that  numerous  anomalies  and  changes  of  a  pathological  character  may  alter 
these  particulars,  and  invalidate  the  justness  of  the  assertion  which  I  have 
now  made. 

§  2.  Examination  of  the  Methods  of  Performing  it. 

Fewer  procedures  have  offered  for  the  high  apparatus  than  for  perineal 
cutting,  and  the  methods  which  belong  to  it  can  only  be  regarded  as  modifi- 
cations of  each  other.  I  shall  consider  them  under  three  principal  heads 
to  analyze  them  more  in  order;  1st,  that  mode  in  which  you  operate  with- 
out a  staff  being  previously  introduced  ;  2d,  that  in  which  the  very  reverse 
is  done;  3d,  that  which  differs  from  either,  in  having  an  accessory  opening 
made  beneath  the  pubis. 

1.  The  Method  of  Roussct. — The  first  plan  laid  down  for  performing  hypo- 
gastric cutting,  is  that  which  Rousset  has  described.  He  began  by  injecting 
barley  water,  tepid  water,  milk,  or  some  vulnerary  decoction  into  the  blad- 
der, so  that  by  its  distension  it  might  rise  above  the  pubis.  The  penis  of  tlie 
])atient  was  either  tied  or  held  by  an  assistant,  to  prevent  the  fluid  from  flow- 
ing out  against  the  wish  of  the  operator.  With  a  good  razor  the  integu- 
ments and  aponeurosis  upon  the  median  line  were  divided.  A  slightly  con- 
cave bistoury  was  then  carried  obliquely  downwards  and  backwards,  between 
the  symphysis  pubis  and  the  bliidder,  the  back  of  the  blade  towards  the  bone, 
so  as  to  open  this  pouch  with  the  utmost  care.  If  the  opening  were  very 
large,  the  bladder  would  at  once  be  evacuated :  it  must  be  merely  sufficient 
to  allow  of  the  introduction  of  a  lenticular  bistoury,  which  immediately 
enlarges  the  incision  from  below  upwards,  not  going  far  enou2,h  however  to 
reach  the  peritoneum.  Then  the  stone  was  withdrawn  with  the  fingers 
alone,  or  artificially  armed  with  stalls,  with  a  scoop,  or  with  forceps. 

a.  Douglas  modified  the  procedure  of  Rousset  in  two  points  of  view.  The 
organ  must  be  very  moderately  distended  by  the  injection,  according  to  him 
not  to  paralyze  its  fibres,  and  because  its  extreme  distension  is  often  quite 
insupportable.  For  the  razor  he  substitutes  a  convex  bistoury.  The  straight 
bistoury,  which  he  employs  instead  of  a  curved  bistoury,  serves,  both  for 
nuiking  the  puncture  into  the  bladder,  and  for  at  once  enlarging  the  wound 
instead  of  resorting  to  the  probe-pointed  bistoury. 

b.  Cheselden,  who  likewise  does  not  approve  of  much  distension,  advises 
the  patient  as  much  as  possible  to  retain  his  urine,  and  to  throw  in  a  quantity 


OPERATIVE    SURGERY.  789 

of  liquid  equal  only  to  what  they  would  naturally  have  voided.  When  he 
has  laid  bare  the  aponeurosis  with  a  convex  bistoury,  and  divided  the  linea 
alba  with  a  straight  one,  he  takes  a  sharp  pointed  concave  bistoury,  to  open 
the  bladder  from  above  downwards,  and  not  from  below  upwards,  as  Rousset 
and  Douglas  had  advised. 

The  curved  scissors  whicli  McGill  has  recommended  instead  of  the  straight 
bistoury  in  this  latter  stage  of  the  (Tperation,  expose  the  peritoneum  too  much 
to  injury  to  be  ever  adopted,  and  in  all  respects  are  of  so  little  importance 
or  advantage  as  not  to  entitle  the  method  to  an  analysis. 

c.  Morand  so  alters  the  procedure  of  Rousset,  that  he  placed  his  patient 
differently,  his  head  and  chest  lower  than  his  pelvis,  and  the  legs  fixed  to 
the  bed  posts.  He  plausibly  insists  on  the  dangers  of  forcing  injection  to 
any  extent,  and  endeavors  to  demonstrate  its  inutility.  He  is  content  with 
the  common  straight  bistoury  for  the  incision  of  the  parietes  of  the  abdomen, 
and  the  concave  one  for  that  into  the  bladder.  He  appears  to  have  origi- 
nated the  idea  of  using  the  left  forefinger,  curved  as  a  hook,  to  keep  the  blad- 
der at  the  upper  angle  of  the  wound,  whilst  its  dimension  is  being  completed 
as  Heister  had  done  before  him. 

d.  Others,  particularly  Le  Dran,  thought  that  the  peritoneum  would  run 
infinitely  less  risk  of  being  wounded  if  it  were  cut  into  crosswise  instead  of 
being  divided  from  above  downwards.  Winslow  asserted,  that  the  necessity 
for  injecting  it,  might  be  done  away  with,  by  making  the  patient  drink  freely 
of  a  diluent  tisana  for  some  weeks  before  he  underwent  the  operation; 
and  he  told  Morand  that  the  position  adopted  by  him  was  ill-suited  to 
the  end.  If  we  rightly  comprehend  him,  it  appears  that  Thibaut,  of  the 
Hotel  Dieu,  had  an  idea  of  returning  to  the  incision  from  above  down- 
wards, and  like  La  Peyronie,  was  of  opinion  that  the  bistoury  should  be  so 
passed  into  the  bladder  at  one  stroke,  as  on  withdrawing  it  to  divide  all  the 
tissues. 

Lecat  followed  this  advice  in  operating  on  two  patients  by  the  high  appa- 
ratus, in  1742  and  1743.  His  cystotome  bistoury,  whichhe  plunged  in  as  if  by 
puncture,  served  him  for  dividing  the  bladder  upwards,  then  for  a  moment  to 
keep  it  suspended  by  means  of  a  projection  on  its  convex  edge,  suddenly 
turned  in  this  direction,  until  he  had  replaced  it  by  a  suspensor  hook. 

e.  Of  late  years  the  procedure  of  Rousset  has  been  subjected  to  fresh  modi- 
fications. M.  Baudens,  a  young  surgeon  from  the  military  hospitals  says, 
that  he  has  found  it  a  good  plan  not  to  introduce  any  fluid  into  the  bladder; 
to  open  this  pouch,  as  Pietre,  Solingen,  &c.  had  advised,  a  little  on  one 
side ;  to  carry  the  left  forefinger  down  to  the  posterior  face  of  the  pubis, 
to  push  the  peritoneum  up  from  below,  and  make  it  and  the  bladder  tense; 
to  pass  in  the  bistoury  to  its  cavity  from  above  downwards;  to  employ  his 
finger  as  did  Morand,  and  so  continue  the  incision  in  the  same  direction  with- 
out removing  it,  as  far  as  the  neck  of  the  bladder.  Moreover,  M.  Baudens 
thinks  that  when  the  removal  of  the  calculus  is  attended  with  some  difficulty, 
we  should  divide  the  rectus  muscle  laterally,  and  also  the  lips  of  the  wound 
in  the  bladder,  as  had  before  been  recommended  by  McGill  and  Le  Dran. 

.  f.  A  particular  instrument  of  an  extremely  ingenious  construction  was  con- 
trived by  M.  Tanchou  to  facilitate  this  procedure.  It  is  a  sort  of  flat  trocar, 
the  sheath  grooved  on  one  edge,  articulated  at  some  distance  from  its  extre- 


790  NEW    ELEMENTS    OF  ^ 

miiy,  and  made  into  a  bistoury  by  a  stem  with  a  cutting  edge.  The  opera- 
tion is  performed  in  the  following  waj.  The  operator  makes  his  incision  on 
the  median  line  down  to  the  forepart  of  the  peritoneum  with  a  convex  bis- 
toury. By  the  assistance  of  the  left  forefinger  carried  to  the  bottom  of  the 
wound,  he  detects  the  fluctuation  of  the  bladder,  which  he  has  previously 
moderately  distended  by  an  injection  of  tepid  water;  he  then  passes  in  his 
trocar,  from  above  downwards  and  before  backwards,  draws  out  the  cutting 
edge  by  means  of  a  spring ;  the  sheath  tEen  bends  at  a  right  angle,  and  forms 
a  sus'pensor  hook  which  is  developed  within,  and  on  the  lower  edge  of  which 
a  common  probe-pointed  bistoury  is  conveyed  in  to  enlarge  the  wound  as 
much  as  may  he  requisite. 

g.  Lastly,  M.  Verniere,  conceived  that  an  advantageous  change  might  be 
made  in  practising  this  operation  by  the  performance  of  a  previous  one,  con- 
sisting in  incision  of  the  wall  of  the  hypogastrium,  and  then  in  placing 
between  it  and  the  front  of  the  bladder  a  flat  surface  {plaque),  intended  to 
compress  from  behind  forwards  the  peritoneum  against  the  inner  surface  of 
the  recto  muscles  for  some  days.  The  adhesions  following  the  pressure  thus 
made,  will,  he  says,  allow  of  our  opening  the  bladder  with  every  security,  and 
without  the  slightest  danger  of  entering  the  cavity  of  the  abdomen.  An  idea 
analogous  to  that  of  M.  Verniere,  has  just  been  communicated  to  me  by  M. 
Vidal  (of  Cassis).  This  surgeon  proposes  to  perform  the  operation  at  two 
separate  times,  between  each  of  which  he  allows  an  interval  of  several  days. 
The  first  stage  consists  in  an  incision  of  the  tissues  which  are  external  to  the 
bladder,  and  the  object  is  to  render  the  cellular  tissue  impermeable  by  infla- 
ming it.  The  second  contains  the  opening  into  the  bladder,  which  according 
to  the  author  is  thus  exempt  from  the  dangers  of  urinous  infiltration. 

Of  all  these  modifications,  no  one  in  reality  is  worthy  of  a  decided  pre- 
ference over  the  others.  I  think  the  wisest  of  them,  as  far  as  concerns  the 
operation  properly  so  called,  is  that  of  Morand.  To  advise  the  patient  to  retain 
his  urine  so  as  to  have  the  bladder  distended,  is  counsel  which  it  is  easier  to 
give  than  for  the  patient  to  follow.  To  be  convinced  of  this,  it  need  only  be 
recollected  how  very  often  calculous  patients  are  compelled  to  pass  their 
water.  Injections,  carried  to  such  an  extent  as  to  render  the  bladder  salient 
above  the  symphysis,  cannot  in  reality  be  endured  :  but  in  the  majority  of 
cases  we  experience  no  difiiculty  in  distending  it  moderately  by  the  intro- 
duction of  some  emollient  liquor,  which  will  suflice  to  indicate  its  presence 
easily  recognizable  behind  the  pubis,  by  the  finger  introduced  through  the 
wound  in  the  linea  alba.  As  to  the  nature  of  the  fluid  to  be  injected,  milk, 
which  Middleton  seems  to  prefer,  is  evidently  less  suited  by  its  tendency  to 
decomposition  than  mallow  infusion,  barley  water,  or  better  still  a  certain 
quantity  of  tepid  water  only.  Air,  the  suggestion  of  which  is  attributed  to 
Solingen,  although  spoken  of  by  Rousset,  who  says  that  in  his  time  they 
were  advised  to  fill  tliebladder  with  wind,  could  have  no  advantage  whatever 
over  a  fluid,  and  deserves  the  neglect  which  it  has  received.  Equal  justice 
has  long  been  done  to  the  precept  of  Bamber,  that  the  injection  is  to  be  made 
only  after  the  opening  of  the  linea  alba,  and  to  that  of  Middleton,  who  thinks 
that  it  should  at  least,  then  be  pushed  a  little  further  than  was  done  before 
the  operation  commenced. 

An  incision  from  below  upwards  with  a  straight  bistoury,  as  in  Douglas's 


OPERATIVE    SURe»RY.  791 

procedure,  or  with  Rousset's  probe-pointed  bistoury,  would  in  truth  allow  of 
much  certainty  in  acting  by  taking  the  pubis  for  a  fulcrum ;  but  undoubtedly 
we  are  by  this  method  too  much  exposed  from  the  instrument's  going  further 
than  we  wish  to  perforate  the  peritoneum,  or  as  Cheselden  says,  to  open  the 
belly.  If  we  adopt  the  incision  from  above  downwards,  it  is  indifferent  whe- 
ther it  be  completed  with  scissors,  a  probe-pointed  bistoury,  straight  or  curved, 
or  with  the  common  straight  one,  if  it  be  done  with  a  steady  hand.  A  trans- 
verse incision  of  the  bladder  would,  as  Winslow  has  remarked,  have  the 
inconvenience  of  presenting  a  wound  perpendicular  to  the  direction  of  outer 
incision,  which  in  retracting  behind  the  bone  would  be  singularly  liable  to 
cause  urinal  infiltration.  Moreover,  it  is  very  certain  that  to  divide  laterally 
the  recto  muscles  as  was  done  by  Pye,  at  another  time  by  M.  Dupuytren,  and 
which  in  our  time  Gehler  washed  to  establish  as  a  rule,  is  suitable  only  in 
particular  cases,  such  as  when  spasmodic  contraction,  sufficiently  violent  to 
prevent  the  introduction  of  forceps  or  fingers  through  the  wound  into  the 
bladder,  occurs,  as  I  once  witnessed  in  a  patient  upon  whom  M.  Roux  operated 
in  1827  at  La  Charite.  M.  Baudens's  procedure,  notwithstanding  its  wonderful 
apparent  simplicity,  has  the  serious  drawback  of  causing  too  much  tearing  of 
cellular  tissue  in  detaching  the  peritoneum.  There  can  be  no  doubt  that  in  a 
case  in  which  the  bladder  was  concealed  quite  in  the  bottom  of  the  pelvis,  the 
absence  of  injection  into  it  would  render  the  operation  extremely  difficult. 

The  mere  announcement  of  M.  Veniere's  idea,  will  suffice  I  fancy  to  give 
all  an  opportunity  to  appreciate  its  worth.  That  of  M.  Vidal  is  more  simple 
and  more  reasonable.  The  wisdom  of  M.  Tanchou's  contrivance  cannot  be 
disputed;  simply,  as  it  requires  a  particular  instrument  having  no  other 
advantage  than  serving  to  carry  a  hook  into  the  bladder,  at  the  same  time 
that  it  is  entered  by  puncture,  and  that  the  puncture  of  this  sac  by  a  bistoury 
admits  the  finger  or  some  suspensory  instrument  to  be  introduced,  I  presume 
that  the  use  of  it  will  be  neglected  by  surgeons,  and  that  good  surgery  can  dis- 
pense with  it.  Some  old  surgeons,  however,  had  previously  felt  the  want  of 
it,  for  Heister  advises  the  puncture  of  the  bladder  by  a  trocar,  grooved  so  as 
to  serve  as  a  director  to  a  bistoury  afterwards. 

2.  The  Method  of  Franco. — Dionis  and  Toilet,  who  have  treated  of  the 
high  apparatus,  think  that  the  surgeon  might  follow  the  advice  of  Franco, 
whose  method  was  to  carry  two  fingers  into  the  rectum  to  raise  the  stone  up 
to  the  hypogastrium,  and  then  to  cut  down  upon  it  a  little  to  one  side  of  the 
linea  alba.  They  are  of  opinion  that  this  is  a  very  easy  and  simple  method,  and 
much  more  certain  than  that  of  which  Rousset  speaks.  If  the  stone  is  small  and 
the  pubis  sufficiently  low,  and  the  parts  altogether  thin  enough  to  allow  the 
fingers  thus  to  push  the  foreign  body  up  above  the  pubis,  this  procedure  would 
be  verj  advantageous  and  deserve  adoption.  Proby  put  it  in  operation,  and 
by  means  of  it  Lassus  and  M.  de  Guise  succeeded  in  removing  stones  from 
the  bladder,  which  through  the  perineum  they  could  not  extract.  In  fact, 
this  is  nothing  but  the  apparatus-minor  of  the  ancients,  applied  to  cutting  by 
the  hypogastrium,  with  this  difference,  that  it  is  easier  to  cut  down  to  the 
stone  above  the  pubis,  than  when  it  has  to  be  extracted  from  the  inferior 
strait.  It  is  useless  altogether  to  give  the  steps  of  the  operation  in  detail. 
Franco  merely  says,  that  his  patient  was  operated  on  "  upon  the  pubis,  a 


792  ^'E^v  elements  o^ 

little  to  one  side  and  upon  the  stone,  whilst  he  raised  this  up  with  his  iingei-s 
which  were  in  the  fundament  on  the  other  side,  confining  it  by  the  hands  of 
a  servant  who  pressed  upon  the  lower  belly."  It  is  well  to  remark,  en  pas- 
sunt,  that  Franco  had  not  previously,  as  a  number  of  books  relate,  and  as  is 
stated  in  the  Dictionary  of  Practical  Surgery,  cut  into  the  perineum  of 
the  child  of  two  years  old  of  whom  he  speaks — and  that  it  was  only  after  he 
had  seen  every  effort  unsuccessful  in  bringing  down  the  stone  that  he  resorted 
to  *'  cutting  the  said  child  above  the  os  pubis." 

3.  3Icthod  of  Frere  Come. — In  the  successive  improvements  which  were 
inade  in  perineal  lithotomy  the  hypogastric  operation  seems  to  have  followed 
every  change.  For  a  long  while  it  was  thought  necessary  to  make  the 
stone  descend  towards  the  neck  of  the  bladder  to  cut  the  parts  over  it;  the 
same  was  the  case  in  the  high  apparatus.  The  plan  of  distending  the  bladder 
with  injection  was  a  precaution  soon  adopted  in  it.  Bamber,  Cheselden,  and 
Foubert,  in  the  last  century,  imagined  the  same  thing  in  perineal  cutting  so  as 
to  dispense  with  the  staff.  And  since  this  instrument  is  believed  to  be  indis- 
pensable now  in  all  species  of  the  low  apparatus,  a  host  of  authors  have  like- 
wise advised  its  use  in  the  super-pubic  method.  Rousset  mentions  without 
advocating  it.  It  seems,  that  in  his  time  it  was  a  hollow  and  crested  staff 
which  w^as  at  once  a  catheter  through  which  to  throw  in  injections  if  thought 
advisable,  and  as  a  '*  catheter  to  direct  the  incision  after  the  manner  of  the 
Marianists ;"  which  means,  no  doubt,  that  the  convexity  or  groove  was  turned 
forwards,  not  a  very  easy  thing  to  do.  Still  later  the  staff  was  advised  by 
Pietre  and  Heister,  &c. ;  by  some  to  distend  and  raise  the  bladder ;  while 
others  had  caused  its  concavity  to  be  grooved,  in  a  manner  proper  for  carry- 
ing the  point  of  the  bistoury  along  it. 

The  instrument  which  has  in  this  respect  excited  most  attention,  is  that 
invented  by  brother  Come  about  the  middle  of  the  last  century,"  and  which 
gave  the  monk  so  great  a  predilection  for  the  high  apparatus,  that  between  the 
years  1758  and  1779,  he  had  performed  it  one  hundred  times.  This  instru- 
ment, known  by  the,  name  of  "sonde  a  dard,^^  consists  of,  1st,  a  silver 
catheter,  opening  by  a  fissure  on  its  concave  side,  ending  in  a  beak  which 
rather  projects  backwards,  and  has  one  or  two  rings  at  its  oute^  end  ;  2d,  of 
a  stem  much  longer,  which  ends  in  a  triangular  steel  point,  also  grooved  on 
its  concave  side,  and  which  has  a  flat  blunt  knob  on  its  other  extremity. 
These  two  portions,  the  last  of  which  is  always  kept  within  the  other  in  such 
a  way  as  to  escape  as  soon  as  pressure  is  made  on  the  button  or  knob  of  its 
free  extremity,  form  an  instrument  whose  mechanism  is  exceedingly  simple. 
It  is  introduced  in  such  a  way  as  that  its  beak  may  glide  from  below  upwards 
behind  the  symphysis,  and  rise  up  above  the  pubis,  passing  against  the  inner 
side  of  the  anterior  region  of  the  bladder.  The  abdominal  parietes  being 
divided,  its  point  or  beak  is  made  to  bulge  up  a  little  into  the  wound  by 
pressing  on  the  top  of  the  handle  as  if  to  push  it  backwards,  and  so  as  to 
depress  it.  The  surgeon  takes  hold  of  it  through  the  coats  of  the  bladder 
by  its  projecting  part  with  his  thumb  and  forefinger;  or  else  he  applies  upon 
its  fore  part  a  canula  hollowed  out  and  shaped  like  a  funnel.  The  knob  then 
being  pushed  fi'om  below  upwards  perforates  the  bladder  as  it  escapes  from 
the  '*  sowrfe,"  and  shows  itself  outwardl}^  Whetlier  this  knob  unscrews  from 
the  stem  so  as  to  leave  the  latter  in  the  wound,  or  whether  they  be  in  one 


OPERATIVE    SURGERY.  793 

• 

piece,  the  bistoury  is  adapted  to  the  groove  in  its  concavity,  then  passed  from 
above  downwards,  and  from  before  backwards  to  cut  the  wall  of  the  bladder 
to  a  suitable  extent.  Nothing  then  remains  but  to  withdraw  the  stylet,  whose 
projecting  beak  has  not  yet  quitted  the  wound,  back  into  its  sheath,  and  then 
to  take  out  the  instrument  itself.  The  other  stage  of  the  procedure  does  not 
differ  from  that  of  Morand's. 

The  sonde  a  dard  thus  completely  does  away  with  the  necessity  of  injec- 
tions, for  it  makes  the  parts  suitably  tense ;  and  its  grooved  stem  makes  an 
excellent  director  when  the  opening  into  the  bladder  is  to  be  enlarged  with 
the  bistoury.  Scarpa  and  M.  Belmas  have  proposed  certain  modifications  in 
it,  with  the  view  of  rendering  its  use  yet  more  efficient.  For  example,  it  is 
often  objected  to  as  escaping  entirely  through  the  puncture  it  has  made,  and 
as  allowing  the  bladder  to  contract  before  it  was  possible  to  finish  the  open- 
ing into  it  with  the  bistoury.  The  surgeon  of  Pavia  thus  obviated  that  defect. 
His  catheter  was  only  grooved  to  within  a  few  lines  of  the  end  which  forms 
its  beak,  which  is  olive  shaped.  The  groove  moreover  is  very  large,  and 
strongly  excavated  so  as  to  leave  a  furrow  on  either  side  of  the  stylet,  deep 
enough  to  slide  the  beak  of  a  bistoury  along.  The  piercing  stem  destined  to 
pass  through  it,  quits  it  by  degrees,  and  passes  out  two  or  three  lines  below 
the  head,  which  thus  remains  in  the  bladder  and  cannot  escape  in  following 
the  stylet.  Scarpa  says,  besides,  that  its  edges  can  always  be  felt  through 
the  bladder  with  the  nail,  and  that  the  bistoury  passing  on  one  side  of  the 
dard,  may  be  carried  into  it  without  danger. 

The  sonde  of  M.  Belmas  is  also  a  very  ingenious  contrivance,  but  is  so 
very  complicated,  that  what  it  has  fundamental  about,  will  not  be  adopted. 
Other  directors  have  besides  been  proposed  at  different  periods.  Cleland, 
for  instance,  contrived  a  sound  in  the  last  century,  which  bifurcated  like 
forceps  when  introduced  into  the  bladder,  and  thus  rendered  the  walls  of 
the  organ  more  or  less  tense.  Kulm  and  Heritier,  &c.  produced  nothing 
better,  and  the  very  complex  apparatus  which  within  a  few  years  M.  Rouget 
endeavored  to  bring  into  use,  the  object  of  which  was  to  pierce  at  one  stroke 
the  entire  thickness  of  the  bladder  and  abdominal  pai'ietes,  is  no  longer 
worthy  of  being  mentioned. 

The  question  is,  to  know  whether  the  only  object  in  the  directing  instru- 
ment shall  be  to  make  the  organ  tense  and  prevent  its  -collapsing,  or  else, 
whether  it  shall  at  the  same  time  puncture  the  reservoir  from  within  outwards, 
so  as  to  furnish  a  more  certain  guide  to  the  bistoury  which  is  to  complete  the 
incision. 

If  the  first  of  these  ends  is  proposed,  a.common  catheter  will  answer  all 
the  surgeon's  expectations  ;  if  the  second,  the  sonde  a  dard,  the  original  or 
that  modified  by  Scarpa,  leaves  us  in  truth  nothing  to  desire. 

The  use  of  directors,  however,  is  not  the  only  change  which  has  been  made 
in  performing  hypogastric  cutting.  Several  surgeons  have  advised  that  an 
additional  incision  should  be  made  beneath  the  pubis.  This  process  had 
been  performed  by  Sermes,  a  dutch  surgeon,  who  was  on  account  of  it  pro- 
secuted by  the  law  and  defamed  by  envy;  it  was  then  reduced  to  simple 
puncture,  and  then  in  some  measure  assimulated  to  lateralized  cutting. 
Sermes  recommended  it  as  a  means  of  introducing  the  suspensor  sound. 
Pallucci  punctured  the  same  part  with  a  trocar,  and  leftacanula  in  the  wound. 
100 


794  NEW  ELEMENTS  OF 

Deschamps  thought  that  the  puncture  should  be  made  through  the  rectum,  so 
that  the  instrument,  armed  with  its  dart,  might  pass  in.  After  all  it  is  to 
brother  Come  that  this  supplementary  incision  owes  all  the  popularity  which 
it  once  enjoyed.  This  lithotomist,  who  commenced  his  operation  with  it, 
cut  the  membranous  and  partly  the  prostatic  portion  of  the  urethra  upon  a 
grooved  staff,  and  then  used  this  wound  to  pass  his  sonde  a  dard  into  the 
bladder.  After  the  operation,  a  thick  and  short  canula  was  left  in  the  wound, 
which  by  giving  vent  to  the  urine  was  to  prevent  it  from  rising  up  into  the 
hypogastrium.  The  arguments  and  success  of  F.  Come  for  a  while  deceived 
the  profession  as  to  the  value  of  this  incision;  but  very  soon  men  began  to 
ask  themselves  if  the  high  apparatus  really  derived  any  advantages  from 
this  incision,  or  whether  it  was  not  the  cause  of  a  dangerous  complication. 
It  was  easy  to  prove,  1st,  that  a  wound  in  perineo  in  nowise  prevented 
the  urine  from  rising  into  the  wound  in  the  epigastrium;  2d,  that  it  was 
not  indispensable  for  introducing  the  sonde  a  dard;  and  3d,  that  it  must 
combine  all  the  dangers  of  perineal  cutting  with  those  of  the  hypogastric 
method  also.  So,  Scarpa  in  1808,  and  Dupuytren  in  1812,  endeavored  to 
suppress  the  modification  of  F.  Come,  and  to  demonstrate  that  it  was  quite  as 
easy  to  operate  with  the  instrument  invented  by  the  latter,  when  carried  into 
the  bladder  through  the  urethra  as  when  introduced  by  the  perineum.  The 
routine  of  the  Feuillant  monk*  continued  to  be  adopted,  when  Mr.  Home  de- 
parting from  the  track  twice  performed  hypogastric  cutting  in  1819  and  1820 
upon  the  principles  laid  down  in  the  essay  of  M.  Dupuytren.  Some  years 
after,  M.  Souberbielle  himself  abandoned  the  precepts  of  his  grandfather, 
which  he  has  never  followed  since  1825;  so  that  this  is  now  a  settled  ques- 
tion upon  which  it  is  no  longer  necessary  to  dwell. 

§  3.  The  Method  of  Operation, 

Notwithstanding  their  points  of  difference,  the  procedures  which  have  now 
passed  us  in  review  possess  features  which  are  common  to  them  all.  These 
rules  relate  either  to  the  position  of  the  patient  or  to  the  incision  of  the 
tissues,  or  to  the  means  of  carrying  off  the  urine,  and  of  dressing  the  wound 
after  the  operation. 

1 .  Position  of  the  Patient, — It  should  be  similar  to  that  recommended  in 
the  operation  for  hernia,  with  this  distinction  however,  that  it  is  proper  to 
raise  the  pelvis  a  little.  If  the  legs  are  allowed  to  hang  over  the  table  or  the 
bed  they  will  put  the  abdominal  muscles  very  much  upon  the  stretch  and 
cause  several  inconveniences  in  this  way.  Flexion  of  them,  as  in  parietal 
lithotomy,  would  interfere  with  the  motions  of  the  operator.  The  operation 
might  in  fact  be  done  on  a  bed  ;  but  a  na,rrow  table,  of  proper  height,  makes 
the  position  of  every  patient  infinitely  more  convenient. 

Injection,  Placing  the  Conductor. — When  we  mean  to  follow  the  plan  of 
injecting  the  bladder  and  eflect  its  distention  by  means  of  liquids,  we  must 
begin  by  introducing  a  common  catheter  into  the  urethra.  To  the  open 
end  of  this,  the  pipe  of  a  syringe  filled  with  warm  water  is  then  fixed. 
The  process  of  injection  is  very  slow,  so  as  to  pour  into  the  bladder  as 
much  fluid  only  as  the  patient  can  bear  without  feeling  too  much  pain.     At 

*  A  friat  of  the  reformation  of  St.  Barnard. — TnAifs. 


OPERATIVE   SURGERY.  795 

the  present  day  no  one  would  think  of  using  the  ureter  of  an  ox,  the  trachea 
of  a  turkey,  or  a  copper  staff,  as  advised  by  Douglas,  Cheselden,  Mid- 
dleton  and  Solingen,  to  connect  the  syringe  with  the  catheter,  so  as  to  avoid 
all  kinds  of  motion  or  shaking.  The  injection  being  finished,  an  assistant  is 
immediately  requested  to  compress  the  urethra,  to  prevent  the  fluid  from 
escaping  too  soon.  Many  patients  it  is  true,  do  not  require  this  caution ;  but 
as  this  is  not  the  case  with  some  others,  prudence  forbids  our  dispensing  with 
it.  The  fingers  are  much  better  than  any  of  the  compressors  invented  by 
Nuck,  Winslow,  and  others. 

Incision  through  the  external  parts. — The  surgeon  proceeds  to  open  the 
wall  of  the  hypogastrium,  standing  on  the  right  side  of  the  patient,  rather 
than  between  his  legs,  as  M.  Belmas  recommends.  It  would  be  childish  to 
argue  about  the  superior  advantages  of  this  over  the  other  bistoury  at  this 
period  of  the  operation.  It  matters  little  whether  it  be  a  razor,  a  straight  or 
a  convex  bistoury,  or  a  small  knife,  so  that  it  be  only  very  sharp ;  except,  that 
as  in  the  sequel  the  straight  bistoury  is  the  most  convenient,  I  think  that  as  a 
general  rule  it  deserves  the  preference.  You  hold  it  in  tlie  first  position,  i.  e. 
like  a  table  knife ;  and  after  having  stretched  tlie  parts  with  the  left  hand,  you 
divide  the  parts  from  above  downwards,  for  a  length  of  at  least  three  or  four 
inches,  1st,  the  integuments,  2d,  the  adipose  cellular  layer,  and  so  come  down 
to  the  aponeurosis.  Whatever  Zang  may  say  this  incision  had  better  be  long 
than  short,  and  though  contrary  to  the  advice  of  Winslow  there  is  an  ad- 
vantage in  carrying  it  down  on  the  fore  part  of  the  symphysis  for  half  an  inch 
below  the  upper  edge  of  the  pubis. 

All  surgeons  do  not  perform  the  division  of  tlie  aponeurosis  in  the  same 
way.  Some  do  it  with  the  instrument  they  have  all  along  used ;  others,  among 
whom  is  Scarpa,  prefer  that,  after  having  cut  it  completely  down,  a  director 
should  be  passed  beneath  it,  which  may  insinuate  itself  between  the  peritoneum 
and  the  abdominal  wall  from  below  upwards,  so  that  on  it  a  bistoury  may  be 
directed  in  the  like  direction  to  cut  the  entire  thickness  of  the  fasciae. 

For  this  purpose  F.  Come  employed  an  instrument  which  ended  by  a  trian- 
gular point  on  one  side,  by  a  handle  cut  in  facets  on  the  other  side,  enclosing 
a  cutting  blade  which  has  a  flat  plate  at  its  free  extremity,  and  which  opens  from 
haft  to  point,  consequently  in  an  opposite  dirfiction  to  the  sheathed  lithotome. 
This  trocar  is  plunged  from  before  backwards,  and  from  above  downwards, 
until  it  gets  between  the  symphysis  and  anterior  wall  of  the  bladder.  The 
surgeon  then  with  his  right  hand  fixes  the  stem  against  the  bone ;  seizes  the 
flat  plate  with  the  thumb  and  forefinger  of  the  left  hand;  carries  this  plate 
from  the  handle  from  below  upwards,  and  divides  in  the  same  direction  the 
linea  alba  and  other  tissues  with  which  the  blade  meets  in  its  passage.  Having 
withdrawn  the  trocar,  F.  Come  substitutes  in  its  place  a  bistoury  ending  in  an 
olive-shaped  point,  solid  in  the  handle  and  cutting  on  its  concavity;  cuts  from 
below  upwards,  holding  this  second  instrument  in  his  right  hand  directed 
by  the  fingers  of  the  left  hand,  all  the  laminae  which  may  at  first  have 
escaped,  and  takes  care  to  pass  the  knob  into  the  bladder,  the  peritoneum, 
and  even  the  deep  surface  of  the  aponeuroses. 

At  first  sight  the  method  of  F.  Comeseemsmoredangerous  than  any  other. 
It  is  terrifying  to  see  his  trocar-bistoury  acting  from  below  upwards  and  from 
before  backwards,  without  any  guide  to  control  its  direction.    However  as  it 


796  NEW   ELEMENTS   OF 

cuts  rather  bj  pressing  than  bj  sawing,  and  as  its  blade  when  open  as  far  as 
possible  represents  a  line  drawn  very  obliquely  from  the  integuments  to  the 
bladder,  it  is  rare  for  the  peritoneum  to  be  really  injured.  The  only  rea- 
sonable objection  which  can  be  raised  against  it  is  that  it  is  not  indispensable, 
and  that  a  person  accustomed  to  perform  the  great  operations  in  surgery  will 
do  it  just  as  surely  with  a  common  bistoury.  With  this  view,  I  do  not 
consider  the  improvement  made  in  the  instrument  by  M.  Belmas  as  of  any 
great  value ;  it  consists  in  making  it  concave  on  the  back  and  convex  on  the 
cutting  edge.  As  to  the  probe-pointed  bistoury  of  the  inventor,  I  have,  I 
dare  say  a  thousand  times  substituted  the  common  probe-pointed  bistoury  for 
it  in  the  hands  of  pupils  operating  upon  the  dead  body,  and  never  yet  felt  the 
want  of  an  instrument  specially  for  the  purpose.  Almost  all  surgeons  at  the 
present  day,  advise  us  to  cut  directly  down  upon  the  median  line;  however, 
returning  to  the  recommendations  of  certain  authors,  M.  Baudens  has  recently 
exerted  himself  to  prove  that  it  is  better  to  cut  outside  of  this  fibrous  line, 
because  the  wound,  if  made  between  it  and  the  inner  edge  of  the  rectus 
muscle,  will  be  less  difficult  to  enlarge  and  it  will  be  more  easy  to  part  its  lips 
to  come  upon  tlie  fore  part  of  the  bladder.  This  is  a  piece  of  advice  again 
which  may  be  followed  or  neglected  without  any  unpleasant  result.  The 
thing  needful  is  to  get  between  the  two  sterno- pubic  muscles,  and  not  to  go 
across  their  fibres.  After  this,  whether  the  linea  alba  remain  untouched  on 
one  side,  or  be  actually  split  into  two  equal  parts,  need  cause  us  no  uneasiness. 
Besides  which  it  is  generally  so  difficult  to  detect  it  beneath  the  adipose  tissue, 
that  the  knife  is  guided  almost  constantly  by  data  approximating  to  that  direc- 
tion in  wliich  it  usually  exists.  I  may  add  that  if  it  is  better  notto  go  through 
fleshy  fibres,  it  is  not  from  any  fear  of  incising  them,  but  because  of  the 
greater  depth  to  be  gone  through  before  we  come  to  the  sub-peritoneal  cellular 
tissue,  and  because  also,  the  serous  membrane  is  found  more  closely  applied  to 
the  thick  wall  of  the  hypogastrium  outside  of  and  not  upon  the  median  line. 
The  straight  bistoury  of  the  common  kind,  held  like  a  table  knife  or  like  a 
writing  pen,  is  as  good  as  any  other  to  divide  the  skin,  fatty  layer  and  apo- 
neurosis from  above  downwards  and  alternately. 

When  the  surgeon  comes  to  this  aponeurosis  he  must  proceed  with  great 
slowness,  and  divide  it  layer  by»layer,  pressing  more  strongly  upon  the  part 
nearest  the  pubis  than  upon  the  upper  end  of  the  wound.  As  we  always 
come  upon  the  pubio-vesical  triangle  on  the  median  line,  and  with  a  little 
attention  we  may  always  tell  when  we  have  reached  it,  the  peritoneum"  runs 
in  truth  no  risk  at  this  part  of  the  operation.  Supposing  that  very  close  ad- 
hesions superiorly  should  prevent  us  from  opening  the  aponeurosis  sufficiently 
deep  in  this  direction,  we  must  then  take  a  probe-pointed  instead  of  a  straight 
bistoury.  Its  point  is  to  be  carried  into  the  triangle  just  indicated  above 
the  pubis,  against  which  the  operator  may  for  greater  security  rest  the  back 
of  the  knife  with  his  right  hand  ;  the  left  thumb  and  forefinger  take  hold  of 
the  blade  by  its  sides  to  pass  it  from  below  upwards,  and  make  its  probe  point 
slide  over  the  anterior  surface  of  the  bladder,  or  the  inferior  portion  of  the 
peritoneum  itself,  for  an  extent  of  about  two  inches  between  these  parts  and 
the  deep  surface  of  the  linea  alba. 

It  is  very  true  that  the  bladder  maybe  opened  with  less  danger  below  than 
higher  up,  but  in  the  first  case  the  cutting  edge  of  the  bistoury  must  be 


OPERATIVE    SURGERY.  797 

turned  towards  the  umbilicus,  bj  which  the  peritoneum  is  considerably  en- 
dangered ;  whilst  in  the  other  we  are  pretty  sure  to  avoid  it  altogether  if  it  is 
not  injured  at  starting. 

The  idea  which  Middleton  and  some  others  had  of  looking  for  the  urachus 
or.the  central  spot  which  separates  this  ligament  from  the  pubis,  is  a  useless 
one.  The  important  point,  and  the  only  one,  is  to  come  upon  the  anterior  wall 
of  the  bladder  at  a  spot  not  covered  by  peritoneum.  This  is  to  be  punctured 
with  the  straight  bistoury,  or  with  the  small  concave  knife  of  Cheselden,  or 
Rousset,  carried  along  the  nail  of  the  left  forefinger  and  inclined  from  above 
downwards.  As  it  is  withdrawn  care  must  be  taken  rapidly  to  enlarge  the 
wound,  so  as  to  introduce  some  suspensory  instrument  immediately  into  the 
bladder.  The  index  finger  crooked  upwards  like  a  hook,  will  at  first  do  in- 
stead of  it.  If  afterwards  the  walls  of  the  abdomen  seem  very  thick,  and 
make  it  difficult  to  get  down  to  the  urinary  bladder,  we  may  adopt  Zang's  advice 
and  pull  the  edges  asunder  by  means  of  small  blunt  hooks.  The  curved  fin- 
ger serves  anew  to  direct  the  bistoury  made  use  of  to  enlarge  the  wound  in  the 
bladder,  and  extend  it  towards  the  neck  for  an  inch  or  more  according  to  the 
supposed  volume  of  the  stone.  In  common  cases  the  same  bistoury,  that  is, 
the  straight  bistoury,  is  here  also  sufficient,  and  is  even  better  than  a  probe- 
pointed  one,  inasmuch  as  that  its  point  when  being  withdrawn  better  divides 
the  tissues.  If  the  embonpoint  of  the  person  should  make  it  difficult  to  em- 
ploy it,  it  might  well  be  superseded  by  Pott's  concave  bistoury,  which 
would  do  away  altogether  with  the  concave  instrument  contrived  by 
tlie  ancients.  As  to  curved  edged  scissors,  I  know  of  no  circumstances  in 
which  they  can  deserve  a  preference.  If  the  finger  takes  up  too  much  room 
at  the  time  of  introducing  the  forceps,  or  of  the  extraction  of  the  stone ;  if  we 
are  afraid  of  getting  it  injured  during  this  latter  manipulation,  as  Deschamps 
instances  an  example,  whether  it  belong  to  the  surgeon  or  the  assistant  it  had 
better  be  removed  and  a  proper  instrument  substituted  for  it.  The  blunt  hook  of 
F.  Come  is  perfectly  proper ;  but  the  sort  of  gorget  with  a  handle  bent  at 
nearly  a  right  angle  near  the  end,  which  was  constructed  by  M.  Belmas,  would 
evidently  do  better.  Indeed  this  suspensor,  the  groove  of  which  should  look 
downwards,  would  keep  open  the  lips  of  the  wound  whilst  it  constituted  an 
excellent  director,  without  giving  any  inconvenience  whatever  to  the  inner 
surface  of  the  bladder  or  the  artificial  opening.  Nothing  now  remains  but  to 
extract  the  stone.  But  before  I  proceed  to  this  step  in  the  operation,  I  shall 
stop  to  consider  those  necessary  when  the  sonde  a  danl  is  used  instead  of 
injections. 

Use  of  the  Director. — When  a  director  is  employed,  it  had  better  be  intro- 
duced before  the  hypogastrium  is  opened  than  afterwards ;  Jirst,  because  its 
beak  will  then  serve  as  a  guide  in  some  cases  above  the  pubi?;  and  secondly, 
because  the  patient  will  suffer  more  from  its  subsequent  introduction.  I 
suppose  now  that  it  is  the  sonde  a  dard,  which  we  are  to  employ.  It  is  intro- 
duced like  a  common  staff,  its  concavity  pushed  behind  the  pubis,  and  thus  its 
point  is  tilted  up  above  the  superior  strait  opposite  the  linea  alba.  An 
assistant  is  directed  to  hold  it  in  this  position,  whilst  the  operator  proceeds  to 
divide  the  integuments  and  aponeurosis.  When  the  bladder  is  laid  bare,  the 
latter  takes  the  sonde  into  his  own  hands  again,  withdraws  it  a  little  to  raise 
its  beak  from  below  upwards,  rubbing  gently  against  the  pubis  in  such  a  way 


798  NEW   ELEMENTS   OF 

as  that  the  peritoneum  may  not  intervene  and  form  a  fold  before  that  point  in 
the  wall  of  the  bladder  through  which  the  point  is  to  pierce  to  pass  into  the 
wound.  The  left  forefinger  passed  down  to  the  bottom  of  the  incision,  follows 
its  motions,  and  indicates  the  degree  of  elevation  and  protrusion  to  M'hich  the 
instrument  has  attained.  Having  suitably  fixed  its  position,  it  is  again  given 
to  the  assistant.  The  surgeon  pinching  the  sides  of  its  salient  extremity  then 
desires  the  assistant  to  push  out  the  dard,  which  passes  to  a  length  of  from 
one  to  several  inches;  he  then,  if  he  fears  that  it  may  inconvenience  him, 
unscrews  its  point.  Without  displacing  the  left  hand,  in  the  right  he  takes  a 
bistoury,  which  according  to  Scarpa  should  be  convex,  but  according  to  Belmas 
just  the  reverse,  and  which  however  does  equally  well  whether  it  be  the 
common  or  the  straight ;  the  point  of  this  held  like  a  pen  he  places  in  the  groove 
of  the  dard ;  passes  it  along  into  the  bladder,  and  divides  this  organ  upon  the 
median  line  from  above  down,  and  from  before  backwards  near  the  neck  or 
prostate  gland  ;  draws  back  the  dart  into  its  sheath,  and  directly  introduces 
his  left  forefinger  into  the  bladder.  The  assistant  removes  the  instrument. 
If  the  surgeon  thinks  it  necessary  to  use  some  artificial  suspensor,  he  sets 
about  the  introduction  of  that  which  he  selects  at  once  >  takes  the  hook  or  the 
curved  gorget,  supposing  him  to  choose  it,  in  his  right  hand  ;  presents  it  at  the 
vesical  opening  in  the  most  suitable  direction ;  raises  it  when  it  has  entered ; 
slips  it,  instead  of  his  finger  which  he  withdraws,  into  the  lower  angle  of 
the  wound,  and  then  gives  it  in  charge  to  his  assistant.  Both  hands  being 
then  free,  he  can  fearlessly  explore  the  inner  part  of  the  bladder,  and  judge 
of  the  situation  and  form  of  the  calculus  which  is  to  be  extracted  as  the 
termination  of  the  operation.  This  may  often  be  done  by  the  curved  finger, 
the  thumb  and  index  finger,  or  the  forefinger  and  a  scoop;  in  others  it  de- 
mands the  use  of  forceps,  which  here  admit  generally  of  more  easy  manage- 
ment than  they  do  in  sub-pubic  lithotomy.  The  precautions  to  be  attended  to 
in  using  them  are  precisely  the  same,  save  that  more  care  must  now  be  taken . 
than  before  to  avoid  detaching  the  bladder  from  the  pubis  and  abdominal 
parietes,  by  tearing  the  lax  cellular  tissues  which  connect  these  parts  with  one 
another. 

The  Dressing. — Cystotomy  above  the  pubis,  different  from  other  varieties 
of  operation  for  stone,  has  much  engaged  the  attention  of  surgeons  as  it  respects 
the  dressings  which  are  adapted  to  it.  In  the  time  of  Rousset  stitching  the 
wound  was  practised,  and  has  since  often  been  put  in  execution.  Through  its 
assistance  it  was  hoped  that  urine  would  be  prevented  from  escaping  by  the 
hypogastrium,  and  causing  infiltration  outside  of  the  bladder.  TJiis  suture, 
which  was  oftener  recommended  than  adopted,  was  not  understood  in  the  same 
sense  by  all  author?  who  ventured  to  advise  it.  Solingen,  one  of  its  warmest 
partisans,  does  not  express  himself  with  sufficient  clearness  for  us  to  under- 
stand positively  whether  he  sewed  the  skin  merely,  or  included  in  the  stitch 
all  the  thickness  of  the  lips  of  the  wound.  Others  have  spoken  on  the  subject 
more  categorically.  Douglas,  for  example,  thinks  that  the  suture  through  the 
integuments  will  be  sufficient.  Professor  Rossi,  on  the  contrary,  maintains 
that  above  all  things  we  must  endeavor  to  sew  the  wall  of  the  bladder  itself, 
and  Dr.  Gehler  asserts,  that  we  should  include  both  in  one  thread. 

The  question  here  stated  is  a  serious  one,  which  can  be  determined  only  by 
experience.     Hitherto  the  cases  related,  either  in  favor  of  or  against  using 


OPERATIVE   SURGERY.  799 

suture  scarcel}'  prove  any  thing.  Heister  indeed  says  that  Pra3bisch  having 
performed  it  upon  a  patient,  the  man  was  soon  attacked  with  such  alarming 
symptoms  that  he  was  obliged  to  cut  the  stitch  and  withdraw  the  threads. 
But  how  was  this  done?  What  tissues  had  it  penetrated?  How  far  was 
coaptation  perfectly  affected  ?  Of  all  this  we  know  nothing  whatever.  Yet 
until  we  do  know  it,  it  is  impossible  to  say  whether  it  is  to  the  stitch  or  the 
surgeon  that  these  symptoms  which  Heister  describes  are  to  be  attributed. 
In  the  year  1825,  M.  Pinel  Gmndchamp  engaged  in  some  researches  upon  this 
subject.  He  opened  and  sewed  up  the  bladder  in  a  certain  number  of  dogs, 
and  in  this  animal  the  operation  so  perfectly  succeeded,  that  in  no  case  did 
the  least  effusion  occur,  but  immediate  adhesion  followed  in  all.  Since  then 
M.  Amussat  has  decided  in  favor  of  it,  and  some  successful  cases  have  been 
related  in  the  Journals  which  were  communicated  by  him  to  the  academy  of 
medicine.  v 

Still  it  is  a  method  against  which  numerous  and  powerful  arguments  may 
be  urged.  And  first  it  is  not  probable  that  any  one  for  the  future  will  resort 
to  suture  of  the  integuments  alone,  nor  to  that  of  aponeurosis  or  muscles.  It 
in  fact  closes  the  passage  of  urine,  but  does  not  prevent  them  from  escaping 
from  the  bladder;  compelling  this  fluid,  in  other  words,  to  effuse  itself  in  the 
pelvis.  As  to  suture  of  the  wound  in  the  bladder  it  is  far  from  being  always 
easy.  Did  the  urinary  bladder  remain  distended  to  the  close,  or  did  the  in- 
cision in  its  anterior  wall  not  go  below  the  upper  edge  of  the  symphysis, 
and  were  the  hypogastrium  always  thin,  we  might  indeed,  I  think,  look  for 
success  from  it.  But  since  the  incision  extends  towards  the  prostate,  how 
can  we  be  sure  that  we  leave  no  void  between  its  edges  in  its  lowest  part  ? 
And  if  they  are  not  in  perfect  coaptation  who  does  not  perceive  that  an  oozing 
of  urine  will  infallibly  occur,  which  fluid  will  be  effused  between  the  organs 
it  is  intended  to  close,  and  more  or  less  solid  tissues  which  surround  it. 
Lastly,  it  is  also  to  be  apprehended  that  the  stitches  themselves  by  enlarging 
will  allow  passage  to  the  urine,  and  some  regard  must  be  had  to  the  pain  which 
they  occasion  and  to  the  length  which  they  give  to  the  time  of  the  operation. 
It  is  a  method,  therefore,  which  is  of  advantage  only  in  cases  where  it 
is  possible  to  coaptate  with  perfect  nicity  the  incision  in  the  bladder  in  its 
entire  extent;  but  it  also  demands  that  the  furrier's  suture,  the  only  one  which 
can  reasonably  be  adopted,  should  be  capable  of  being  perfonned  without 
tearing  too  much,  or  disturbing  too  extensively  the  circumjacent  cellular 
tissue.  As  it  is  necessary  to  leave  a  portion  of  the  thread  to  hang  out  of  the 
wound,  which  of  itself  would  not  fail  to  prove  a  cause  of  abscess  and  infiltration, 
I  think  upon  the  whole  that  in  hypogastric  cutting,  suture  in  any  form  ought 
to  be  rejected. 

The  indication,  nevertheless,  which  the  introduction  of  stitches  is  intended 
to  answer,  is  one  of  a  very  important  kind ;  and  has  therefore  unceasingly 
engaged  attention.  After  many  trials  it  was  thought  that  to  leave  a  catheter 
in  the  wound  would  be  a  very  sure  way  of  carrying  off  the  urine  outwardly. 
Solingen  seems  to  have  been  one  of  the  first  who  conceived  this  idea.  It  is 
not  yet  quite  certain  whether  the  leather  catheter  of  which  he  speaks  was  not 
introduced  per  urethram,  and  not  into  the  hypogastrium ;  but  a  German  sur- 
geon, Huermann,  leaves  no  doubt  on  the  subject,  for  Sprengle  distinctly  states 
that  htt  much  lauded  the  usefulness  of  a  catheter  buried  in  the  incision  after 


800  NEW  ELEMENTS  OF 

the  operation.  An  operation  performed  in  the  month  of  December  1818,  and 
published  in  the  following  year  in  Dublin  by  Mr.  Kirby,  shows  that  this 
gentleman  had  confidence  in  Huermann's  practice,  for  having  performed  the 
nigh  apparatus  he  left  a  tube  in  the  wound.  In  France,  M.  Amussat,  who 
thought  the  idea  original  with  himself,  expressed  himself  strongly  in  its  favor. 
The  tube  he  uses  is  two  or  three  inches  long,  as  thick  as  a  finger,  and  terminates 
m  the  bladder  by  a  swelled  extremity  perforated  with  holes  like  the  spout  of 
a  watering  pot.  When  introduced  he  closes  the  cut  directly  above  and  below, 
either  by  stitches  or  adhesive  straps.  Unhappily  the  hopes  by  some  enter- 
tained of  this  practice  have  not  been  realized.  Mr.  Kirby  after  four  days 
perceived  the  urine  passing  out  between  the  canula  and  the  edges  of  the 
wound.  In  some  operations  performed  by  M.  Amussat  himself,  the  same 
thing  happened.  Afterwards  the  case  of  a  patient  at  the  Hospital  St.  Louis, 
in  whom  the  tube  did  not  hinder  even  if  it  were  the  cause,  the  formation  of 
an  urinary  abscess.  Moreover  it  is  impossible  to  conceal  one's  surprise  that 
M.  Amussat  should  extol  such  a  method,  and  ascribe  such  vast  advantages  to 
it,  when  he  confesses  himself  that  he  has  lost  three  patients  out  of  twelve; 
while  more  than  a  century  ago  Sermes  lost  only  one  in  sixteen,  and  Thornhill 
two  out  of  thirteen.  It  is  a  law  of  the  human  organization  that  an  enclosed 
foreign  bpdy,  pressing  equally  on  every  side  in  the  centre  of  a  wound,  is  soon 
at  liberty,  and  allows  fluids  to  escape  upon  its  external  surface.  A  canula 
therefore  cannot  prevent  urinal  infiltration;  and  as  its  presence  must  be 
attended  with  inconvenience  it  well  deserves  the  neglect  in  to  which  it  has 
fallen.  With  so  much  reluctance  have  surgeons  abandoned  this  idea,  that 
they  have  turned  their  thoughts  into  another  channel  in  order  to  eiFect  the 
object — that  of  carrying  off  the  urine  externally  as  rapidly  as  it  is  furnished 
by  the  ureters. 

For  this  purpose  M.  Segales  has  proposed  that  a  skein  of  cotton  should  be 
enclosed  in  a  gumelastic  catheter ;  that  one  end  of  this  skein  should  be  placed 
in  the  bladder,  and  the  other  end  be  left  hanging  out  of  the  urethra  to  act  as  a 
filter ;  doubtless  forgetting  that  even  admitting  its  efficacy,  the  thing  should 
answer  exactly  the  same  end  though  it  were  placed  in  the  wound  in  the  hypo- 
gastrium.  M.  Souberbielle  has  recommended  the  use  of  a  breath  syphon, 
made  of  a  thick  flexible  catheter  placed  in  the  urethra,  and  of  a  long  gum- 
elastic  stem,  which  is  plunged  into  a  vase  placed  beneath  the  level  on  which 
the  patient  lies.  To  fulfill  the  same  indication,  M.  Heurteloup  has  invented 
the  "  uretro-cystic  tube,"  which  in  a  measure  combines  the  plans  of  MM. 
Segales  and  Amussat,  as  it  is  composed  of  a  hollow  stem  which  passes  out  of 
the  wound,  and  a  similar  one  which  fills  the  urethra,  so  that  the  urine  must 
enter  by  lateral  apertures  which  it  meets  with  near  the  neck  of  the  bladder, 
and  of  course  escape  by  one  end  or  the  other.  Experience  has  not  yet 
declared  in  favor  of  either  of  these  resources  :  and  when  we  reflect 
upon  the  irritation  to  which  they  subject  the  urethra,  the  bladder,  or  the 
wound;  when  it  is  noticed  that  in  the  horizontal  posture  assumed  by  the 
patient  after  the  operation,  the  level  of  the  artificial  wound  is  sometimes 
lower  than  that  in  the  urethra  opposite  the  suspensory  ligament  of  the  penis, 
it  is  really  difticult  to  coincide  with  the  inventors  in  the  advantages  which 
they  promise  themselves.  One  thing  to  which  enough  attention  has  not  been 
paid,  is  the  reason  of  this  almost  insuperable  tendency  which  the  urine  has  to 


OPERATIVE    SURGERY.  801 

flow  over  the  pubis.  It  seems,  at  first  glance,  that  it  must  ascend  contrary  to 
gravity.  But  on  a  closer  inspection,  this  does  not  appear  to  be  the  case.  In 
fact,  it  is  rare  for  the  vesical  incision  in  hypogastric  cutting  not  to  descend 
nearly  as  low  as  the  prostate,  and  at  least  to  the  middle  of  the  height  of  the 
symphysis.  This  granted,  it  is  easy  to  assure  oneself  that  the  urethra  when 
it  escapes  from  under  the  arch  rises  to  as  great  a  heiglit  at  least,  even  when  a 
man  stands  in  an  upright  position  ;  and  that  lying  down  or  in  a  horizontal 
posture,  the  urine  certainly  has  further  to  go  to  get  there  than  to  reach  the 
lower  angle  of  the  wound.  It  is  consequently  all  labor  lost  which  is  spent  in 
the  attempt  to  use  similar  measures.  Most  practitioners  limit  themselves  to 
the  use  of  skeins  of  cotton  or  strips  of  linen,  of  which  one  end  rests  in  the 
bladder  to  act  as  a  filter.  Pledgets  of  lint  and  dried  roots  of  plants  would  do 
more  harm  than  good.  It  is  not  certain  that  the  simple  strip  of  raveled  linen, 
used  by  F.  Come  has  any  solid  advantages.  Certainly  if  it  be  recurred  to  it 
ought  not  to  be  steeped  in  oil,  nor  any  sort  of  grease ;  and  as  blood,  pus,  &c. 
wliich  it  imbibes  speedily,  before  long  destroy  its  permeability,  very  little 
benefit  can  be  expected  from  it.  The  only  real  necessity  which  the  surgeon 
feels  is  to  prevent  the  parts  as  they  approximate  too  soon  towards  the  integu- 
ments from  off'ering  any  impediment  to  the  flow  of  fluids  coming  from  the 
bladder.  If,  during  the  first  twenty-four  hours,  we  were  to  put  nothing 
between  the  lips  of  the  v/ound,  some  danger  might  be  apprehended  in  this 
respect;  but  later  than  this,  when  the  morbific  process  has  commenced  the 
perviousness  of  the  tissues  is  so  much  lessened  that  we  rely  upon  the  organism 
for  all  that  concerns  cicatrization  and  the  exit  of  urine. 

The  position  of  the  patient  after  cutting  by  the  high  apparatus  need  not  be 
continued  as  long  as  iii  perineal  lithotomy.  He  may  turn  to  one  side 
and  to  the  other,  and  even  sit ;  at  the  present  time  no  one  would  advise 
that  he  should  lie  constantly  on  Ids  abdomen,  as  was  tlie  idea  of  some  one  in 
the  last  century.  I  may  add,  that  when  the  time  for  the  first  symptoms  to 
occur  is  past,  at  tlie  end  of  five,  six^  or  eight  days,  and  no  accidents  have 
happened,  and  no  fever  is  present,  the  patient  may  leave  his  bed  and  soon 
after  walk  about  without  risk,  and  on  the  contrary,  with  advantage;  for  a  ver- 
tical posture  or  a  sitting  one  indisputably  favors  the  passage  of  urine  through 
the  natural  passage. 

Unfavorable  Occurrences. — Hemorrhage,  to  prevent  which  so  much  care 
has  been  taken  in  perineal  lithotomy,  and  against  which  it  should  seem  that 
cutting  through  the  hypogastrium  must  offer  security,  has  notwitlistanding 
several  times  been  known  to  follow  this  latter  operation.  Pye  has  recorded  a 
remarkable  example  of  it.  Another  exists  among  the  cases  of  Thornhill,  as 
related  by  Middleton  ;  a  third  in  the  works  of  M.  Belmas ;  and  I  understand 
that  last  year  it  had  nearly  proved  fatal  to  a  patient  operated  on  by  M.  Sou- 
berbielle.  Tims  far  surgeons  have  not  specified  the  particular  vessel  from 
which  it  issues.  Some  have  thought  that  it  depended  on  the  subcutaneous 
veins  or  arteries  being  larger  than  usual.  Others  have  supposed  arterial 
anomalies  in  the  thickness  of  the  linen  alba,  or  in  the  fascia  propria.  It  has 
also  been  attributed  to  sano-uineous  exhalation  from  the  inner  surface  of  the 
bladder.  All  these  are  merely  more  or  less  probable  suppositions;  not  facts 
really  demonstrable.  Anatomy  would  soon  explain  the  occurrence  if  prac- 
tice had  been  more  intent  on  determining  its  seat.  It  might  so  happen,  for 
101 


802  •  NEW  ELEMENTS  OF 

example,  that  the  arteries  which  ascend  naturally  over  the  sides  of  the  bladder 
and  cross  one  another  above  its  neck,  might  form  a  loup  large  enough  to  produce 
it.  It  would  be  equally  possible  that  the  dorsal  arteries  of  the  penis,  coming 
directly  from  the  hypogastric  and  passing  on  the  sides  of  or  above  the  pros- 
tate, as  described  by  Burns,  Senn,  Shaw,  &c.  might  be  divided  if  the  incision 
extended  very  far  down. 

Be  this  as  it  may,  the  event  is  an  uncommon  one,  and  art  possesses  several 
means  of  conquering  it  with  facility.  If  it  occurs  during  the  performance  of 
the  operation,  all  the  divided  tissues  being  beneath  the  eye,  it  may  be  possible 
to  lay  bare  the  open  artery,  to  seize  it  with  forceps  of  sufficient  length,  and  to 
twist  or  tie  it.  Under  opposite  circumstances,  that  is  to  say,  when  hemorr- 
hage does  not  come  on  until  after  the  dressings  are  applied,  we  may  begin  by 
keeping  them  moist  with  cold  water  for  several  hours,  unless  the  quantity  lost 
is  likely  to  exhaust  the  patient.  In  that  case  we  must  remove  the  dressings, 
and  look  for  the  vessel.  If  it  can  not  be  got  at  or  its  situation  be  discovered, 
tampons  soaked  in  the  eau  de  Rabel,  or  some  other  styptic  liquid,  should  be 
passed  down  even  within  the  bladder  itself;  or  we  might  pass  into  it  a  roll 
of  lint  of  some  size,  tied  in  the  middle  by  a  long  double  thread,  capable  of 
receiving  between  its  two  ends  a  second  tampon,  on  which  they  should  be 
fastened  in  front  of  the  wound  in  such  a  way  as  to  compress  the  tissues  suf- 
ficiently from  behind  forwards.  We  should  previously  remove  all  the  coagula 
contained  in  the  bladder,  and  wash  out  this  sac  freely  by  injections  of  water. 
Middleton  says,  that  the  prostate  may  be  wounded  when  the  incision  is  too 
deep,  which  is  true ;  and  besides,  that  this  wound  often  gives  rise  to  a  dan- 
gerous ulcer,  which  appears  to  me  to  be  wholly  unfounded.  He  also  speaks 
of  injury  done  to  the  symphysis  pubis,  and  the  consequences  which  may 
result;  but  at  this  day  no  one  troubles  himself  about  such  lesions,  which  in 
fact  are  not  worth  being  pointed  out. 

Abscess. — The  formation  of  abscesses  round  about  the  bladder  is  one  of  the 
occurrences  most  to  be  apprehended.  Douglas,  Cheselden,  and  almost  al! 
authors  who  since  then  have  treated  of  hypogastric  cutting,  have  mentioned 
them.  There  are  two  orders  of  them  which  we  must  be  careful  not  to  confound. 
The  one  depends  upon  the  infiltration  of  a  greater  or  less  quantity  of  urine 
between  the  bladder  and  surrounding  tissues ;  the  other  is  the  mere  result  of 
inflammation  in  the  cellular  tissue  of  the  pelvis. 

It  is  easy  to  see  that  if  the  operation  has  been  attended  with  a  gootl  deal 
of  detachment  and  extensive  laceration,  urine  will  easily  escape  into  the  cel- 
lular tissue,  instead  of  escaping  externally,  and  we  all  know  how  dangerous 
are  the  inflammations  caused  by  the  irritation  of  urine.  When  no  detach- 
ment has  occurred,  infiltration  is  very  rarely  observed.  Indeed,  after  a  few 
hours,  the  lips  of  the  wound  have  lost  much  of  their  porousness,  and  fluid 
goes  through  them  without  getting  into  their  meshes  by  weight  or  capillary 
attraction,  as  might  have  been  feared;  so  that  unless  an  excavation,  a  cul- 
de-sac  allows  of  its  accumulation  in  it  outside  of  the  bladder,  it  is  not  com- 
mon for  its  escape  through  the  opening  in  the  hynogastrium  to  be  troublesome 
after  the  first  day.  Unless  the  reaction  be  excessive  the  parts  become  very 
red;  unless  tliere  be  very  high  fever  with  a  strong  full  pulse,  sanguineous 
evacuation,  either  general  or  by  leeches,  is  rarely  required  in  such  cases. 
Urine  spreading  by  transudation  into  the  lamellar  tissue,  is  a  death-bearing 


OPERATIVE    SURGERY.  803 

fluid.  If  there  is  anything  that  can  stay  its  ravages,  it  is  only  incisions  in 
large  numbers,  made  deep  into  all  the  infiltrated  parts  and  their  neighborhood 
as  soon  as  possible.  Unhappily  this  means  cannot  always  reach  the  seat  of 
the  evil ;  but  of  course  they  must  be  always  performed  wherever  they  can  be 
made  with  safety.  The  wounds  are  then  dressed  immediately,  at  least  until 
the  eliminatory  inflammation  shows  itself,  with  camphorated  brandy,  decoc- 
tion of  kino,  or  some  of  the  chloruretted  solutions.  Common  abscess,  without 
urinal  infiltration,  is  less  frequent;  and  depends  almost  always  upon  the 
manner  in  which  the  operation  has  been  performed. 

When  the  bladder  has  been  opened  by  the  dard  or  bistoury,  it  is  so  easy  for 
the  forefinger  to  push  it  back  instead  of  entering  its  cavity,  that  it  often  de- 
taches it  entirely  from  the  back  of  the  pubis ;  and  creates  here  a  large  pouch, 
which  almost  necessarily  causes  violent  phlogosis  followed  by  profuse  sup- 
puration. I  have  no  doubt  that  this  has  happened  in  most  of  those  cases  in 
which  it  has  been  asserted  by  operators  that  the  bladder  consisted  of  two 
cavities,  the  one  anterior,  in  which  nothing  was  found,  and  a  posterior  one 
which  contained  the  calculus.  Here  an  antiphlogistic  treatment  is  necessary 
when  the  patient  is  able  to  support  it ;  and  that  this  serious  aft'ection  is  not 
furtiier  complicated  by  urinal  infiltration  the  fluid  must  be  evacuated,  as 
freely  as  possible  and  we  must  not  fear  to  multiply  incisions  or  to  extend 
their  length  in  diff*erent  directions. 

Injury  of  the  Peritoneum, — The  injury  most  spoken  of  in  hypogastric  cut- 
ting is  incontestibly  that  of  the  peritoneum.  Nearly  all  authors  have  con- 
sidered it  as  one  of  the  most  alarming,  and  some  as  being  invariably  fatal. 
Without  wishing  to  extenuate  its  danger,  I  do  think  that  the  risk  has  been 
singularly  exaggerated  nevertheless.  Certainly  it  alone  is  not  very  much  to 
be  feared.  It  is  dangerous  rather  from  allowing  the  urine  to  pass  into  the 
abdomen.  Now  the  operation  is  no  sooner  ended  than  the  bladder  collapses, 
retracts,  and  gathers  itself  into  a  heap  behind  the  symphysis  pubis.  The 
w^ound  in  its  wall  then  ceases  to  coincide  with  that  in  its  serous  tunic.  Con- 
sequently the  urine  cannot  in  truth  escape  in  that  way  and  reach  the  abdomi- 
nal cavity.  What  proves  this  much  better  than  argument,  is  the  fact  that 
the  peritoneum  has  often  been  wounded  without  any  serious  accident  result- 
ing, and  that  in  those  who  have  died  with  this  injury  about  them,  causes  of 
death  perfectly  unconnected  with  its  occurrence  have  been  discovered.  One 
of  Douglas's  patients  had  the  peritoneum  opened,  and  yet  recovered  as  well  as 
if  nothing  had  happened.  One  of  Thornhill's  was  equally  fortunate.  It  is 
even  said  of  another  who  likewise  recovered,  that  the  intestines  came  through 
the  wound,  and  their  reduction  became  necessary.  This  accident  has  been 
met  with  by  F.  Come  and  M.  Souberbielle,  who  neither  of  them  seem  to  fear 
it.  A  woman,  who  was  operated  on  at  Tours,  in  1828,  by  M.  Crozat,  had  also 
a  very  large  opening  in  the  peritoneum;  nevertheless  she  perfectly  recovered. 
They  say  that  last  year  a  celebrated  operator  was  not  equally  lucky;  but  if 
the  statement  given  of  the  operation  is  a  faithful  one,  a  pledget  was  intro- 
duced into  the  interor  of  the  serous  cavity  instead  of  into  the  bladder ;  and 
therefore  this  case  can  be  considered  as  no  criterion  of  the  danger  of  cutting 
the  peritoneum.  It  would,  I  think,  be  adding  greatly  to  its  danger  when  it 
does  happen  to  sow  its  edges,  as  McGill  recommends,  or  to  stitch  up  the 
whole  solution  of  continuity,  at  least  in  its  upper  part,  as  Douglas  advises  us 


804  NEW    ELEMENTS   OF 

to  do.  A  pledget  of  lint  or  a  strip  of  linen  placed  quite  below  the  cut,  pene- 
trating even  into  the  bladder  is  all  that  in  such  a  case  is  reallj  required.  A 
strip  of  diachylon  plaster  may  be  put  on  above,  and  the  patient  should  be 
prohibited  from  making  any  motion  capable  of  pusning  the  viscera  towards 
the  peritoneal  aperture. 

B.  Of  Cutting  for  Stone  in  the  Female, 

Women  are  much  less  liable  to  calculous  affections  than  men,  and  get  rid 
of  them  much  more  easily.  The  urethra  in  them  is  short,  straight,  and  wide, 
so  that  small  calculi  pass  through  it  with  the  greatest  ease,  and  seldom  grow 
to  any  size  within  the  urethra.  However,  they  are  sometimes  observed,  and 
then  it  becomes  necessary  to  have  recourse  to  the  same  means  which  are 
employed  in  the  other  sex  for  their  extraction.  Lithotomy  in  women  is 
equally  performed  by  the  high  and  the  low  apparatus.  The  first  of  these 
methods,  as  it  is  subjected  to  the  same  rules  in  every  respect  as  in  man, 
requires  from  us  no  description ;  not  so  the  second,  in  which  we  shall  perceive 
that  recto-vesical  cutting  is  superseded  by  the  vagino-veiscal  and  lateraiized 
cutting  by  incision  of  the  urethra. 

Art.  1. — Anatomical  Remarks, 

The  bony  strait,  which  in  females  is  much  wider  and  more  shallow,  offers 
in  other  respects  the  same  anomalies,  the  same  peculiarities,  gives  insertion 
and  attachment  to  the  same  muscles  and  aponeuroses  as  in  the  male.  The 
soft  parts  alone  are  not  similarly  distributed,  Thevagina,  situated  between 
the  rectum  and  the  bladder,  is  the  cause  of  most  of  the  differences  observed 
in  it.  It  is  this  part,  which  renders  the  -^tudy  of  the  posterior  aponeurosis 
and  of  the  intestine,  and  likewise  of  the  perineum  properly  so  called,  almost 
useless,  as  to  whatever  concerns  lithotomy  in  the  female;  which  makes  the 
horizontal  aponeurosis  almost  wanting;  and  which  does  away  almost  with  the 
free  triangular  space  between  the  ischio,  and  bulbo  cavernosi  muscles,  so  that 
our  remarks  must  be  confined  wholly,  or  nearly  so,  to  the  urethra,  uretro 
vaginal  septum,  and  the  tissues  which  immediately  connect  and  surround 
tliem.  The  urethra  is  from  twelve  to  fifteen  lines  in  length;  it  is  wider  back- 
wards than  in  front  by  a  diameter  of  two  to  three  lines;  superiorly  it  is 
slightly  concave,  and  is  neither  surrounded  by  prostate  gland,  bulb,  or  by  a 
spongy  portion,  so  that  in  some  manner  it  is  reduced  to  the  membranous 
portion  of  tlie  male.  Backwards  it  is  adherent  in  its  whole  extent  along 
rhe  median  line  to  the  wall  of  the  vagina,  and  corresponds  to  the  longi- 
tudinal ridge  to  the  anterior  median  column  of  this  canal,  which  interposes 
between  their  interiors  a  thickness  of  three  or  four  lines.  As  the  vagina 
is  much  wider,  it  naturally  extends  on  either  side  beyond  the  urethra,  and 
seems  even  in  certain  cases  to  turn  up,  laterally,  as  if  to  embrace  its  con- 
cavity ;  from  whence  it  follows,  that  a  cutting  instrument  would  infallibly 
wound  it,  which  should  pass  from  the  duct  of  urine  obliquely  outwards  and 
downwards.  It  is  conceivable  moreover  that  this  wound  would  be  the  more 
likely,  according  to  the  width  of  the  vulvo  uterine  canal,  and  to  the  number  of 
labors  greater  or  less  had  by  the  woman,  consequently  greater  in  the  mar- 


i 


OPERATIVE    SURGERY.  805 

ried  woman  than  in  virgins  and  children.  The  bas-fond,  or  vesical  trigonal 
space,  is  like  the  urethra  connected  with  the  anterior  face  of  the  vagina ;  but 
instead  of  quitting  it  as  in  man  it  quits  the  rectum,  this  portion  of  the  blad- 
der ascends  almost  up  to  the  body  of  the  wound  before  the  peritoneal  layer  is 
reflected  over  it;  a  very  great  advantage,  insomuch  as  that  with  such  an 
arrangement  of  parts  we  may  fearlessly  divide  the  whole  vesico-vaginal  sep- 
tum from  the  os  tinea  down  to  the  urethra.  It  must  moreover  be  remarked, 
that  as  we  need  have  no  concern  for  vesiculae  seminales,  vasa  deferentia,  or 
ejaculatory  canals,  the  surgeon  is  much  freer  to  search  for  the  stone,  and  in 
fact  has  nothing  to  fear  but  wounding  the  ureters,  which  are  placed  sufficiently 
outwards  to  be  almost  always  easily  avoided. 

The  female  urethra,  inspected  upon  its  anterior  surface,  does  not  differ  as 
much  from  that  of  the  male;  still  it  is  covered  by  the  prostatic  frenum,  no 
muscle,  and  has  only  the  loose  cellular  tissue  which  separates  it  from  the 
pubis,  the  small  veins  which  environ  it,  and  the  dense  filamentous  tissue 
which  attaches  it  beneath  the  arch  in  common  with  the  other.  This  tissue, 
by  the  bye,  is  sufficiently  remarkable.  It  is  dense,  elastic,  and  possesses  a 
certain  degree  of  porousness;  presenting  some  of  the  characters  of  the  yel- 
low fibrous  tissue,  and  forming  a  thick  stratum  several  lines  thick,  conti- 
nuous in  front,  behind,  and  also  below,  with  the  sub-pubic  ligament,  and  also 
with  the  inferior  face  of  the  clitoris  which  corresponds  to  the  end  of  the 
symphysis.  The  labia  minora,  which  coming  from  the  corpora  cavernosa, 
seem  to  lose  themselves  obliquely  outwards  on  the  inner  surface  of  the 
larger  ones  two  or  three  inches  lower  down,  have  between  them  a  triangular 
separation,  whose  summit  is  represented  by  a  small  excavation  which  divides 
the  urethra  from  the  clitoris,  and  through  which  a  bistoury  can  pass  directly 
into  the  bladder.  Following  their  direction  and  inner  edge,  lateralized  cut- 
ting after  the  method  of  frere  Jacques  may  be  performed.  The  riieatus  urina- 
rius  may  be  distinguished  amid  all  its  parts  by  the  little  tumor  which  it 
forms  just  above  the  opening  into  the  vagina.  The  arteries  are  so  small  in 
the  female  perineum  as  to  scarcely  deserve  the  surgeon's  attention.  The 
transverse  and  that  of  the  bulb  are  reduced  to  small  twigs;  the  pudic  itself, 
very  small  posteriorly,  is  extremely  delicate  long  before  it  terminates  upon 
the  clitoris. 

Art.  2. — Examination  of  the  Methods  of  Cutting. 

By  some  surgeons  it  has  been  said,  that  all  lithotome  procedures  applicable  to 
man  might  be  equally  practised  on  the  woman.  This  assertion  is  certainly  erro- 
neous. The  apparatus  major  for  one  will  never  be  performed ;  and  as  much 
may  almost  be  said  of  bilateral  cutting,  at  least  if  done  by  the  lower  surface 
of  the  urethra.  We  have  then  remaining  the  lateralized  operation,  and  that 
by  the  apparatus  minor  and  vaginal  cutting. 

§  1.  Old  Methods. 

•  a.  Lateralized  method,  better  called  Lateral  cutting. — The  ancient  Greeks, 
Arabians,  and  surgeons  of  the  middle  ages,  performed  lateral  cutting  in  women 
as  in  men.    Whilst  staffs  were  not  in  use,  they  brous:lit  down  the  calculus 


m 


NEW   ELEMENTS  OF 


into  the  neck  of  the  bladder,  and  held  it  there  by  two  fingers  in  the  vagina, 
or  if  the  patient  was  a  virgin  in  the  rectum,  curved  like  hooks.  They  then 
incised  from  the  integuments  towards  the  bladder  all  the  tissues  laying  over 
the  stone,  in  an  oblique  direction  from  above  downwards  and  outwardly  from 
within.  Brother  Jacques  altered  the  process  merely  by  using  a  staff  to  make 
the  parts  tense,  whereby  he  was  enabled  to  avoid  seeking  the  stone  by  the  fin- 
gers in  the  rectum  or  vagina.  The  trials  made  by  this  monk  before  Marechal 
andDeMery,  having  shown,  as  a  correct  anatomical  knowledge  of  parts  might 
have  led  us  to  suppose,  that  the  vagina  was  always  wounded  and  that  the 
rectum  could  easily  be  injured,  it  was  speedily  abandoned,  so  that  at  present 
it  is  neither  recommended  by  any  one  nor  performed. 

b.  Method  of  Celsus  or  of  M,  Lisfrcmc. — Celsus  expresses  himself  so  ob- 
scurely, and  with  such  little  minuteness  about  cutting  in  the  female,  that  it  is 
difficult  to  know  accurately  what  he  meant  by  these  words  ;  "mulieri  vero 
inter  urinse  iter  et  os  pubis  incidendum  est  sic  ut  utroque  loco  plaga  trans- 
versa sit."  Some,  M.  Desruelles  among  others,  think  that  in  the  days  of  this 
author  an  incision  was  made  either  transverse  or  semilunar  between  the  meatus 
nrinarius  and  the  root  of  the  clitoris,  and  that  through  that  they  went  in 
search  of  the  stone,  as  in  men  is  done  between  the  scrotum  and  anus.  But 
as  lias  been  remarked  by  M.  Coster,  it  is  not  impossible  that  Celsus  had  in  his 
mind  the  incision  into  the  urethra  itself  instead  of  that  which  1  have  detailed. 
It  is  not  clear,  either,  how  surgeons  contrived  to  make  the  stone  bulge  out 
above  the  urethra,  and  it  is  difficult  in  such  a  case  to  agree  literally  to  M. 
Desruelles's  version. 

From  this  it  would  appear  that  M.Lisfranc's  operation,  which  consists  in  en- 
tering at  the  vestibule,  is  not  a  reproduction  from  the  ancients.  It  was  sup- 
ported by  M.  Meresse,  in  1823,  at  Montpelier,  and  explained  at  length  in 
the  Archives  for  the  year  1824,  and  is  done  in  the  following  way. 

A  staff  is  first  passed  into  the  bladder,  in  such  a  way  as  that  its  groove  or 
convexity  should  be  turned  upwards  and  forwards,  instead  of  resting  as  in 
man  downwards  and  backwards.  Seated  before  the  perineum,  provided  with 
a  straight  bistoury  the  surgeon  makes  an  incisionof  a  semilunar  shape  between 
the  clitoris  and  external  orifice  of  the  bladder  which  skirts  the  inner  surface 
of  the  labia  minora,  has  about  the  same  curve  as  the  pubic  arch  at  its  upper  half, 
and  besides  includes  the  vagina  in  its  concavity.  He  then  divides  alternately, 
and  layer  by  layer,  all  the  tissues  which  separate  the  vestibulum  from  the  in- 
terior of  the  pelvis ;  comes  down  upon  the  anterior  surface  of  the  bladder,  at  the 
urethra  with  the  neck  of  the  organ ;  strikes  on  the  stafi';  cuts  upon  its  groove, 
carries  the  incision  further  up  turning  the  edge  of  the  bistoury  in  that  direc- 
tion and  downwards  so  as  to  divide  longitudinally  the  posterior  part  of  the 
urethra,  or  else  cut  across  the  reservoir  of  urine  for  a  length  of  twelve  or  fif- 
teen lines.  As  the  adhesions  of  the  urethra  have  all  been  destroyed  by  the 
anterior  incision,  it  becomes  easy  to  press  down  this  canal  and  crowd  it  down 
to  the  lower  wall  of  the  vagina,  and  so  create  a  large  space  in  the  upper  part 
of  the  pubic  arch,  of  which  1  have  many  times  satisfied  myself  upon  the  dead 
body.  Nevertheless  this  is  a  method  in  many  other  respects  so  faulty  th^t 
we  may  henceforward  assert  that  it  will  never  be  adopted.  Do  it  as  you  will 
the  stone  must  always  pass  through  the  narrowest  point  in  the  pelvic  outline. 
The  l^lad<ier  longitudinally  opened  can  never  give  passage  to  calculi  of  much 


OPERATIVE  SURGERY.  307 

size.  If  it  were  divided  cross-wise,  the  inevitable  separation  of  the  lips  of  its 
wound  in  a  place  so  encircled  with  cellular  tissue,  would  probably  not  fail  to 
give  rise  to  infiltrations  and  abscesses  of  the  alarming  nature  described  when 
speaking  of  hypogastric  cutting.  We  should  either  have  to  fear  an  urinary  fis- 
tula, or  incontinence  of  urine. 

c.  Vesico -vaginal  cutting. — The  idea  of  extracting  calculi  through  the  va- 
gina goes  back  at  least  to  the  time  of  Rousset,  as  this  author  states  that  he 
removed  in  this  way  eleven  from  a  Moman  in  whom  the  bladder  projected 
at  the  vulva.  Fabricius  Hildanus  followed  the  example  of  Rousset,  in  a 
case  in  which  the  vesieo-vaginal  septum  was  partially  perforated  by  the 
stone ;  then  afterwards  in  another  calculus  female,  whose  bladder  had  been 
lacerated  during  delivery.  Ruysch  also  performed  this  operation,  and  removed 
forty-two  stones  from  the  same  female,  in  whom  there  was  inversion  of  the 
vagina.  Tolet  did  the  same  under  circumstances  nearly  similar.  In  1740, 
Dr.  Gooch  encountered  a  patient  in  whom  the  vesieo-vaginal  wall  had  been  ulce- 
rated by  inflammation,  into  which  he  cut  to  remove  a  stone  which  weighed 
three  or  four  ounces.  M.  Faure  of  Limoges  transmitted  to  the  faculty  at  Paris 
in  1810  a  piece  of  wood  which  he  had  removed  from  the  bladder  of  a  young 
girl  by  an  incision  through  the  vagina.  M.  Clemot,  a  surgeon  of  Rochfort, 
performed  it  for  the  first  time  in  1814,  upon  a  young  female  aged  twenty-one ; 
and  soon  after  repeated  it  upon  another  patient.  Since  then  he  has  a  third  time 
had  recourse  to  it.  At  a  rather  later  period  M.  Flaubert  of  Rouen,  performed 
the  same  procedure  to  extract  a  needle  and  a  pin  which  had  become  the  nu- 
cleus of  a  stone  in  a  child  eleven  years  old.  In  1816,  he  operated  on  a  female 
thirty-three  years  old,  who  had  a  calculus  as  big  as  a  nut;  afterwards  upon 
another  one  aged  forty,  in  whom  the  stone  was  nearly  as  large  as  a  billiard 
ball.  On  the  lOtli  Dec.  1818,  he  did  it  a  fourth  time  upon  a  woman  twenty- 
one  years  of  age  and  removed  a  stone  as  big  as  a  large  nut.  M.  Rigal  de 
Gailiac,  also  operated  per  vaginam,  in  1814,  upon  a  woman  forty  years  old  in 
whom  the  stone  weighed  two  ounces  and  a  half.  The  same  surgeon  performed  it 
once  several  years  previously,  in  a  woman  thirty-eight  years  of  age 
who  for  eight  years  had  had  a  considerable  stone.  A  recent  example  has  been 
recorded  by  M.  Lavielle ;  and  M. Rigal,  jr.  has  lately  communicated  another  to 
the  Academy.  So  that  we  have  now  about  twenty"  cases  of  vesieo-vaginal  cut- 
ting, not  including  two  attributed  by  Dr.  Gooch  to  surgeons  of  his  country, 
about  which  he  gives  no  particulars. 

The  method  ojf  Operation^ — Many  of  those  who  have  performed  this  opera- 
tion, are  silent  as  to  the  procedures  which  they  adopted.  F.  Hildanus  who 
first  formally  proposed  it,  advised  that  a  scoop  of  very  small  calibre  should  be 
carried  into  the  bladder  through  the  uretlira  to  embrace  the  stone  in  its  spoon 
and  press  it  down  towards  the  vagina,  drawing  it  to  the  neck  of  the  bladder, 
so  that  the  surgeon,  cutting  down  on  the  projection  which  it  makes  in  the 
vulvo-uterine  canal,  may  extract  the  stone  by  tnis  passage.  The  procedure 
of  Mery,  which  consists  in  substituting  for  the  scoop  recommended  by  Fabri- 
cius, a  common  staff,  so  as  to  divide  the  vesieo-vaginal  partition  upon  its 
groove,  must  forever  have  done  away  with  the  adoption  of  that  of  the  Swiss 
surgeon.  Indeed  it  is  this  operation,  modified,  which  modern  surgeons 
pursue;  some  by  the  addition  of  a  gorget,  by  the  outer  end  of  which 
they  depress  the  vaginal  posterior  wall,  whilst  the  other  end  butts  against  the 


808  NEW    ELEMENTS    OF 

staff  in  front  of  the  cervix  uteri :  others  like  M.  Flaubert,  for  instance,  con- 
Uning  themselves  to  carrying  in  the  bistoury  flatwise  on  the  'right  forefinger, 
then  turning  its  edge  upwards  and  cutting  the  septum  from  before  backward 
or  from  behind  forwards  to  a  greater  or  less  distance  from  the  meatus  urina- 
rius. 

Position  of  the  Patient. — It  is  undoubtedly  possible  by  placing  the  woman 
in  the  position  for  ordinary  lithotomy,  to  attain  the  proposed  end.  However, 
I  think  that  if  she  lies  upon  the  abdomen  with  the  thighs  and  legs  flexed,  it 
would  be  easier  still  to  perform  the  necessary  incisions. 

The  instruments  necessary  are  merely  a  staff',  a  Marchettis*s gorget, a  straight 
bistoury  and  forceps.  The  staff"  is  first  introduced,  and  its  handle  elevated 
towards  the  pubis,  so  as  to  depress  the  bas-fond  of  the  bladder  upon  the 
median  line.  An  assistant  is  entrusted  with  keeping  it  in  the  situation.  The 
gorget  introduced  to  the  bottom  of  the  vagina  is  given  to  a  second  assistant, 
who  depresses  the  handle,  being  careful  to  make  it  a  fulcrum  for  the  staff*  at 
its  other  extremity,  and  that  its  groove  should  look  upwards  and  forwards 
when  the  woman  lies  upon  her  back  ;  and  backward,  on  the  contrary,  if  she 
is  placed  on  her  abdomen.  The  surgeon  separates  the  labia  majora  with 
the  thumb  and  first  fingers  of  his  left  hand  :  takes  his  bistoury,  holding  it  like 
a  pen  :  carries  its  point  behind  the  urethra,  that  is  to  say  to  a  depth  of  an 
inch  into  the  vagina  at  least ;  strikes  it  into  the  groove  of  the  staff',  slips  it 
along  upon  this  instrument  to  an  extent  of  eight  or  ten  lines  or  more  if  neces- 
sary, and  ends  his  incision  by  lowering  the  knife  a  little  ta  make  it  fall  into 
the  groove  of  the  gorget. 

It  may  also  be  held  in  the  second  position  :  i.  e.  the  hxindle  in  the  hollow  of 
the  hand,  and  the  cutting  edge  towards  the  bladder,  so  that  its  p^int  may 
enter  as  deeply  as  may  be  desired  to  divide  the  septum  from  behind  forwards, 
still  upon  the  groove  of  the  staff".  These  two  modes  diff'er  so  little  in  their 
definite  result,  and  in  the  ease  with  which  they  are  effected,  that  we  must 
leave  the  preference  of  one  over  the  other  to  the  taste  of  the  operator.  There 
can  be  no  doubt,  likewise,  that  the  surgeon  may  himself  hold  the  staff*  in  his 
left,  whilst  he  makes  the  incision  with  his  right  hand,  as  was  done  by  M.  Flau- 
bert, or  else  as  M.  Clemot  recommends  he  may  take  charge  of  the  gorget 
instead,  so  as  not  to  be  embarrassed  by  his  assistant  whilst  dividing  the  sep- 
tum; in  truth,  we  may  do  without  the  gorget  altogether,  in  imitation  of  the 
surgeon  of  Rouen,  and  carry  in  the  bistoury,  covered  by  the  inside  of  the  fore- 
finger into  the  vagina ;  so  as  to  open  the  bladder  without  any  other  assistance 
than  that  of  the  persons  who  attend  to  the  patient.  Yet  it  cannot  be  denied  that 
the  operator  who  has  both  hands  at  liberty,  will  be  more  at  his  ease  in  perform- 
ing his  principal  incision,  and  that  the  gorget  has  the  advantage  of  rendering 
tense  and  exposing  the  parts  which  are  to  be  divided  ;  only  it  would  be  well 
that  this  instrument  should  have  a  handle  bent  at  an  angle,  the  groove  ending 
in  a  cul-de-sac.  There  is  this  inconvenience  in  the  procedure  of  M.  Flaubert, 
of  beginning  the  incision  some  lines  behind  the  meatus  urinarius,  so  as  to  in- 
clude a  greater  or  less  extent  of  inner  wall  of  the  urethra:  first,  that  it  inno- 
v/ise  assists  the  exit  of  the  stone,  and  then  that  it  renders  cicatrization  of  the 
wound  long  and  difficult.  It  is  better  then  to  follow  MM.  Clemot,  Rigal,  and 
others,  and  to  begin  it  only  at  the  apex  of  the  trigone  vesicale  if  we  cut  from 
before  backwards,  or  to  terminate  it  at  that  point  if  we  prefer  incising  from 
behind  forwards.    The  vagina  being  four  or  five  inches  in  length,  we  have 


OPERATIVE    SURGERr.  809 

still  by  this  procedure  an  extent  of  two  inches  which  may  be  divided  without 
any  danger.  Besides  as  these  tissues  enjoy  a  considerable  distensibility,  it  is 
useless  to  make  a  larger  aperture  than  the  presumed  size  of  the  stone  would 
require. 

Extraction  of  the  Stone. — The  incision  being  made,  the  staft"  is  withdrawn. 
If  the  stone  do  not  of  itself  oifer  at  the  wound  or  fall  spontaneously  into  the 
vagina  as  sometimes  happens,  the  operator  proceeds  at  once  to  investigate  its 
situation  and  character  by  the  assistance  of  his  left  forefinger;  and  then 
extracts  it  with  proper  forceps  pursuant  to  the  rules  previously  established. 
When  the  stone  is  very  bulky,  and  we  are  operating  on  a  young  girl,  the 
narrowness  of  the  vagina  may  offer  some  difficulty  in  the  extraction.  In  a 
case  of  this  kind,  M.  Flaubert  was  obliged  to  break  the  foreign  body  and 
remove  it  piecemeal.  However,  as  the  canal  which  we  have  to  traverse  is 
easily  dilatable,  it  is  scarcely  possible  to  suppose  that  it  can  be  an  insurmount- 
able obstacle  to  the  termination  of  the  operation  of  cystotomy. 

Having  removed  the  stone  the  woman  is  replaced  in  bed,  and  subjected 
to  the  care  necessary  in  the  usual  sequeli  of  operations  for  calculus. 
The  consequences  in  the  vesico-vaginal  method  are  usually  very  simple. 
Hitherto  no  case  is  related  in  which  they  have  produced  death.  Generally 
not  even  fever  attends  them.  No  large  artery  can  be  opened.  The  peri- 
toneum is  too  high  up  to  run  any  risk,  and  the  cellular  tissue  in  the  septum  too 
dense  to  admit  of  urinal  infiltration.  The  wound,  however,  does  not  always 
heal  in  a  way  to  please  either  the  surgeon  or  his  patient.  Its  location  alone 
might  have  induced  the  supposition  that  it  would  turn  frequently  to  fistula, 
and  experience  unhappily  confirms  the  conjecture.  Without  including  in  the 
account  any  of  the  patients  first  operated  on,  who  continued  to  be  afflicted 
with  it,  though  it  is  not  mentioned  in  the  reports  of  their  cases,  it  is  certain 
that  in  three  cases  M.  Clemot  saw  it  once ;  that  three  patients  treated  by 
M.  Flaubert  are  affected  with  it;  and  that  the  one  whose  case  M.  Rigal,jr. 
related,  was  not  more  fortunate;  whence  it  follows  that  this  occurrence 
takes  place  once  in  four  cases.  M.  Coste  thinks  that  it  might  be  avoided  by 
approximating  the  edges  of  the  wound  by  suture  immediately  after  the  removal 
of  the  stone ;  but  then  vaginal  cystotomy  would  be  rendered  an  extremely 
long  operation  ;  and  we  may  even  entertain  some  doubts  from  our  experience 
of  such  attempts  for  the  cure  of  vesico-vaginal  fistula  of  the  common  kind, 
whether  we  should  derive  from  it  the  success  upon  which  this  surgeon  seems 
to  calculate. 

§  2.  Urethral  Methods  for  Extracting  Stones, 

For  many  years  past,  perineal  lithotomy  in  the  female  has  been  done 
almost  entirely  by  cutting  into  the  urethra.  This  canal  is  so  very  distensible, 
that  for  a  long  while  it  was  thought  practicable  to  remove  stones  from  it 
w'ithout  any  sort  of  incision.  Bartholin  speaks  of  a  patient  who  expelled  a 
calculus  of  the  diameter  of  more  than  two  inches ;  Borelli  of  another  which 
was  as  large  as  the  thumb.  Middleton  relates  that  in  a  fit  of  coughing  a 
woman  passed  one  which  was  four  ounces  in  weight.  Heister  has  collected 
some  examples  of  the  same  kind,  in  which  it  will  be  seen  that  a  stone  as 
big  as  a  nut  or  even  as  a  hen''s  egg,  passed  through  the  urethra  by  natural 
102 


SWI  NEW   ELEMENTS    OF 

-eflbrts  alone.  Francis  Collot  mentions  one  of  the  size  of  a  goose  egg,  which 
occasioned  ischuria  of  eight  days'  continuance.  Molineux  states  that  he  has 
seen  one  which  weighed  two  ounces  and  a  half;  and  that  of  which  Yeloli 
speaks,  weighed  upwards  of  three.  In  conclusion,  some  even  still  larger  are 
recorded  in  the  bibliotheque  of  Planque.  Kerkringius,  Morand,  Grunewald, 
and  the  scientific  compilations  both  ancient  and  modern  contain  many  more  not 
less  extraordinary.  Although  many  of  these  stones  may  have  come  from  the 
uterus  and  vagina,  and  not  have  formed  in  the  bladder,  it  is  incontestable 
nevertheless  that  many  among  them  were  really  expelled  per  urethram,  and 
that  in  certain  cases  this  extreme  dilation  has  not  been  followed  by  inconti- 
nence of  urine. 

a.  The  Method  by  Dilation  which  arose  upon  these  observations,  is  done  in 
two  principal  ways ;  in  one  we  proceed  rapidly  by  means  of  metallic  instru- 
ments ;  in  the  other,  on  the  contrary,  it  is  done  with  extreme  slowness,  and 
by  the  aid  of  pervious  bodies  for  the  time  left  to  remain  in  the  canal.  The 
author  of  the  first  of  these  plans  is  Tolet,  and  Douglas  that  of  the  second. 

Sudden  Dilatio7i. — The  procedure  of  Tolet  consists  in  introducing  the 
dilating  instruments  of  the  greater  apparatus  into  the  bladder,  and  gently 
separating  the  branches  until  it  is  possible  to  pass  in  both  fingers  and  forceps 
between  them  and  thus  extract  the  stone.  The  old  dilators  have  since  been 
superseded  by  the  following  procedure.  A  grooved  sound  acts  as  a  director 
to  a  gorget  whose  anterior  portion  is  narrow  which  rapidly  grows  thicker 
towards  its  handle.  By  its  assistance,  the  fore  or  little  finger  ®f  one  hand 
then  enlarges  the  urethra  from  before  backwards,  to  create  a  passage  for  the 
forceps;  in  what  way  soever  this  operation  be  attempted,  it  is  so  extraordi- 
narily painful  that  many  women  cannot  endure  it,  and  it  is,  moreover,  often 
followed  by  incontinence  of  urine,  laceration  of  the  urethra,  &c. 

Slow  Dilation. — Douglas  thought  that  he  could  do  away  the  inconveni- 
ences in  Tolet's  method  of  rough  and  sudden  dilation  by  effecting  it  with  a 
sponge  tent  or  a  dried  root  of  gentian.  To  this  day  this  plan  is  pursued  by 
those  who  think  it  possible  to  dispense  with  incising  the  urethra.  The  cjdin- 
der  made  of  the  coecal  appendix,  introduced  collapsed  into  the  bladder  filled 
with  water  and  then  drawn  forwards  from  behind  as  Bromfield  advises ;  and 
the  same  kind  of  dilator  contrived  by  M.  Arnolt  are  not  more  advantageous ; 
and  a  sponge  even  has  this  advantage,  that  it  allows  of  our  placing  in  its  mid- 
dle a  catheter  which  will  give  exit  to  the  urine  in  cases  in  which  it  is  neces- 
sary to  retain  it  long  in  the  part. 

It  would  be  wrong  to  suppose  after  all  that  this  species  of  dilatation  was 
much  less  painful  than  the  other,  or  that  it  protects  the  patient  against  incon- 
tinence and  the  many  other  accidents  which  the  former  is  accused  of' causing 
It  is  very  certain  that  pure  and  simple  incision,  as  it  is  now  performed,  brings 
with  it  no  more  danger,  causes  less  pain,  and  allows  of  a  more  speedy  relief 
to  the  patient;  so  that  dilation,  whether  slow  or  sudden,  is  suitable  only  to 
such  stones  as  do  not  exceed  five  or  six  lines  in  their  smallest  diameter. 

b.  Urethrotomy. — Incision  of  the  urethra  may  in  fact  be  performed  at  any 
part  of  the  two  upper  thirds  of  the  circumference  of  this  canal. 

Fleurant  has  proposed  to  divide  it  on  both  sides  at  once  with  a  double  litho- 
tome  introduced  closed,  and  withdrawn  open ;  beginning  the  incision  at  the 
neck  of  the  bladder  and  terminating  it  at  the  meatus  urinarious.  ,  Lewis, 


OPERATIVE   SURGERY.  811 

who  adopted  the  same  method,  preferred  cutting  from  before  backwards.  For 
this  purpose  he  had  invented  a  flattened  sheath  open  on  the  sides,  into  which 
passed  a  double  edge-cutting  instrument  from  without  inwards.  Le  Blanc, 
to  whom  he  communicated  his  project,  suggested  to  him  that  an  instrument 
which  cut,  or  a  sheath  which  was  open  only  on  one  side,  would  do  equally 
well.  But  all  the  procedures  done  with  the  like  instruments  are  now  fallen 
wholly  into  disuse,  and  all  that  is  necessary  for  performing  cutting  of  the 
urethra  is  a  straight  bistoury,  a  grooved  staif,  or  a  brother  Gome's  lithotome ; 
unless  indeed  we  renew  Fleurant's  proposal,  when  Dupuytren's  double  litho- 
tome may  find  a  new  application.  The  oldest  method,  and  that  which  has 
been  longest  pursued,  is  that  which  consists  in  passing  a  grooved  staft*  into 
the  bladder  to  act  as  director  to  a  long  straight  bistoury  with  which  the  whole 
extent  of  urethra  is  obliquely  divided  from  top  to  bottom,  and  from  right  to 
left.  But  this  procedure,  which  has  been  simplified  by  F.  Come  and  M.  Du- 
puytren  by  the  use  of  a  sheathed  lithotome  instead  of  the  bistoury  and  staff,  was 
often  followed  by  wounds  of  the  vagina,  and  also  admitted  of  a  division  of 
the  superficial  vessels  of  the  perineum,  a  swell  as  of  the  pudic  artery  itself 
if  the  incision  were  extended  a  little  too  far,  and  it  has  owing  to  these  circum- 
stances been  generally  abandoned  since  the  adoption  of  the  plan  of  cutting 
the  urethra  directly  from  above  downwards.  The  date  of  the  origin  of  the 
last  method  goes  back  at  least  to  the  sixteenth  century,  though  attributed  to 
M.  Dubois.  Pare  gives  the  credit  of  it  to  Collot ;  after  having  given  a  plate 
of  the  grooved  staff,  he  says:  **  Other  practitioners  operate  in  another  way, 
as  I  have  seen  master  Laurent  Collot  do  often ;  which  is  not  by  putting  the 
fingers  into  the  breech,  nor  into  the  neck  of  the  womb,  but  by  simply  placing 
directors  in  the  urethra;  then  after,  they  make  a  small  incision,  quite  above 
and  in  a  straight  line  from  the  orifice  of  the  neck  of  the  bladder,  and  not 
on  one  side  as  is  done  in  men."  As  revived  by  M.  Dubois  it  is  now  executed  in 
like  manneras  the  former,  with  a  bistoury  and  staff,  or  with  a  sheathed  lithotome. 
In  the  first  case  we  introduce  a  stout  staff,  the  groove  turned  uppermost,  and 
ending  in  a  cul-de-sac.  The  surgeon  holds  it  by  the  handle  in  his  left  hand, 
and  with  it  presses  down  the  forepart  of  the  vagina  forcibly.  With  the  right 
hand  he  passes  in  a  straight  and  sharp  bistoury  upon  it,  with  which  he  incises 
the  upper  wall  of  the  urethra  in  all  its  length,  and  the  surrounding  tissues  as 
far  as  the  sub-pubic  ligament.  Thus  we  obtain  an  opening  of  six  or  eight 
lines,  which  is  sometimes  increased  to  eight  or  ten,  whilst  tractive  efforts  are 
being  made  upon  the  stone.  It  would  not  be  safe  however  to  attempt  the 
removal  through  it  of  a  stone  of  more  than  twelve  or  fifteen  lines  in  size.  I 
have  seen  one  of  these  dimensions  extracted  by  M.  Bougon  from  a  young 
woman  who  perfectly  recovered ;  and  M.  Thomas  of  Tours  was  not  less  for- 
tunate in  a  similar  case.  It  is  of  consequence  when  we  withdraw  the  forceps 
to  press  strongly  against  the  inferior  plane  of  the  canal,  and  to  raise  the  han- 
dles sufficiently  to  make  them  act  in  the  axis  of  the  lower  strait.  Otherwise 
the  stone  and  the  blades  of  the  forceps  also  will  be  stopped  behind  the  symphysis, 
and  the  surgeon  will  create  an  insurmountable  difficulty,  while  he  at  the  same 
time  exposes  the  woman  to  dangerous  contusions.  A  good  operator  was  for 
a  long  time  delayed  by  this  obstacle  in  1824  in  one  of  the  hospitals  of  Paris, 
and  after  all  the  stone,  which  was  easily  extracted  when  the  direction  of  the 
forceps  was  changed,  was  no  bigger  than  a  partridge  egg ! 


812  NEW   ELEMENTS   OF 


Art,  3. — Hecapitulation. 

From  this  detail  it  appears  that  no  species  of  perineal  cutting  on  the  female 
allows  of  our  extracting  large  stones.  The  lateral  incision,  or  the  lateralized 
itself,  could  not  in  this  respect  be  of  much  service.  The  upper  incision, 
being  situated  in  the  pubic  arch  at  the  top,  necessarily  gives  a  very  small 
opening.  A  bilateral  incision  without  any  doubt  would  offer  greater  advan- 
tages ;  but  as  yet  experience  has  not  proved  that  it  could  be  practised  with 
any  chance  of  success ;  and  reasoning  strongly  leads  to  the  fear,  that  to  sepa- 
rate thus  the  urethra  into  two  parts  would  cause  fearful  urinous  infiltrations, 
or  produce  an  incurable  incontinence.  Still  I  think  with  Dupuytren,  that  it 
would  be  well  to  take  this  question  into  consideration  and  decide  it  by  the 
authority  of  facts.  When  we  consider  that  in  the  female  sex  lithotomy  is 
most  often  called  for  by  large  stones,  we  must  choose  between  hypogastric 
cutting  and  that  per  vaginam.  Fistulas,  which  too  frequently  follow  the  first 
method,  are  so  disgusting  an  infirmity,  and  so  generally  incurable,  that  we 
shall  seldom  decide  on  adopting  it  until  quite  sure  that  we  can  succeed  by  no 
other.  Now,  cseteris paribus,  the  other  being  the  easier  because  of  the  lesser 
height  of  the  pubis,  and  the  greater  rise  of  bladder  above  the  strait  of  the 
pelvis,  and  having  always  seemed  less  dangerous  than  in  man,  it  should,  I 
think,  be  preferred  in  every  case  in  which  the  bladder  retains  its  dilatability  ; 
inasmuch  as  that  those  calculii  which  we  cannot  extract  by  incision  of  the 
urethra  will  require  a  too  large  opening  in  the  vesico-vaginal  septum  for  us 
not  to  fear  the  production  of  a  fistula.  To  sum  all  up,  it  appears  to  me  that 
dilation  will  do  for  small  stones — the  upper  incision  for  those  which  are  not 
larger  than  a  small  egg — that  the  oblique  incision  should  be  attempted  if  the 
stone  is  only  a  little  bigger,  or  if  the  vagina  is  not  dilated  by  it  to  a  degree 
which  makes  its  lesion  almost  inevitable,  whilst  vaginal  cutting  is  proper  only 
for  stones  as  large  as  a  hen's  egg,  or  at  most  a  turkey's ;  supposing  that  we 
are  on  no  account  willing  to  go  above  the  pubis,  which  operation  is  however 
the  only  one  after  all  which  is  suited  to  stones  of  a  still  larger  size. 

It  is  useless  to  add  that  the  position  of  the  patient,  assistant^  and  operator — 
the  apparatus — the  precautions  necessary  in  extracting  the  foreign  body,  and 
the  consequences  of  the  operation,  are  similar,  or  nearly,  to  those  which  have 
been  under  the  same  circumstances  in  the  male. 

Relative  Value  of  the  Different  Modes  of  Cutting  for  Stone  in  the  Male. 

One  question  yet  remains  to  be  answered  ;  it  is  to  know  which  of  the  me- 
thods deserve  to  be  adopted  as  a  general  one  in  preference  to  the  others.  To 
solve  the  problem  we  must  first  consider  to  what  circumstances  the  fatality  of 
the  operation  for  stone  is  owing  in  patients  who  fall  victims  to  it.  Many 
perish  from  hemorrhage.  Others  die  from  inflammation,  abscess,  sphacelus 
of  the  pelvic  cellular  tissue,  and  of  peritonitis.  Some  seem  to  be  hurried 
into  the  grave  by  organic  affections,  more  or  less  distant  from  it;  such  as 
diseases  of  the  brain  and  viscera,  ataxic  and  adynamic  symptoms ;  serous  or 
purulent  effusions  in  the  pleura,  and  especially  numerous  abscesses  of  the 
parenchymatous  organs.     Besides  these  lesions  there  are  others  which  are 


OPERATIVE    SURGERY.  813 

infirmities  merely;  sucn  are  incontinence  of  urine,  division  of  the  rectum, 
and  urinary  fistulse  of  every  kind. 

Recto-vesictd  cutting  is,  it  is  true,  less  liable  than  any  other  to  pelvic  sup- 
puration, and  to  metastatic  abscesses.  But  it  is  more  often  followed  by 
phlegmasia  of  the  bladder  and  intestines.  It  undoubtedly  most  often  gives 
rise  to  urinary  fistulae,  and  does  not  allow,  as  is  generally  supposed,  of  safer 
extraction  of  large  stones  than  any  other  method. 

Hypogastnc  cutting  can  be  attended  with  hemorrhage  very  rarely — it  is 
safe  from  fistulse — almost  always  from  inflammation  of  the  bladder,  from  in- 
continence of  urine,  intestinal  phlogosis,  and  the  multiplied  foci  of  suppura- 
tion in  distant  parts.  It  allows  of  the  extraction  of  very  large  stones,  and  is 
not  difficult  to  perform ;  but  the  wounding  of  the  peritoneum  is  of  itself  alone 
a  very  alarming  accident,  for  if  an  inflammation  of  this  organ  ensues  death 
almost  always  follows.  It  must,  besides,  be  added,  that  no  where  are  abscess, 
gangrene  in  the  cellular  tissue  of  the  pelvis,  and  infiltrations  more  to  be 
dreaded  ;  and  that  no  where  have  we  less  means  of  avoiding  them. 

Perineal  Cutimg,  which  exceeds  the  limits  of  the  prostate,  exposes  the 
patient,  though  in  a  less  degree  to  similar  infiltrations,  to  wounds  of  the 
rectum  in  some  cases ;  to  recto-vesical,  recto-urethral,  or  simply  urethral  fis- 
tulse ;  to  incontinence  of  urine ;  and  also  to  metastatic  suppuration  in  a  greater 
degree  than  the  two  preceding  ones ;  which  is,  I  think,  in  part  owing  to  its 
dividino*  large  veins  which  inflame  and  also  to  small  abscesses  formin"; 
about  the  wound,  the  pus  from  which  in  some  way  or  other  enters  the  general 
circulation.  As  it  is  confined  within  the  circle  of  the  gland,  it  allows  readily 
of  our  avoiding  both  arteries  and  intestine;  can  be  but  seldom  followed  by 
idiopathic  or  symptomatic  abscess,  and  really  has  no  other  objection  than  that 
of  not  allowing  a  large  enough  passage  for  very  large  stones.  In  that'  case 
the  bilateral  operation  or  the  multiplied  openings  of  the -method  of  M.  Vidal 
will  furnish  i^s  with  a  suflicient  resource;  and  incontinence  of  urine  or  the 
fistulae  urinariae,  which  in  this  case  might  be  dreaded,  are  neither  frequent 
enough  nor  so  difficult  of  cure  as  that  we  need  be  much  afraid  of  them:  so 
that  perineal  cystotomy  is  after  all  that  which  possesses  the  greatest  advan- 
tages, and  which  is  entitled  to  conclude  our  analysis  to  the  preference  as  a 
method  of  general  adoption. 

Recto-vesical  cutting  will  be  adopted  only,  as  I  think,  as  an  occasional 
exceptional  method;  in  cases,  for  example,  wherein  tumors,  ulcerations, 
and  alterations  of  greater  or  less  depths  in  the  perineum  do  not  allow  of  our 
going  through  this  region ;  or  else,  when  the  stone  is  found  fastened  to  one 
end  in  the  prostate ;  in  diseases  of  this  gland,  as  ulceration,  or  when  it  is'the 
seat  of  an  excavation  which  would  make  it  dangerous  or  difficult  to  attempt 
an  incision  upon  its  sides ;  or  when  the  stone  seems  to  have  thinned  or  ulce- 
rated the  recto-vesical  wall  itself.  The  high  apparatus  should  be  reserved 
for  performance  on  very  large  calculi  occurring  in  children  and  in  women, 
when  the  bladder  can  be  easily  distended  or  the  operation  is  not  rendered 
difficult  by  the  eynhonpohit  of  the  patient.  However,  it  is  worthy  of  remark, 
that  if  obesity  be  an  obstacle  to  hypogastric  cutting,  it  has  on  the  other  hand 
the  advantage  of  removing  the  peritoneum  from  before  the  knife,  by  means 
of  the  quantity  of  fat  which  usually  accumulates  between  it  and  the  parietes 
of  the  abdomen.    In  case  of  meeting  with  horny  hardness  or  thickening  of 


814  NEW   ELEMENTS   OF 

the  walls  of  the  bladder,  we  must  consider  them  as  belonging  to  the  list 
which  justifies  recto-vesical  lithotomy,  unless  perineal  cutting  can  be  applied 
to  them. 

D.  Nephrotomy, 

Our  science  is  possessed  of  numerous  cases  of  stones  retained  in  the  kidneys 
themselves ;  and  there  acquiring  considerable  development,  so  as  to  cause 
the  death  of  the  patients.  Hence  the  idea  of  nephrotomy  has  originated, 
which  may  be  defined  the  incision  of  the  organ  through  the  healthy  tissues- 
and  that  of  an  abscess  upon  the  stone  which  may  be  felt  through  the  lumbar 
region  :  or  else,  the  mere  enlargement  of  urinal  fistula,  with  a  view  to  favor 
the  exit  or  extraction  of  the  foreign  body.  One  cannot  deny  that  it  may  be 
possible  to  come  upon  the  urinary  gland  by  its  posterior  surface,  by  dividing 
the  soft  parts  of  the  side  between  the  last  rib  and  crest  of  the  ileum  on  the  one 
hand,  the  sacro-lumbar  mass,  and  posterior  edge  of  the  oblique  muscles  on 
the  other.  I  have  often  succeeded  in  pursuing  this  plan,  and  my  opinion 
with  regard  to  it  is  perfectly  in  accordance  with  that  of  M.  Gerdy. 

But  when  it  is  remembered  that  it  is  scarcely  possible  to  be  satisfied  that 
stone  exists  in  the  kidney  by  any  physical  means,  and  that  all  its  rational 
signs  are  more  or  less  deceptive;  when  we  reflect  again,  that  though  its  pre- 
sence even  be  admitted,  it  is  yet  to  be  ascertained  whether  it  occupies  the 
entrance  of  the  ureter  or  the  pelvis  of  the  kidney,  instead  of  the  thickness  of 
one  wall  of  the  organ.  Whether  it  is  or  is  not  accompanied  by  ulceration,  by 
purulent  secretion,  in  short,  by  any  disorganization  whatever,  we  must  re- 
nounce nephrotomy  so  often  as  no  external  appearance  shall  indicate  the 
point  upon  which  our  search  should  be  begun. 

There  is,  moreover,  no  proof  of  its  ever  having  been  attempted.  The 
passage  cited  from  Hippocrates  I  do  not  think  refers  to  it.  The  much 
boasted  operation  on  the  bowman  can  have  no  weight  in  such  a  matter; 
for  it  is  a  circumstance  which  may  well  be  a  sheer  fabrication.  Who 
can  place  any  confidence  in  it,  when  it  is  seen  that  Mezerai  makes  this  cri- 
minal come  from  Bagnolet,  while  Monstrelet  places  him  at  Meudon ;  that 
some  authors  rank  it  under  the  reign  of  Charles  VII ;  others  under  that  of  Louis 
XI ;  that  CoUot  and  the  author  of  the  History  of  France  are  of  opinion  that  it 
was  to  nephrotomy  that  he  was  subjected;  Rousset  and  Sprengel  that  he 
was  operated  on  by  thfe  high  apparatus ;  Mery  that  he  was  cured  by  perineal 
cutting,  while  Toilet  asserts  that  it  was  gastrotomy  to  remove  a  volvulus  ? 

The  case  of  Hobson,  the  consul,  is  not  more  conclusive,  upon  whom  it  is 
said  to  have  been  performed  by  Marchettis.  Bernard,  who  relates  it,  had  no  other 
authority  for  the  fact  than  the  statement  of  the  patient  and  of  his  wife,  and 
yet  Marchettis  says  not  a  word  about  it  in  his  '' I)^ Observaiions  Bares J^ 
It  is  to  be  hoped,  that  the  discussions  originated  in  the  schools  of  surgery,  in 
1784,  by  Masquelier  and  Bordeu,  and  Coussinot  a  century  before,  to  settle 
whether  nephrotomy  was  applicable  or  not,  will  never  again  be  revived.  It 
can  be  proposed  with  propriety  only  in  the  very  few  cases  in  which  the  side, 
presenting  evident  fluctuation  after  numerous  symptoms  had  existed  of  calcu- 
lous affection  in  the  kidney,  will  allow  of  our  reaching  with  facility  and  cer- 
tainty the  focus  of  disease;  again,  in  such  as  are  attended  with  a  fistulous 


OPERATIVE    SURGERY.  815 

ulcer,  which  allows  of  the  stone  being  touched  with  a  sound;  and  lastly, 
in  which  the  calculus  itself  projects  outwardly,  and  may  be  detected  througli 
the  integuments. 

The  operation  then  becomes  so  simple,  so  trifling,  and  must  be  varied  to 
suit  so  many  circumstances,  that  it  would  be  useless  to  describe  it  in  detail. 
All  that  can  be  said  about  it  is,  that  having  made  our  opening  large  enough,  or 
having  sufficiently  increased  that  which  previously  existed  with  a  bistoury 
alone,  or  directing  it  upon  a  grooved  conductor,  we  must  seek  with  caution  for 
the  stone,  and  extract  it  either  with  common  forceps,  polypi  forceps,  dressing 
forceps,  hooks  or  scoops ;  or  sometimes  the  fingers  alone  will  suffice. 


Calculi  impacted  out  of  the  Bladder. 

1st.  In  the  Ureter. — What  I  have  just  said  of  calculi  fastened  in  the  kid- 
neys, applies  with  greater  force  to  those  which  are  impacted  in  the  ureters. 
Although  they  may  be  retained  at  any  part  of  this  duct  in  its  whole  length, 
it  is  especially  in  its  upper  third,  and  towards  their  vesical  extremity,  that 
they  are  met  with  most  frequently.  They  may  under  the  first  of  these  cir- 
cumstances ulcerate  and  pass  in  part  into  the  cellular  tissue  of  the  side  and 
so  create  an  abscess,  which  may  be  opened  above  the  crest  of  the  ileum,  or 
make  its  own  way  through  this  region.  A  patient,  who  died  quite  suddenly 
in  my  department  at  La  Pitie  last  year,  offered  a  remarkable  peculiarity, 
which  the  reader  perhaps  will  not  be  sorry  to  see  inserted  in  this  place. 

The  kidneys  were  in  a  perfectly  healthy  state,  as  were  also  the  left  ureter 
and  the  bladder  which  contained  no  stone ;  but  the  right  ureter,  largely  dilated 
for  about  three  inches  below  its  origin,  was  perforated  behind  by  a  stone  as 
large  as  a  nut,  which  projected  into  the  cavity,  and  extended  outwardly  at  the 
bottom  of  an  abscess  beneath  the  ascending  colon.  In  the  centre  of  this  cal- 
culus was  a  pin.  The  stone  appeared  to  have  caused  all  the  great  thickening, 
induration,  engorgement,  and  suppuration  even  of  the  cellular  tissue  and 
muscles,  which  extended  from  the  kidney  to  the  bottom  of  the  pelvic  cavity, 
so  as  almost  to  close  up  entirely  the  lower  strait  of  the  pelvis. 

This  stone,  as  I  satisfied  myself  on  the  dead  body,  might  easily  have  been 
extracted  through  the  flank  of  the  same  side.  But  who  could  have  assured  us 
of  its  existence  during  the  life  of  the  patient,  and  who,  without  such  certainty 
and  on  mere  suspicion,  would  have  ventured  to  perform  such  an  operation  ? 

2d.  In  the  thickness  of  the  Vaginal  Septum. — If  a  calculus  concretion  forms 
between  the  urethra  and  vagina,  of  which  M.  Macario  relates  a  case,  and  its 
presence  can  in  any  way  be  determined,  its  extraction  should  be  effected  by 
incising  through  the  viilvo-uterine  passage,  and  to  a  suitable  extent  the  thick- 
ness of  cyst  separating  it  from  the  urethra. 

Sd.  In  the  Prostate  Gland. — The  gland  which  surrounds  the  commence- 
ment of  the  urethra  suppurates  and  ulcerates  very  frequently.  Urine,  by 
being  effused  in  the  small  hollows  which  are  thus  formed,  may  deposite  gra- 
velly particles  susceptible  of  acquiring  more  or  less  considerable  dimensions. 
At  other  times  calculi  stop,  and  are  fastened  simply  in  the  width  of  the  canal 
which  it  encloses.  These  may  either  be  pushed  back  into  the  bladder  or 
seized  with  a  forceps  fitted  with  a  sheath  {pince  a  gaine)  and  drawn  out;  or 


816  NEW   ELEMENTS    OF 

they  may  be  broken  into  pieces  in  situ.  On  the  contrary,  the  others  can  be 
seized  through  the  urethra  but  with  very  great  difficulty.  We  are  obliged  to 
seek  for  them  through  the  perineum.  The  same  is  to  be  said  of  those  wliich 
are  formed  sometimes  in  the  substance  of  this  region  ;  either  after  the  opera- 
tion for  stone  when  some  fragments  of  gravel  have  been  caught  in  the  wound, 
or  when  a  small  calculous  concretion  has  escaped  into  the  adjoining  tissues, 
owing  to  some  laceration  or  to  an  ulceration  of  the  urethra.  The  position  of 
the  patient  is  the  same  in  perineal  cystotomy.  After  the  introduction  of  the 
catheter,  where  no  impediment  exists  we  are  to  seek  anew  to  determine  pre- 
cisely by  the  finger  the  position  of  the  stone.  The  operator  then  cuts  upon  it 
and  lays  it  bare.  If  he  does  not  think  the  first  incision  large  enough,  he 
enlarges  it  by  commencing  at  its  angles,  protecting  his  instrument  upon  a 
director.  The  extracting  agents  then  are  the  forceps,  the  scoop,  or  the  fin- 
gers. On  this  subject  Louis's  memoir,  inserted  among  those  of  the  academy, 
may  be  advantageously  consulted. 

4th.  In  the  Urethra. — Stones  are  met  with  in  every  part  of  the  excretory 
duct  of  the  urine,  in  which,  when  of  any  siz,e,  they  speedily  give  rise  to  very 
serious  difficulties.  When  stopped  behind  the  meatus  urinarius,  or  in  the 
fossa  navicularis,  it  is  seldom  that  the  gush  of  urine  and  the  eflforts  of  the 
bladder  are  insufficient  to  expel  them.  If  it  be  otherwise,  however,  we  are 
to  seek  for  them  with  a  pair  of  dressing  forceps,  having  a  beak  somewhat 
flattened  and  concave ;  or,  as  Sabatier  advises,  by  slipping  beneath  them  a 
loop  of  some  metallic  wire,  brass  for  example ;  and  else  by  the  aid  of  a  small 
scoop,  of  a  hook  shape,  as  was  done  by  M.  Civiale  in  the  case  of  M.  Boissean 
in  September  1828 ;  and  lastly,  if  all  these  means  are  attended  with  too  much 
difficulty,  by  incising  the  lower  wall  of  the  urethra  in  front  of  the  stone,  by 
carrying  a  narrow  bistoury  into  the  canal,  and  bringing  it  back  from  behind 
forwards;  unless  we  prefer  to  make  use  of  a  sort  of  sheathed  bistoury,  such  as 
is  used  by  M.  Civiale  under  tlie  name  of  uretrotome.  One  indispensable  pre- 
caution, whatever  be  the  mode  we  adopt,  consists  in  fixing  the  penis  firmly 
with  the  thumb  and  forefinger  behind  the  calculus  so  as  to  favor  its  expulsion, 
or  at  least  to  prevent  it  from  being  pushed  backwards  by  the  instrument. 
When  the  stone  is  locked  in  the  beginning  of  the  spongy  portion  which,  from 
the  gradual  construction  which  the  canal  experiences  hereabouts,  is  often 
seen,  the  surgeon  in  like  manner  fixes  the  hinder  portion  of  it  with  one  hand, 
and  with  the  other  endeavors  to  withdraw  it  with  the  metallic  loop  of  Sabatier 
or  of  Marini,  such  as  M.  E.  Rousseau  has  recently  employed  with  success. 
This  not  sufficing,  we  resort  to  the  pince  a  gaine^  having  denticulated  grasps 
made  thin,  firm,  and  concave,  and  only  separating  when  they  arrive  at  the 
anterior  surface  of  the  stone  to  dilate  the  urethra  as  it  were,  so  that  the  foreign 
body  when  pressed  by  the  finger  may  come  easily  between  them.  To  be  sure 
that  we  have  it,  and  that  we  may  not  uselessly  close  the  forceps,  M.  Civiale 
advises  that  they  sliould  be  traversed  by  a  stylet,  the  head  of  which  opens  the 
forceps  when  withdrawn  towards  the  sheath.  The  operator  feels  with  this 
stylet  where  the  stone  is,  displaces  it  when  it  is  unfavorably  grasped,  and 
runs  no  risk  whatever  of  injuring  the  patient.  When  it  is  once  firmly  seized 
it  is  drawn  out,  slowly  if  rather  large,  and  so  as  if  possible  not  to  produce 
the  least  tearing.  If  the  size  of  the  calculus  renders  it  difficult  of  extraction, 
which  it  seldom  does  as  it  can  hardly  have  been  long  enough  in  the  urethra  to 


OPERATIVE    SURGERY.  817 

have  increased  much  in  size,  its  fracture,  if  fragile,  must  be  eflfected,  or  else 
it  must  be  drilled  with  a  perforator  for  this  purpose  carried  in  instead  of  the 
stylet,  so  that  it  may  afterwards  be  more  easily  cruslied. 

Calculi,  which  are  arrested  in  the  bulbous  portion,  are  to  be  treated  upon 
similar  principles.  In  the  membranous  portion,  where  nevertheless  they  are 
found  most  frequently  impacted,  more  difficulty  will  evidently  be  experi- 
enced. If  the  preceding  attempts  which  may  be  modified  by  a  change  of 
instruments,  by  using  for  instance  a  forceps  more  or  less  curved,  all  fail, 
and  the  affection  is  urgent,  incision  into  the  urethra  becomes  our  sole  resort- 
It  is  the  same  also  in  the  other  cases  we  have  pointed  out,  in  which  drilling 
and  extraction  are  only  measures  to  be  first  tried. 

Incision  having  become  decidedly  necessary,  it  is  thus  performed  :  When 
stone  occupies  the  second  portion  of  the  urethra,  an  assistant  is  to  keep  it 
fixed  there  by  the  introduction  of  two  fingers  into  the  anus.  The  surgeon 
with  a  straight  bistoury,  divides  the  integuments  previously  well  stretched, 
then  the  cellular  tissue,  then  all  the  parts  contained  in  the  base  of  the  recto- 
urethral  triangle,  and  comes  down  upon  the  foreign  body.  Having  sufficiently 
enlarged  the  incision,  he  extracts  the  calculus  with  the  assistance  of  suitable 
instruments,  and  for  fear  there  should  be  others  in  the  bladder,  prostate,  or 
in  the  remainder  of  the  urethra,  he  examines  all  these  parts  with  a  grooved 
staff,  a  female  staff,  or  any  species  of  catheter.  Behind  the  scrotum  the  spongy 
portion  of  the  urethra  has  such  movable  coverings  that  they  are  in  general 
easily  enough  divided.  For  this  reason  it  is  proper  to  carry  a  grooved  and 
^y  strong  staff  through  the  natural  passage  to  the  stone ;  to  raise  the  scro- 
tlmi  as  much  as  possible;  sedulously  to  stretch  the  integuments  ;  to  have  the 
stone  supported  behind  by  the  fingers  of  an  assistant,  and  make  t!ie  incision 
into  the  integuments  longer  than  that  into  the  urethra  itself.  The  object  of 
this,  is  firstly  to  come  more  surely  on  the  foreign  body;  secondly,  to  prevent 
infiltrations.  The  same  course  is  to  be  pursued  for  stones  which  lie  in  front 
of  the  scrotum,  save  that  the  scrotum  has  then  to  be  crowded  down  towards  the 
anus.  It  is  important  in  these  cases  not  to  open  the  urethra  at  first  at  more,  than 
one  point  over  the  stone,  and  then  to  enlarge  the  incision  on  a  director  back- 
wards or  forwards.  By  an  opposite  procedure  we  should  produce  a  jagged 
wound,  with  edges  more  or  less  fringed,  far  from  favorable  to  cicatrization, 
v^hilst  the  latter  mode  produces  one  which  is  very  even,  and  tiie  fittest  possi- 
ble for  instant  adhesion,  or  at  least  for  a  very  speedy  one. 

As  to  Phila^rius's  advice,  who  recommends  in  order  to  avoid  fistula  that 
we  should  open  into  the  urethra  through  the  dorsuni-penis,  it  would  be  found 
applicable  only  for  very  small  stones  stopped  in  front  of  the  scrotum,  and  I 
do  not  think  that  even  at  any  rate  it  will  be  revived.  Besides  is  it  quite 
certain  that  Philagrius  meant  to  speak  of  opening  of  the  urethra  rather 
than  calculi  and  opening  of  the  bladder  ?  Moreover,  fistulas  after  incision 
into  the  urethra  such  as  I  have  often  described,  are  much  less  frequent  than 
one  might  have  supposed.  M.  Civiale  relates  the  case  of  a  patient  ope- 
rated on  at  La  Pitie,  by  a  pupil  at  that  hospital,  who  had  three  bulky 
stones  in  the  bulbous,  membranous,  and  prostatic  portions  of  the  urethra. 
The  operation  was  long,  laborious,  created  a  very  uneven  wound,  yet  was 
not  followed  by  a  fistula.  The  division  heals  of  "itself,  and  only  requires 
as  perfect  coaptation  as  possible  to  be  maintained  between  the  different  layers 
103 


818  NEW   ELEMENTS   OF 

through  which  it^  goes,  and  to  be  covered  with  lint  spread  with  cerate.  It 
is  of  no  benefit  to  leave  catheters  in  the  bladder,  which  indeed  interfere  with 
the  recuperative  eiforts  of  the  organization. 

5th.  Betiveen  the  Gland  and  Prepuce.- — Children  are,  as  we  have  said,  very 
subject  to  contraction  or  stricture  of  the  preputial  opening,  and  the  covering 
of  the  glans  penis  in  them  is  naturally  very  long.  From  this  it  results  that 
the  urine  spreads  into  it  as  into  a  sac  before  it  escapes  outwardly  on  leaving 
the  urethra,  and  that  it  there  forms  frequently  stony  concretions,  which  are 
also,  though  much  more  seldom,  seen  among  adults.  They  may  acquire  a 
a  size  which  is  truly  astonishing.  Morand  preserved  one  which  was  as  large 
nearly  as  an  egg,  and  which  had  a  furrow  on  its  upper  surface  for  the  passage 
of  urine.  Sabatier  was  the  owner  of  another  which  was  larger  still.  The 
extremity  of  the  penis  on  these  persons  is  swelled,  heavy,  and  dependent  like 
the  clapper  of  a  bell.  Their  removal  is  extremely  easy.  All  that  is  required 
is  to  introduce  a  director  between  the  foreign  body  and  the  prepuce,  on  which 
a  bistoury  is  passed  down,  which  cuts  and  divides  the  tissues  from  within 
outwards.  This  might  as  well  be  done  from  without  inwards  by  acting  per- 
pendicularly on  the  calculus.  An  operation  of  this  kind  made  a  great  noise 
in  Switzerland  at  the  beginning  of  the  last  century,  and  was  said  by  some 
persons  to  be  a  case  of  super-pubic  lithotomy. 

§  2.  Lithotniy, 

Cutting  for  stone  is  still  so  dangerous,  notwithstanding  the  many  improv 
ments  it  has  undergone,  that  efforts  are  constantly  being  made,  to  render 
unnecessary,  and  to  substitute  for  it  some  operation  of  a  less  cruel  nature. 
There  are  many  who  think  that  this  desirable  end  has  at  length  been  attained 
by  modern  surgery ;  and  that  by  means  of  lithotrity  we  may  for  the  future, 
in  a  very  great  majority  of  cases  at  least,  dispense  with  performing  lithotomy. 
We  shall  see  as  we  proceed  how  far  such  hopes  may  perhaps  be  entertained. 

Lithotrity,  or  the  breaking  of  a  stone  by  grinding  and  bruising  it,  consists 
in  the  comminution  of  a  stone  into  fragments,  and  their  extraction  per  vias 
nahirales^  by  means  of  particular  instruments  for  that  purpose.  In  its  widest 
j^ignification  it  comprises  pure  and  simple  extraction,  crushing,  pulverization, 
breaking  by  bruising,  perforation  and  trituration  of  stones,  even  within  the 
interior  of  the  bladder  or  urethra.  The  names  of  "  lithoprinia,  lythodyalisie, 
lithotripsy,  lithocenosis,"  which  it  has  been  wished  to  substitute  for  lithotrity, 
being  no  less  liable  to  objections  do  not  deserve  the  preference  which  has 
been  claimed  for  them  by  their  inventors. 

»^rt.  1. — Historical  Account, 

The  idea  of  extracting  calculi,  either  entire  or  after  having  been  broken, 
without  an  incision  of  the  parts  is  not  by  any  means  a  new  one.  For  tliose 
at  least  which  were  arrested  in  the  urethra  it  has  in  every  age  been  suggested. 
Albucasis  mentioned  an  instrument  which  enabled  him  to  seize  them  at 
the  bottom  of  this  canal.  The  sheathed  forceps  with  three  or  four  branches, 
described  and  delineated  in  the  Bibliotheque  of  Manget  under  the 
name  of  Asta,  appeared  to  Fabricius  Hildanus,  suited  to  the  same  end.     A 


OPERATIVE  SURGERY.  819 

tube  with  three  elastic  branches,  was  in  the  same  way  made  use  of  by  Sanc- 
torius.  Franco  with  this  view  had  contrived  a  •*  quadruple  vesical,"  and 
Pare  a  sort  of  trepan  or  elevator,  "  bis-fond,"  which  he  passed  down  to  the 
stone  through  a  canula.  Fabricius  Hildanus  employed  a  forceps  with  three 
branches,  which  after  it  had  grasped  the  stone  was  capable  of  breaking  it. 
Still,  though  it  has  appeared  easy  to  all  authors  almost  to  sei/.e  small  calculi 
to  pierce  and  break  them  in  the  urethra,  it  is  not  quite  so  clear  tliat  they  ever 
carried  their  instruments  further  on  to  fulfill  the  same  intent.  However,  an 
Arabian  author,  who  is  evidently  no  other  than  Albucasis,  in  a  work  in  which 
the  names  of  Alsaharavius  or  Acaravius,  are  given  him,  says  that  we  must 
introduce  softly  a  subtile  instrument  called  **  maschabarebilia"  into  the  blad- 
der, to  seize  the  calculus,  crush  it  if  soft  enough,  and  extract  it.  Alexan- 
der Benedictus  also  says  that  a  stone  may  be  crushed  with  metallic  instru- 
ments without  any  wounding  of  parts.  Lastly  it  appears  that  Sanctorius, 
Franco,  and  Fabricius  Hildanus,  also  were  accustomed  to  search  for  small 
stones  even  into  the  bladder;  but  the  very  imperfect  details  which  they  have 
left  of  their  proceedings,  are  too  vague  to  be  of  much  weight  upon  the  sub- 
ject. 

During  the  last  century,  Hoin  of  Dijon  related  the  account  of  a  monk  at 
Citeaux,  who  by  means  of  a  flexible  tube,  and  a  stem  of  iron  sloped  at  its 
extremity,  succeeded  in  breaking  a  stone  under  which  he  labored,  by  striking 
on  it  by  quick  and  small  strokes  with  a  mallet,  as  on  the  chisel  of  a  sculptor. 
The  journals  of  Calcutta,  and  subsequently  M.  Marcet,  have  made  known 
a  fact  even  more  conclusive;  that  of  Colonel  Martin  who  died  in  1800,  who 
succeeded  in  his  own  case  in  reducing  a  calculus  to  powder  by  means  of  a 
metallic  stem  which  ended  in  a  file,  and  was  introduced  into  the  bladder 
through  a  curved  catheter.     I  have  been  unable,  as  was  M.  Civiale,  to  meet 
with  the  work  of  Dr.  Marco,  published  at  Venice  in  1799,  and  entitled  *'a 
New  Method  of  dividing  a  Stone  in  the  Bladder."     The  forceps  invented  by 
Hales,  and  called  Hunter's,  enabled  Desault  to  take  out  three  vesical  calculi 
of  very  small  size,  and  Sir  A.  Cooper,  who  modified  it,  removed    with  it 
in    this   way    about    eighty    from    the    bladder    of    a    chimney    sweeper. 
None  of  these  however   constituted  regular  methods;  and  in  spite  of  the 
much  more  systematic  labors  of  M.  Gruthuisen,  Mr.  Eldgerton,  who  also 
endeavored  to  break  the  calculus  within  the  bladder,  still  employed  a  curved 
catheter  into  which  he  introduced  a  rasp,  which  by  a  motion  backwards  and 
forwards,  should  wear  away  the  stone.     The  plan  of  Gruthuisen,  though 
unapplied  and  perhaps  inapplicable,  at  least  went  further  than  any  other. 
This  gentleman  delineated  numerous  instruments,  made  multiplied  experi- 
ments, and  clearly  demonstrated  that  straight  canulaa,  4,  5,  and  6  lines  in 
diameter  could  be  passed  through  the  urethra.     Altliough  its  chief  object 
was  to  decompose  them  by  galvanic  action,  he  notwithstanding  invented  an 
instrument  to  break  them  ;  the  apparatus  consists  of  a  large  straight  canula 
of  a  loop  of  brass  wire,  which  enlarges  at  the  vesical  end  of  the  tube,  and  of 
a  perforator  which  may  be  pushed  out  and  withdrawn  at  pleasure.     The 
surgeon  seizes  the  stone  in  the  loop  of  wire,  draws  the  wire  towards  him  so 
as'to  bring  the  calculus  against  the  beak  of  the  canula,  then  taps  and  perfo- 
rates it  with  the  drill,  which  is  turned  by  a  bow. 

The  attempts  made  by  Gruthuisen  had,  like  those  which  preceded  them, 


820  NEW  ELEMENTS  OF 

nevertheless  sunk  into  oblivion,  when  several  of  our  fellow-countrymen, 
impelled  bj  the  same  necessity,  engaged  in  an  attempt  to  establish  lithotrity» 
Here  a  difficulty  presents  itself  for  solution;  to  whom  belongs  the  credit  of 
being  the  original  founder  of  lithotrity  as  it  is  now  performed  ? 

M.  Civiale,  who  since  1818  had  been  engaged  in  searching  for  a  method 
of  dissolving  stones  in  the  bladder,  and  had  conceived  an  idea  of  some 
instruments  for  seizing  and  breaking  them,  asserts  that  he  invented  those 
which  he  now  employs.  M.  Leroy  d'Etioles,  on  the  contrary,  declares  that 
then  M.  Civiale  had  only  invented  some  instruments  which  were  inapplicable 
to  the  end ;  and  that  he  was  entirely  ignorant  of  the  ("  pince")  forceps  with 
three  elastic  branches,  which  is  merely  a  modification  of  that  of  Sanctorius, 
or  the  ball  extractor  of  Alphonso  Feri.  I  indeed  remember  that  M.  Leroy 
showed  me  the  forceps  which  is  now  in  daily  use  before  he  laid  it  before  the 
academy,  in  April  1823  ;  and  that  which  is  to  be  found  in  M.  Civiale's  first 
book,  published  in  the  course  of  the  same  year,  differs  exceedingly  from  it, 
and  much  more  resembles  the  quadruple  vesical  of  Franco.  Still  it  is  very 
difficult  to  take  any  side  in  this  affair,  particularly  as  Percy,  in  his  report  to 
the  academy  of  sciences,  in  1824,  decided  wholly  in  favor  of  M.  Civiale; 
whilst  in  the  years  1825, 1828,  1831,  the  same  learned  body  awarded  to  M.  Le- 
roy the  prize  for  inventing  the  principal  instruments,  among  others  the  three 
branch  forceps  now  used  by  almost  every  lithotritist.  The  detail  of  the 
various  procedures  actually  adopted,  and  of  the  different  instruments  which 
have  hitherto  been  used,  will  oblige  us  to  return  to  the  question,  and  enable 
us  also  to  decide  more  equitably  upon  it. 

Art,  2. — Examination  of  Methods. 

Lithotrity  comprises  two  methods  distinct  from  each  other,  as  to  the  appa- 
ratus which  either  requires :  the  one  necessitating  the  use  of  straight,  the 
other  that  of  curved  instruments. 

§  1.  The  Rectilinear  Method. 

One  of  the  difficulties  which  longest  opposed  itself  to  the  practitioner  was 
to  penetrate  to  the  bladder  with  straight  stems;  so  that  lithotrity  has  in 
reality  been  created  from  the  period  when  the  possibility  of  rectilinear 
catheterism  was  recognized.  The  straight  catheter  then  having  become  a 
capital  instrument,  we  have  no  cause  for  astonishment  at  the  importance  which 
is  attached  by  some  persons  to  its  invention.  On  this  point,  as  in  almost 
every  other  of  the  great  operations  in  surgery,  we  have  arrived  at  the  reali- 
zation of  the  fact  only  by  degrees,  and  the  real  discovery  will  be  found 
separated  from  the  period  of  its  declaration  by  a  very  considerable  lapse  of 
time.  It  may  not  be  entirely  proved  that  Albucasis,  Sanctorius,  or  any  other 
old  author  had  any  idea  of  a  straight  instrument  for  entering  the  bladder; 
and  we  may  doubt  perhaps  whether  the  straight  stems  found  by  E.  Clark  in 
the  ruins  of  Herculaneum,  or  if  those  in  the  office  of  a  surgeon  at  Portici, 
ever  were  instruments  of  catheterism.  It  may  be  incorrect  to  say  that  Ranieau 
proposed  catheters  perfectly  straight,  but  it  is  at  least  undoubted  that  Lieu 
taud  did  formerly  promulgate  the  thought,  and  that  the  proposition  has  been 


I 


OPERATIVE    SURGERY.  8S1 

far  from  forgotten.  It  is  in  fact  reproduced  in  the  Elements  of  Surgery, 
published  in  1768,  by  M.  Portal ;  and  afterwards  in  the  Dictionary  of  Sur- 
gery, edited  by  Louis.  In  1795,  Santarelli,  a  surgeon  of  Rome,  returning  to 
its  consideration,  attempted  to  prove  that  the  urethra  has  no  curve  in  its  pro- 
static portion,  and  that  it  is  easy  to  do  away  that  which  occurs  beneath  the 
symphysis,  by  depressing  the  penis.  Lassus  made  similar  statements  in  his 
lectures  at  the  school  of  medicine,  and  M.  Montagut  confidently  asserted 
in  1810  that  rectilinear  catheterism  is  as  easy  as  it  is  useful  in  a  majority  of 
cases.  Another  French  physician,  M.  Fournier  of  Lempdes,  who  paid  much 
attention  to  lithontriptic  means  in  the  year  1812,  employed  a  straight  instru- 
ment. The  well  authenticated  certificates  collected  in  the  book  which  he 
has  just  published,  leave  no  doubt  upon  the  subject.  The  work  of  M. 
Gruthuisen,  published  in  1813,  at  length  revealed  all  its  advantages ;  so  that, 
even  excluding  the  assertions  of  several  army  surgeons,  MM.  Larrey  and 
Ribes  among  others,  w^ho  state  that  they  have  often  used  straight  catheters  on 
service,  it  would  be  quite  impossible  to  claim  for  our  own  time  entirely  the 
invention  of  catheterism  with  straight  instruments,  which  was  contended  for 
by  M.  Moulin,  in  his  turn,  as  late  as  1829. 

In  fact,  custom  and  prejudice  had  opposed  it;  particularly  in  so  much  that 
as  a  means  of  entering  the  bladder  and  giving  exit  to  urine,  a  straight  catheter 
is  incontestibly  much  less  convenient  than  a  curved  one.  It  was  necessary, 
in  order  to  allow  this  species  of  catheterism  to  take  rank  in  practice,  that  it 
'  should  be  presented  under  some  other  point  of  view.  Between  the  years 
1815  and  1823,  the  want  of  some  means  of  destroying  calculi  without  resort- 
ing to  a  sanguinary  operation  was  felt  more  powerfully  than  ever,  and  several 
surgeons  engaged  about  the  same  time,  in  researches  on  this  subject,  in  simi- 
lar ways  or  by  different  modes.  Upon  these  experiments  the  possibility  of 
passing  the  urethra  with  catheters,  &c.  not  curved  was  anew  proclaimed. 
M.  Amussat,  though  in  order  to  induce  conviction  he  laid  a  great  stress  upon 
an  anatomical  error,  succeeded  at  length  in  awakening  the  attention  of  sur- 
geons to  the  subject.  Whilst  he  was  laboring  vainly  to  demonstrate  how 
exceedingly  mankind  had  been  deceived  as  to  the  real  course  of  the  urethra, 
MM.  Leroy  d'Etioles,  and  Civiale  seized  upon  the  practical  inference,  and 
left  M.  Amussat  to  wrangle  out  the  discussion  in  which  he  had  engaged.  It 
does  not  appear,  indeed,  that  until  then  they  had  thought  of  a  straight  sound 
for  fracturing  the  stone  ;  and  the  instruments  of  M.  Leroy  were  still  straight 
at  that  time.  The  statements  of  Lieutaud,  Sautarelli,  Montagut,  and  the 
labors  of  Gruthuisen,  which  would  have  been  of  such  great  service  to  them, 
had  evidently  escaped  their  observation.  We  may  then  say  with  every  confi- 
dence that  from  this  period  only  does  lithotrity  date. 

Breaking  up  a  stone  is  now  practised  in  divers  ways,  so  different  that  each 
requires  a  succinct  analysis.  In  one,  that  which  was  first  practised  on  the 
living  subject,  we  are  content  to  perforate  the  stone  in  several  directions ; 
then  to  break  it  into  fragments,  and  to  perforate  or  break  each  of  these  one  after 
the  other,  and  extract  them  piecemeal,  unless  the  bladder  should  itself  expel 
them  along  with  the  urine.  In  the  other,  simple  perforation  alone  is  not  con- 
sidered sufficient.  The  surgeon  endeavors,  by  means  of  special  lithotritic 
instruments,  to  excavate  the  stone  from  centre  to  circumference,  to  reduce  it 
to  a  shell  which  is  then  reduced  to  fragments,  and  divided  as  above.     In  a 


I 


*T 


822  NEW    ELEMENTS    OF 

third  method  the  instruments  act  from  the  circumference  to  the  centre  only, 
and  serve  to  pulverize  by  true  concentric  friction.  A  fourth  way  of  acting 
is  that  which  aims  at  grinding  or  crushing  the  stone  without  previous  perfo- 
ration either  from  the  centre  to  the  circumference  or  from  before  back- 
wards. 

a.  Perforation,  pure  and  simple,  which  was  by  M.  Civiale  adopted  from  the 
beginning,  is  the  method  which  he  still  prefers.  The  instruments  required 
for  it  are,  Ist,  a  large  canula  from  two  to  four  lines  in  diameter,  from 
nine  to  twelve  inches,  which  serves  in  a  measure  as  "  chemise"  or  covering 
to  the  other  instruments;  Sd,  of  a  forceps  called  litholabe,  intended  to  seize 
and  hold  the  stone;  Sd,  of  a  drill,  either  cylindrical,  three  or  four  pointed, 
or  else  having  a  head,  and  of  a  trephine  shape;  4th,  of  accessory  articles, 
such  as  a  crank  or  winch,  rings,  chevalets,  mandrel  lathe  or  tour  en  Pair, 
vices,  &c. ;  all  of  which  serve  to  support  the  principal  pieces  from  without, 
and  make  them  act  inside  of  the  bladder. 

1st.  The  Chemise  or  outer  canula  is  a  part  of  eivery  apparatus,  and  is  found 
in  every  procedure.  When  it  has  been  introduced  into  the  urethra  it  remains 
in  it,  and  serves  to  protect  it.  As  it  should  be  moulded  upon  this  canal  there 
must  be  some  of  different  sizes,  of  greater  or  less  dimension,  according  to 
the  age  and  peculiar  structure  of  the  patient.  It  is  requisite  that  with  as  thin 
walls  as  possible  it  should  combine  great  powers  of  resistance;  at  the  vesical 
end  at  least.  Its  outer  extremity  is  usually  fitted  with  a  leather  or  cork  box, 
and  cut  quadrangularly  for  an  inch  or  two  so  as  to  be  seized  by  the  vice  or 
lathe. 

2d.  The  Litholabe  is  the  part  which  has  been  most  frequently  varied,  and 
which  also  constitutes  a  portion  in  every  procedure.  Under  this  head  it  is 
needless  to  speak  of  the  first  instrument  by  M.  Civiale,  which  was  analagous 
to  the  quadruple  vesical  of  Franco,  nor  of  that  which  M.  Leroy  described  in 
1822,  and  which  was  composed  of  four  watch  springs  which  were  capable  of 
forming  when  extended  or  relaxed  a  double  loop  crossed  in  the  bladder,  or 
having  joined  to  them  as  auxiliary  a  net  so  as  to  transform  this  cage  into  a 
true  sac  ;  or  else  in  the  place  of  springs,  branches  jointtd  in  the  middle  to 
approach  or  diverge  when  their  external  portion  is  pushed  or  pulled  upon  ; 
again,  these  branches  may  be  of  chain  work,  and  by  the  aid  of  canula3  may 
be  made  to  form  a  cage  of  three  or  four  branches  around  the  stone  by  turning 
one  upon  the  other,  particularly  as  these  instruments  have  never  been  by  any 
one  adopted,  not  even  by  the  inventors  themselves,  whilst  that  of  Mr.  Lukens, 
a  mechanic  in  Philadelphia,  is  no  better.  M.  Colombe  has  proposed  one 
composed  of  two  concentric  canals,  each  ending  in  two  elastic  branches, 
united  at  their  extremities,  and  which  can  be  made  to  cross  each  other  at  a  right 
angle  round  the  stone  when  seized.  This  instrument  is  evidently  constructed 
on  a  similar  plan  to  that  of  the  litholabe  of  Leroy  or  of  Lukens,  and  will  in 
all  probability  suffer  a  like  fate. 

Thus  far  surgeons  have  generally  resorted  to  the  forceps  properly  so  called. 
This — which  is  a  mere  modification  of  the  triple  canula  of  Sanctorius  or 
Hildanus,  of  the  ball  extractor  of  A.  Ferri,  or  Andrew  de  la  Croix — has 
also  been  that  for  whose  invention  most  persons  have  advanced  claims.  M. 
Leroy  first  made  it  known  in  April  1823  ;  but  it  is  asserted  by  M.  Civiale, 
who  has  given  us  a  delineation  of  another  in  his  work  printed  in  June  1823, 


OPERATIVE  SURGERY.  823 

that  ever  since  the  year  1820  he  had  been  engaged  in  experiments  with  an 
instrument  constructed  upon  the  principle  of  the  Ferrian  ball  extractor. 
Three  elastic  branches,  which  are  curved  crotchetwise  and  lap  over  so  that 
they  may  be  closed  and  reduced  to  the  dimensions  of  the  principal  stem  when 
withdrawn  into  their  sheath,  compose  its  vesical  end.   The  other  has  a  leather 
box,  but  no  vice  such  as  the  first  canula  has.      The  litholabe,  such  as  I 
have  now  described  it,  has  not  suited  the  wants  of  all  lithotritists.     Several 
have  endeavored   especially  to  increase  the  number  of    branches.     Some 
have  given  it  four.      M.  Amussat  has   proposed   five.      Meirieu   divided 
them  into  twelve.     M.  Tanchou  prefers  ten.     That  which  M.  Recamier  has 
proposed  is  composed  of  two  canulae,  which  have  each  of  them  five,  and 
which  by  turning  on  one  another  soon  form  a  forceps  of  five  or  of  ten  branches. 
These  different  alterations  have  all  been  made  with  the  view  of  holding  the 
stone,  when  once  laid  hold  of,  with  greater  firmness  and  security,  and  not  to 
let  fall  the  principal  fragments.     The  litholabe  of  Meirieu,  successively  per- 
fected by  MM.  RecamJer  and  Tanchou,  is  distinguishable  from  every  other 
in  having  a  hole  in  the  free  end  of  every  branch  to  allow  passage  to  a  silk 
string  of  great  strength,  which  is  intended  to  close  them  as  does  a  purse  string ; 
and  which  passes  through  a  particular  groove  in  the  canula  to  get  outwards. 
That  of  M.  Recamier  can  moreover,  by  the  rotation  of  its  two  canulae,  pre- 
sent a  large  opening  on  one  of  its  sides  to  the  calculus,  and  close  afterwards 
around  the  foreign  body.     In  the  apparatus  of  Meirieu  and  Tanchou  we  meet 
with  the  same  contrivance,  but  under  another  form ;  that  is  to  say,  one  branch 
of  the  forceps  remaining  in  the  canula  leaves  a  lateral  aperture  to  receive  the 
stone,  and  then  by  pulling  on  the  silken  string  may  be  thrust  out  level  with  the 
others.     Recently  Dr.  Ashmead,  of  the  United  States,  has   presented  one 
to  this  academy  which  has  four  divisions;  three  of  which  are  pretty  near  each 
other,  and  the  fourth  sensibly  divergent.     In  this  way  the  forceps  leaves  on 
one  side  all  necessary  space  for  receiving  large  stones,  and  represents  in 
the  other  direction  a  firm  grating  which  is  to  be  turned  downwards  during  the 
grinding  that  no  fragments  of  any  size  may  escape.     It  would,  no  doubt,  be 
better  if  we  could  keep  hold  of  a  calculus  until  its  entire  destruction  was 
effected  ;  but  all  the  instruments  proposed  effect  this  advantage  at  the  sacri- 
fice of  a  great  many  others.     By  multiplying  branches  you  necessarily  weaken 
it  much.     As  calculi  are  very  far  from  having  regular  shapes,  or  from  being 
seized  by  their  centres  opposed  to  the  centre  of  the  forceps,  it  would  be  very 
much  to  be  apprehended  that  one  of  these  many  stems  might  have  to  bear 
alone  the  whole  effort,  and  consequently  bend  and  break.     This  accident 
would  be  rendered  much  less  alarming  by  uniting  the  ends  of  the  branches 
by  silk  strings  as  in  Meirieu's  plan ;  and  the  little  cage  offers  a  good  deal  of 
regularity ;  but  may  the  string  of  silk  not  break  ?  may  it  not  become  entangled 
in  the  stems  of  the  instrument?  and  are  we  always  certain  to  be  able  to  make 
it  play  freely  ?     Besides  having  once  closed  the  litholabe,  how  are  we  to  dis- 
engage the  stone  from  it  if  the  bladder  chance  to  empty  itself  and  contract 
violently?     If  the  forceps  of  tiiree  branches  will  not  answer,  that  of  Dr- 
Ashmead,  which,  while  it  preserves  more  strength,  allows  of  our  obtaining  a 
tighter  grating  tlian  a  common  forceps,  can  alone  be  substituted  for  it  I  think, 
at  least,  in  the  procedure  by  simple  perforation. 

Lithotritors. — This  is  a  stem  or  rod  of  steel,  the  vesical  end  of  which  is  to 


824  '  NEW   ELEMENTS   OF 

act  upon  the  stone,  and  which  end  alone  can  be  susceptible  of  any  material 
modification.  In  M.  Leroy's  first  apparatus  this  rod  was  cylindrical,  and 
terminated  by  points.  In  the  instruments  of  M.  Grnthuisen  there  is  one  tO  be 
found  whose  extremity  has  a  head  shaped  like  the  crown  of  a  trephine.  This 
Jatter  form  is  preferred  by  M.  Civiale.  It  follows  therefore  that  his  lithotri- 
tor  has  to  be  introduced  at  the  inner  extremity  of  the  forceps,  and  can  only 
be  withdrawn  along  with  the  whole  instrument;  while  the  cylindrical  drill 
enters  and  is  taken  out  at  the  outer  end,  on  the  other  hand  these  drills  with 
heads  make  a  much  larger  perforation  evidently  than  the  others;  and  M.  Ci- 
viale, to  obtain  a  yet  larger-opening,  has  had  some  made  which  were  excentric, 
that  is  to  say,  whose  axis  was  outside  that  of  the  rod.  With  such  an  instru- 
ment a  stone  may  be  perforated  through  and  through ;  but  prudence  generally 
requires  us  not  to  go  on  quite  to  its  farthest  extremity,  or  at  least  not 
to  the  level  of  the  hooks  of  the  forceps,  for  fear  of  wounding  the  bladder. 
The  advantages  which  it  has  are  its  great  solidity,  its  acting  powerfully  and 
surely,  and  that  it  endangers  the  occurrence  of  no  serious  accident.  The 
real  objection  which  is  made  to  it  is  that  it  can  only  make  an  opening  of  three 
or  four  lines ;  that  it  requires  the  position  of  the  stone  to  be  changed  fre- 
quently, and  increases  the  number  of  sittings  necessary  if  the  stone  be  a 
large  one. 

Development  Drills. — Struck  with  the  imperfection  just  mentioned,  several 
surgeons  have  attempted  to  remedy  it.  M.  Leroy,  one  of  the  first,  con- 
structed Some  drills,  the  "/raises"  of  which  were  more  complicated,  and 
with  opening  or  developing  points  {lances).  Likewise  a  drill  split  at  the  end, 
by  which  he  could  first  pierce  the  hole,  and  then  enlarge  it,  because  when  the 
fraise  was  pushed  out  of  the  canula  its  two  branches  separated  forcibly  owing 
to  their  natural  elasticity.  Another  instrument  of  the  same  kind  appeared 
to  him  to  be  capable  of  answering  the  end  still  better.  The  two  branches 
diverged  by  the  retraction  of  the  head  of  the  drill  between  them.  At  length 
M.  Leroy,  still  following  up  the  same  idea,  employed  successfully  a  cylin- 
drical rod  enclosing  a  double  blade  fraise,  which  when  pressed  upon  issues 
through  two  apertures  placed  near  the  extremity  of  the  drill.  He  has  besides  in- 
vented a  simple  bent  file  very  much  like  that  of  M.  Eldgerton ;  also  a  double 
one  with  two  elastic  branches,  but  none  of  these  are  worthy  of  being  retained 
in  practice  except  his  drill  with  two  apertures  enclosing  the  double  fraise, 
which  has  two  branches  equally  elastic. 

The  double/m/ses  of  M.  Civiale,  which  are  separated  by  a  transverse  bar 
or  a  simple  head  being  drawn  back  through  them  by  the  power  of  a  return 
screw  acting  on  the  central  stem,  do  not  seem  to  me  to  deserve  to  be  retained 
either.  It  would  appear  that  M.  Heurteloup  had  been  attentive  to  the  im- 
provement of  which  we  are  now  speaking.  In  order  to  obtain  an  excavation 
of  eight  or  twelve  lines  in  diameter,  he  employs  a  drill  with  a  cylindrical 
head  and  an  aperture  on  one  side,  and  which  serves  at  first  for  piercing  the  stone. 
When  afterwards  he  wishes  to  begin  to  hollow  out  and  excavate  the  stone  so  as 
to  reduce  it  to  a  mere  shell,  he  pushes  out  the  base  of  a  denticulated  shoulder 
virgule  which  is  contained  in  the  crown  of  his  drill,  and  which  escaping 
directly  through  the  lateral  aperture  exceeds  its  circumference  by  one,  two, 
or  three  lines.  This  shoulder,  though  jointed,  possesses  great  solidity,  and 
its  inventor  has  frequently  employed  it  in  practice  with  the  completest  success. 


OPERATIVE  SURGERY.  825 

b.  Excavation. — ^For  calculi  of  a  still  larger  size  M.  Heurteloup  uses  what 
he  calls  his  ''  forceps  excavator"  [evideur  a  forceps) ;  that  is  to  say,  a  cylin- 
drtcal  drill  with  a  jointed  fraise  capable  of  lateral  divergence  so  as  to  give 
rise  to  an  excavation  of  more  than  an  inch  in  diameter;  the  first  glance  of 
this  instrument  however  forbids  us  to  attach  much  confidence  to  it,  and 
shows  that  it  can  possess  but  little  strength.  M.  Amussat  has  also  attended 
to  excavation.  His  drill,  which  is  constructed  on  the  principle  of  one 
by  M.  Leroy,  is  composed  of  a  central  crown  and  two  lateral  points.  When 
the  stone  has  been  pierced  into  with  the  closed  instrument,  the  stem  is  drawn 
back  by  a  screw  between  the  two /raises,  which  it  separates  in  such  a  way  as 
to  allow  of  a  very  considerable  increase  of  the  excavation.  This  instrument 
has  been  successively  modified  by  two  distinguished  cutlers,  MM.  Greling 
and  Charriere ;  the  one  giving  a  firmer  support  to  the  two  lateral  wings  ;  the 
other  a  more  rapid  divergence,  and  supplying  them  with  a  solid  stay  fixed  to 
the  surfaces  of  the  crown  of  the  drill  by  two  little  perpendicular  supports. 
It  is  quite  certain  that,  as  constructed  by  M.  Charriere,  this  drill  seems  capa- 
ble of  creating  an  excavation  of  from  six  to  eight  lines  quite  as  easily  as  the 
common /mise  of  M.  Civiale  will  produce  one  of  three  or  four. 

The  cylindrical  drills  with  a  virgule  or  shoulder  which  diverges  three  or 
four  lines  from  the  axis  of  the  principal  rod,  such  as  have  been  advocated  by 
MM.  Tanchou  and  Pecchioli,  seem  to  me  to  be  much  less  convenient.  I  must 
say  the  same  of  the  triangular  pointed,  wind-mill  armed  counter  sinks  invented 
by  M.Pravaz;  and  of  that  which  has  been  just  recommended  by  M.Rigal  de 
Gaillac,  with  its  sheathed  drill.  This  surgeon,  besides,  has  proposed  to  him- 
self a  plan  other  than  that  of  any  his  predecessors.  When  the  perforation  is 
eifected,  a  return  screw  draws  back  the  fraise  between  the  two  blades  which 
makes  the  chemise  or  sheath,  separates  them,  and  fiistens  them  solidly  against 
the  centre  of  the  stone,  which  is  as  it  were  set  into  a  handle  made  by  the  drill, 
in  such  a  way  that  it  may  be  bruised  against  the  inner  surface  of  the  litho- 
labe.  M.  Rigal  also  thinks  that  by  opening  the  forceps  of  his  instrument  the 
stone  may  be  shivered  by  excentric  efforts.  Herein  he  has  followed  in  the 
steps  of  M.  Civiale,  who  propose!  a  similar  measure  after  lithotomy,  where  a 
stone  is  too  large  to  be  removed  without  danger ;  of  M.  Leroy,  who  says  the 
same  respecting  calculi  in  the  urethra,  as  had  previously  been  suggested  by 
Fischer  and  some  other  authors  in  the  last  century  but  one.  By  way  of  recapitu- 
lation, we  may  observe  that  it  is  doubtful  whether  lithotrity  by  excentric  rup- 
ture will  ever  become  a  method  of  general  adoption,  whether  it  be  effected  by 
sheathed  drills,  by  divergent  blades,  or  by  percussion  on  the  free  end  of  the 
lithotritic  instrument.  As  to  excavation,  the  instrument  which  will  do  it 
most  safely  and  solidly,  is  the  elastic  double  branch  fraise  of  M.  Leroy,  as 
perfected  by  M.  Amussat ;  although  the  mandrel  {a  virgule)  by  M.  Heurteloup, 
and  the  development  forceps  by  M.  Pecchioli,  are  calculated  in  many  cases 
advantageously  to  supersede  it. 

c.  Concentric  Friction. — Instead  of  opening  the  stone  through  its  centre, 
and  excavating  it  from  its  interior  outwardly,  Meirieu  has  conceived  the  idea 
of  grinding  it  to  powder  by  acting  upon  its  surface  and  towards  its  central 
portion  with  a  cylindrical  drill  supplied  with  two  shoulders,  which  develop 
laterally,  capable  of  being  voluntarily  widened,  and  of  making  a  sort  of 
clover  leaf  with  the  stem.    MM.  Recamier  and  Tonchou  have  followed  the 

104 


826  NEW  ELEMENTS  OF 

same  plan,  and  their  efforts  have  had  no  other  aim  than  to  render  its  applica- 
tion more  easy  by  improvements  either  in  the  litholabe  or  the  lithotritor.  It 
is  not  possible  to  deny  the  greater  rapidity  of  this  sort  of  trituration ;  that  by 
means  of  it  we  may  in  fact  pulverise  a  large  stone  at  a  single  sitting ;  that  it 
guards  against  all  risk  of  parcelling  the  stone  into  fragments,  or  that  it  allows 
us  to  keep  it  fast  until  all  is  finished  without  letting  it  go.  But  the  drills  and 
fraises  which  it  is  necessary  to  use  are  unavoidably  weak  and  may  bend  and 
break.  The  separation  from  each  other  of  the  virgules,  leads  to  the  apprehen- 
sion of  their  becoming  entangled  with  the  branches  of  the  forceps  if  it  is 
necessary  to  bring  them  too  near  the  sheath.  We  have  besides  all  those  in- 
conveniences of  which  I  spoke  when  on  the  subject  of  the  litholabe  with 
many  branches  connected  by  silken  strings.  The  essays  of  Meirieu,  and 
those  of  M.  Recamier  have  been  performed  only  on  the  dead  body.  M.  Ton- 
chou  on  the  contrary  has  gone  farther  than  this.  He  has  just  announced  to 
the  institute  that  he  had  been  enabled  by  means  of  his  instrument  to  grind  to 
powder  at  one  sitting  a  stone  of  some  size,  in  a  patient  who  is  now  perfectly 
cured  of  the  calculous  affection.  He  also  last  year  performed  in  my  presence 
several  attempts'  upon  an  adult  man  whom  I  sent  to  him  for  the  purpose. 
The  stone  could  not  be  seized,  however,  and  I  thought  it  proper  to  cut  him  for 
it.  We  then  ascertained  that  the  foreign  body  was  of  entirely  too  large  a  size  for 
lithotrity  by  any  method  to  have  succeeded.  It  would  be  unjust  therefore  to 
refuse  to  M.Tanchou's  apparatus  the  possibility  of  being  applied  with  advan- 
tage. There  is  something  at  first  sight  very  ingenious,  nay,  very  plausible  in 
M.  Rigal's  plan  of  concentric  friction  by  means  of  the  inner  surface  of  the 
litholabe,  against  which  the  stone  socketed  by  the  sheathed  drill  is  made  to 
turn ;  but  the  slightest  reflection  wull  serve  to  show  that  is  an  idea  which  must 
remain  unapplied. 

d.  Crushing  the  Stone  is  one  of  the  methods  to  w^hich  the  ancients  paid 
particular  attention.  Accordingly  it  is  crushing  and  not  friction  which  we 
find  mentioned  by  Acaravius,  and  which  F.  Hildanus  and  others  per- 
formed. M.  Amussat  likewise  operated  by  crushing  in  1822.  This  method  of 
treating  calculi,  for  awhile  forgotten  seems  now  likely  to  dispute  the  palm 
with  lithotrity  properly  so  called.  Some  among  those  who  propose  it,  adopt  it 
only  as  an  accessory  method,  and  for  small  stones,  or  the  fragments  which 
follow  perforation  or  excavation ;  others  again,  seek  to  extend  its  fame  as  a 
generally  applicable  method.  In  the  first  case  it  has  usually  been  combined 
with  the  other  methods.  M.  Civiale,  when  he  finds  that  the  stone  he  has 
seized  is  only  three  or  four  lines  in  size,  for  instance,  immediately  compresses 
it  with  great  force  between  the  branches  of  his  litholabe,  and  crushes  it  at 
once  by  pushing  the  head  of  the  lithotritor  with  the  palm  of  the  right  hand. 
He  does  the  same  with  all  fragments  of  any  size,  or  too  considerable  to  be 
drawn  on  trial  through  the  urethra.  M.  Civiale  had  also  contrived  a  forceps 
with  two  grasps,  capable  of  sliding  over  each  other  and  crushing  small  stones 
by  a  backward  and  forward  motion,  very  like  that  of  M.  Amussat.  Tliis 
instrument  has  been  modified  by  M.  Rigal,  who  made  it  act  through  the  medium 
of  a  return  screw,  dispensing  with  the  motion  backward  and  forwards.  M. 
Columbat  thought  it  might  more  easily  be  managed,  by  adding  to  it  flyers  to 
make  it  move,  and  by  fastening  a  small  chain  to  the  end  of  each  grasp, 
Ui  draw  it  out  without  danger  if  it  should  chance  to  give  way  and  break. 
The  forceps  constructed  with  this  view,  which  has  attracted  most  notice,  is 


OPERATIVE    SURGERY.  t^9lf 

tliat  of  M.  Heurteloup,  delineated  in  his  book  under  the  name  of  **  brise- 
coque"  (shell-breaker).  The  two  grasps  rub  on  each  other,  and  are  enabled 
to  re-enter  the  external  canula  by  means  of  spring- work,  which  they  do  with 
such  power  as  to  shiver  into  splinters  the  hardest  stones,  and  those  which 
offer  the  greatest  resistance.  I  have  seen  this  surgeon  use  it  at  the  school  of 
Perfectionnement  and  cure  two  patients,  each  at  a  single  sitting.  It  is  an  in- 
strument whose  compressing  force  is  perfectly  incalculable.  It  is  much  to  be 
regretted  that  it  is  able  only  to  undergo  very  trifling  divergence,  and  can 
therefore  include  small  stones  merely.  A  forceps  was  constructed  by  M, 
Rigaud,  in  1829,  while  yet  engaged  in  the  study  of  medicine,  upon  nearly  the 
satne  principles,  but  instead  of  two  grasps  having  three.  It  is  a  sort  of  grinder 
which  can  lay  hold  of  stones  of  an  inch  in  diameter,  or  more  even,  just  in 
the  way  that  tiie  common  litholabe  does.  Spring-work  machinery  of  a  very 
complicated  kind  in  the  handle,  enables  the  three  branches  to  move  and  to 
exercise  friction  on  three  parts  of  the  stone  at  once,  which  reduces  it  to  a 
fine  powder,  and  allows  of  its  entire  destruction  before  it  is  let  go.  It  is  a 
stone,  or  shell-breaker,  which  is  not  so  powerful  as  that  of  M.  Heurteloup, 
but  which  has  the  superior  advantage  of  destroying  the  stone  by  friction, 
instead  of  shivering  it  into  fragments.  Still  more  recently,  a  clever  cutler, 
Mr.  Sirhenry,  has  constructed  another  forceps  equally  capable  of  crushing 
the  stone.  It  is  of  three  branches,  which  have  no  hooks,  and  have  a  denticu- 
lated crista  on  their  inner  surface,  which  is  applied  on  the  foreign  body.  It 
is  introduced  into  the  bladder  like  the  common  litholabe.  When  the  stone  is 
fairly  laid  hold  of,  the  branches  are  drawn  back  into  the  sheath  by  a  return 
screw,  which  acts  with  such  prodigious  power  that  silicious  stones  and 
pebbles  cannot  resist  it.  In  an  attempt  which  was  made  with  it  some  time 
since  at  the  Hotel  Dieu,  one  of  its  branches  broke ;  and  this  is  indeed  the 
fear  which  a  view  of  it  at  first  inspires ;  but  to  this  Mr.  Sirhenry  replies,  that 
the  instrument  used  was  an  extremely  weak  one,  never  intended  for  such 
large  stones,  and  that  he  had  warned  them  of  the  possibility  of  the  accident. 
Certainly,  that  one  which  he  showed  me,  and  before  which  the  hardest  calculi 
gave  way,  was  possessed  of  such  strength  that  it  appeared  really  impossible 
to  break  it. 

Some  persons  have  urged  as  an  objection  to  it,  that  the  bladder  is  liable  to 
be  injured  by  the  fragments  of  stone  which  are  scattered  by  the  instrument. 
This  danger  is  clearly  chimerical.  No  pain  resulted  when  a  stone  was  thus 
shivered  between  my  hands,  and  as  we  act  in  the  bladder  filled  with  liquid 
there  is  nothing  to  be  feared  in  this  quarter.  Surely  the  brise  coque  of  M. 
Heurteloup,  and  some  other  instruments  of  which  we  have  yet  to  speak, 
should  possess  similar  inconveniences  which  nevertheless  have  not  interfered 
with  their  application  on  the  living  man. 

e.  Of  the  Four  Ways  of  Breaking  Stones. — No  particular  one  deserves  adop- 
tion to  the  exclusion  of  the  others,  nor  does  any  deserve  absolute  proscription. 
Perforation  of  a  stone  of  five  or  six  lines  is  very  advantageously  combined 
with  crushing ;  for  after  the  fraise  has  made  an  opening,  say  for  example  of 
four  lines,  we  may,  after  having  drawn  it  near  the  sheatli,  pull  the  litholabe 
forcibly  backwards,  and  afterwards  use  it  as  a  *'  hrise  coque.''^  Instead  of  this 
procedure  we  may,  if  the  exploratory  means  used  have  demonstrated  almost 
certainly  that  the  stone  is  a  small  one,  employ  the  grinder  of  M.  Heurteloup, 


■^ 


82fe 


NEW  ELEMENTS  OF 


or  some  one  either  of  the  spring-work  flyer,  "  volaintp  or  rectum-screw  forceps 
previously  described.  When  the  stone  exceeds  ten  lines  or  one  inch,  per- 
foration, excavation,  and  then  crushing  are  successively  proper..  To  conclude, 
to  me  it  appears  incontestible,  that  with  Rigaud's  forceps  we  should  succeed 
without  much  difficulty  in  breaking  calculi  of  from  eight  to  twelve  lines  in 
diameter ;  and  the  same  I  think  might  be  done  more  easily  still  by  that  of 
Mr.  Sirhenry. 

One  remark  which  must  not  be  allowed  to  escape  observation  is,  that  with 
crushing  forceps  the  operation  is  made  wonderfully  more  simple,  as  drills, 
strawberry-shaped  files  [/raises),  supports,  &c.  become  all  useless.  So  that 
if  their  employment  ever  becomes  general,  it  will  be  a  very  certain  means  of 
making  lithotrity  popular, 

§  2.  Curvilinear  Method. 

It  is  a  singular  thing  that  bruising  of  calculi  could  never  be  effected  until 
the  possibility  of  passing  straight  instruments  into  the  bladder  was  demon- 
strated. To  render  the  proofs  of  this  possibility  incontestible,  serious 
anatomical  errors  have  been  maintained  ;  and  now  when  no  one  entertains  a 
doubt  on  either  of  these  subjects,  everyone  perceives  that  curved  instruments 
are  perfectly  able  to  fulfill  the  end  which  had  been  aimed  at  for  so  long  a  time. 

The  file-mandrel  or  stylet  (mandrin  a  lime),  used  by  colonel  Martin,  was 
carried  through  a  curved  sound.     M.  Eldgerton's  instrument  had  the  natural 
curvature  of  all  catheters,  and  so  had  the  first  lithoprionic  instrument  in- 
vented by  M.  Leroy.     The  most  difficult  point  in  this  system  was  to  turn 
the  lithotritic  instrument  on  its  own  axis.     However,  M.  Pravaz  triumphed 
over  this  obstacle,  and  in  1828  succeeded  in  rendering  the  motions  of  a  drill, 
strawberry-shaped  file  (/raise)  quite  as  easy  in  a  curved  as  in  a  straight 
canula.     To  accomplish  this  he  transformed  the  lower  fourth  of  his  perforator 
into  an  articulated  stem,  into  a  small  chain  not  less  solid  however  than 
cylindrical  rods  made  of  a  single  piece.     Still  his  instrument  which  had  an 
arch  of  a  long  circle,  did  not  possess  all  the  advantages  which  it  was 
intended  to  have :  and  the  inventor  finished  by  giving  it  a  curve  like  that 
of  ordinary  catheters ;  that  is  including  in  it  only  the  vesical  fourth.     M. 
Pravaz  failed  with  this  instrument  in  an  application  of  it  at  one  of  the 
hospitals  in  Paris,  on  the  living  subject.      This  want  of  success  might  be 
owing  however  to  a  want  of  practice,  to  the  indocility  of  the  patient  who  was 
but  a  child,  and  particularly  to  the  peculiar  situation  of  the  stone.     It  would 
be  difficult  to  assert  that  his  apparatus,  which  in  no  way  but  in  the  direction 
of  its  principal  pieces  differs  from  any  other,  should  not  be  capable  of  pro- 
ducing similar  effects.     I  should  even  say  that  it  must  certainly  be  much  more 
easy  of  introduction,  and  much  less  fatiguing  to  the  urethra.     M.  Leroy 
showed  one  quite  similar  as  to  the  disposition  of  the  chain  and  drill  which 
was  curved  like  a  common  sound ;  and  which  he  had  yet  further  to  modify  in 
order  to  adapt  it  for  application  to  a  patient  whom  it  was  impossible  to  sound 
with  straight  instruments.     It  had  this  peculiarity,  the  third  branch  of  the 
litholabe  was  fixed,  and  a  component  part  of  the  conducting  canula.     The 
instrument  of  M.  Pravaz,  and  that   of  M.   Leroy,  admit  of  perforation, 
excavation,   and   friction,  like  straight  instruments  ;    but  their   shape    is 


OPERATIVE   SURGERY. 

still  better  adapted  to  crushing.  Mr.  Welsh  of  London,  and  M.  Rigal,  have 
given  a  slight  curve  to  their  friction  or  spring-work  forceps,  and  M .  Jacobson 
constructed  a  species  of  nipper  which  is  equally  curved.  This  latter  in- 
strument is  composed  of  an  outer  sheath  or  canula  like  all  the  rest — then 
of  a  cylindrical  steel  stem  which  completely  fills  it,  and  extends  it  for  three 
inches  towards  the  bladder — this  stem  is  in  two  halves,  jointed  at  top,  placed 
the  one  above,  the  other  beneath,  in  such  a  way  as  that  the  lower  one  being 
pushed  forward  separates  from  the  upper  which  is  fixed  and  forms,  by 
means  of  two  or  three  hinge-like  divisions,  a  loop  capable  of  embracing  a  stone 
of  twelve,  fifteen,  or  eighteen  lines.  A  return  screw  at  its  free  extremity 
allows  it  to  be  restored  to  its  primitive  position.  As  it  was  proposed  by 
the  Danish  surgeon,  it  had  but  two  divisions,  "  brisures,^^  in  its  inferior  branch. 
M.  Dupuytren  thought  that  it  would  be  better  to  give  it  three,  to  make  the 
loop  rounder  and  more  regular.  It  is  introduced  closed  into  the  bladder. 
Then  by  pushing  upon  its  outer  extremity  the  inferior  half  separates  a  little. 
This  makes  a  space  between  it  and  the  other  half,  which  space  may  be  en- 
larged ad  libittiin,  and  the  extent  of  which  is  pointed  out  by  figures  on 
the  outside  of  the  nut  or  box.  In  this  void  or  loop  the  stone  is  engaged. 
When  accurately  seized,  we  act  on  the  return  screw,  as  if  to  isolate 
and  close  the  instrument  by  the  approximation  of  its  two  branches. 
Nothing  can  be  more  simple  than  such  mechanism ;  nor  need  any  thing  be 
easier  than  the  operation  itself.  Here  we  have  not  even  to  fear  fracturing 
the  instrument,  for  its  articuiations  will  always  allow  us  to  withdraw  the 
fragments  without  danger.  All  that  can  be  said  against  it  is  that  having  only 
two  branches  it  cannot  so  easily  as  the  others  lay  hold  of  the  stone,  and  that 
if  we  confine  ourselves  to  crushing  it  we  are  obliged  to  reseize  every  separate 
piece.  I  must  add  to  this,  that  the  detritus  of  stone  which  sometimes  remain 
sticking  to  the  inner  surface  of  each  grasp  are  calculated  to  render  their 
approximation  very  difficult.  M.  Dupuytren  who  used  it  on  a  patient  was 
much  pleased  with  it,  and  four  or  five  sittings  were  sufficient  to  enable  him 
completely  to  destroy  a  voluminous  stone ;  so  that,  either  as  it  now  is,  or  after 
it  shall  have  received  such  modifications  as  I  conceive  it  to  be  susceptible 
of,  this  instrument  may  yet  make  eccentric  friction,  either  by  perforation  or 
excavation  much  less  rare,  and  in  a  great  many  cases  do  away  with  the  ne- 
cessity of  straight  instruments.  Adopting  the  curved  lithotritor,  M.  Segalas 
also  thought  fit  to  modify  it  in  the  case  of  a  patient  who  could  not  bear  the 
introduction  of  straight  instruments.  The  improvements  by  this  surgeon 
chiefly  relate  to  the  rod  of  the  perforator,  which  after  his  plan,  instead  of  being 
made  with  a  jointed  chain,  is  made  of  metallic  wires  collected  into  a  fasciculus 
or  bundle  ;  and  also  the  means  of  pulling  out  the  fragments  of  the  litholabe 
if  it  happens  to  break  in  the  bladder,  without  danger;  in  all  which  I  see  but 
changes  of  trifling  importance  and  useless  complexity. 

M.  Heurteloup,  returning  to  the  idea  of  themonkof  Citeaux,  has  proposed  a 
curved  instrument  which  opens  after  the  manner  of  a  shoemaker's  foot-rule  or 
measure;  and  which  after  having  securely  grasped  or  fastened  the  stone 
between  its  blades,  allows  it  to  be  broken  and  reduced  to  fragments  by 
means  of  blows  inflicted  with  a  hammer  on  the  end  of  its  upper  or  movable 
branch. 


A 


856  NEW  ELEMENTS  OF 

This  system,  which  the  author  calls  lithotrity  by  percussion,  has  already 
been  several  times  practised  by  him  with  entire  success  in  London :  and  the 
attempts  which  he  has  made  on  the  dead  body  in  Paris  prove  effectually  that 
stones  may  be  destroyed  by  it  with  more  force  and  quickness  than  by  any 
other  method.  Yet  as  it  requires  instruments  of  immense  calibre  and  great 
strength  to  avoid  breaking  inside  of  the  bladder,  I  am  doubtful  whether  this 
new  method  will  ever  obtain  the  currency  which  M.  Heurteloup  seems  to 
anticipate. 

§  3.  Accessory  Apparatus, 

Whatever  be  the  lithotritic  system  we  have  chosen  to  adopt,  the  means  by 
which  it  is  set  in  operation  deserves  the  attentive  consideration  of  the  surgeon. 
The  mechanism  of  stone-breakers  (hrist-pierres),  of  shell-breakers  [brise- 
coques),  of  saxifrages  and  grinders  {grugeoirs),  having  throughout  been  brought 
forward  in  the  system  of  return  screws,  double  levers,  spring-work  {encUque- 
tage),  or  wheel  and  catch  work  (engrenage),  makes  a  part  of  the  principal  in- 
strument, and  requires  no  separate  description.  Not  so  however  with 
breaking,  properly  so  called,  effected  either  by  perforation,  excavation,  or 
concentric  pulverization.  Two  orders  of  springs  then  become  indispensably 
necessary;  1st,  to  keep  the  litholabe  firmly  together;  2d,  to  make  the  lilho- 
tritor  act. 

Under  the  first  intention,  the  chevalet  (easel)  a  sort  of  lathe,  ''tour  en  P  air, ^^ 
proposed  first  by  M.  Leroy,  after  Ducamp,  and  slightly  altered  by  MM. 
Civiale,  Rigal,  &c.  has  generally  been  adopted.  Some  persons  however  have 
preferred  to  substitute  an  ebony  vice  with  one  or  two  handles ;  but  the  chevalet 
is  evidently  better.  Others  have  exercised  their  ingenuity  in  fixing  the 
instruments  as  well  as  the  patient.  Hence  the  beds  with  or  without  support, 
contrived  by  MM.  Leroy,  Heurteloup,  Tanchou,  Rigal,  &c.;  contrivances 
perfectly  useless  evidently,  and  which  M.  Civiale  has  always  been  able  to 
dispense  with.  The  bare  idea  of  metallic  supports,  to  remain  immovable 
upon  the  foot  of  the  operating  table  as  in  that  of  M.  Charriere,  or  the  me- 
chanical bed  like  that  of  M.  Heurteloup  is  alarming.  Let  us  fancy  to 
ourselves  in  fact  some  sort  of  forceps  and  lithotritor  working  in  the  bladder 
of  a  living;  man,  whilst  an  inflexible  bar  of  iron  planted  upon  the  table  fastens 
them  without,  and  we  shall  then  see  whether  the  least  disorderly  or  unex- 
pected motion  of  the  patient  is  not  of  a  nature  to  make  us  tremble  for  the 
consequences.  However  ingeniously  they  be  contrived,  the  use  of  this  arti- 
ficial force  must  be  abandoned,  and  their  place  supplied  by  able  assistants 
or  the  hand  of  the  surgeon  himself.  By  pressing  with  his  chest  against  the 
lithotritor,  through  the  intermedium  of  a  crescent-shape  handle,  in  such  a 
way  as  to  hold  the  litholabe  with  his  left  hand,  whilst  with  the  right  he  turns 
the  drill  with  a  wooden  instrument  like  a  wimble.  M.  Amussat  avoids  all 
these  dangers ;  but  he  acts  with  less  power  than  by  employing  a  lathe  and 
tires  himself  much  more;  so  that  all  things  considered  the  easel  or  chevalet 
does  best  after  all. 

Tl\ere  are  two  powers  to  be  directed  in  the  action  of  a  drill ;  that  which 
presses  upon  its  outer  extremity  to  keep  it  in  contact  with  the  stone,  and 
that  which  obliges  it  to  turn  upon  its  axis.    Those  persons  who  supposed  that 


OPERATIVE    SURGERY.  8SI 

they  could  find  the  former  in  the  thumb,  the  forepart  of  the  chest,  or  the  knee, 
have  evidently  deceived  themselves;  unless  they  could  discover  a  system 
which  is  a  better  combination  than  that  of  the  wheels,  wimbles,  and  cranks 
hitherto  invented.  The  spring  en  boudin,  enclosed  in  the  movable  "poupee^^ 
(puppet)  of  the  lathe  certainly  is  far  from  satisfying  our  wants.  Still  as  long 
as  the  drill-bow  shall  continue  to  be  preferred  as  the  rotary  agent,  I  see 
nothing  by  which  it  can  be  advantageously  replaced.  Rings,  flyers,  handles, 
which  would  seem  at  first  sight  sufficient  for  the  power  of  rotation,  have  not  an 
extended  action,  and  neither  sufficiently  favor  the  forces  set  in  play,  and  their 
movements  are  of  little  service.  The  catch -wheels  placed  beneath,  as  in  M. 
Leroy's  contrivance,  and  as  are  again  proposed  by  M.  Rigal,  or  on  the  side 
as  in  M.  Pravaz's  apparatus,  whether  they  act  upon  a  pinion  placed  parallel 
to  the  axis  of  the  litholabe,  or  whether  they  catch  in  an  indented  pinion,  coni- 
cal and  circular,  give  to  the  drill  as  rapid  a  motion  as  is  required ;  but  the 
means  of  compressing  its  extremity  with  sufficient  force  at  the  same  time  still 
remains  to  be  discovered.  The  mechanism  of  the  drill-bow  is  the  same  in 
lithotrity  as  in  any  of  the  mechanical  arts  in  which  it  is  employed.  Until 
wheels  can  be  substituted  for  it,  prudence  requires  that  its  use  be  continued, 
and  the  good  end  which  it  has  already  answered  after  all  allows  us  to  repose 
more  confidence  in  its  use  than  in  that  of  any  other  instrument  which  tends 
towards  the  attainment  of  the  same  object. 

*^rt,  4. — Method  of  Operation. 

Before  we  proceed  to  perform  lithotrity,  there  are  some  special  precautions 
to  be  observed.  Supposing  the  urethra  to  have  been  diseased,  its  natural 
dimensions  must  first  be  restored  as  well  as  its  original  dilatability.  Even 
though  this  canal  should  be  wide  enough  to  allow  the  instruments  to  pass,  it 
must  nevertheless  be  subjected  for  some  days  to  the  action  of  bougies  or 
flexible  sounds  to  dull  its  sensibility,  and  accustom  it  to  the  prescence  of 
foreign  bodies.  With  this  view  it  is  often  useful  for  the  same  reason  to 
inject  the  bladder  several  times  to  diminish  its  irritability,  that  it  may  the 
more  readily  allow  itself  to  be  distended  at  the  time  of  the  operation.  Though 
not  indispensable  these  are  preparatory  steps,  which  except  in  a  very  few 
persons  should  not  be  neglected. 

a.  Position  of  the  Patient. — lii  civil  practice  it  answers  very  well  to  let 
the  patient  lie  on  his  back  on  the  edge  of  his  bed,  his  pelvis  supported  by  a 
rather  hard  cushion,  his  feet  resting  upon  two  stools,  and  the  head  slightly 
bent  upon  the  chest.  In  one's  own  house,  or  in  a  public  institution,,  he  would 
be  placed  on  a  narrow  bed  of  a  convenient  height,  so  that  his  legs  might  pro- 
ject beyond  the  foot  of  it,  and  be  sustained  as  in  the  preceding  case.  In  this 
position  he  neither  requires  to  be  tied  nor  bound  ;  the  posterior  wall  of  the 
bladder  becoming  the  lowermost  it  allows  the  stone  to  go  further  from  the 
urethra;  and  thus,  as  it  were,  to  off'er  itself  to  the  litholabe.  It  is  easy  to 
alter  it  according  to  necessity,  either  by  giving  the  pelvis  a  loftier  elevation, 
where  the  stone  has  a  tendency  to  stay  in  the  bas-fond  or  by  diminishing 
the  thickness  of  the  cushion  when  the  contrary  is  feared ;  a  resource  which 
we  have  not  to  the  same  degree  in  lithotritic  beds  or  tables. 

b.  Injections, — A  first  stage  of  the  operations  consists  in  filling  the  blad- 


832  NEW   ELEMENTS  OF 

der  with  warm  water  or  some  emollient  decoction.  But  for  this  the  lithotri- 
tor  and  litholabe  could  not  play  freely ;  the  stone  could  not  always  be  seized  ; 
and  the  organ  would  be  pinched  almost  infallibly.  It  is  done  with  a  common 
catheter  and  a  hydrocele  syringe  much  more  surely  than  by  bladders,  or 
india  rubber  bottles,  or  by  the  sheath,  or  canula  of  the  litholabe.  The  silver 
catheter  when  introduced  serves  anew  for  feeling  the  presence  of  the  stone. 
An  assistant  takes  hold  of  it  for  the  surgeon  to  adapt  the  pipe  of  the  syringe, 
and  send  on  the  liquid.  When  eight  or  twelve  ounces  are  thrown  in,  or  bet- 
ter still  when  the  patient  expresses  a  strong  wish  to  urinate,  we  withdraw 
the  catheter  and  instantly  substitute  the  lithotritic  apparatus  before  there  has 
been  time  for  the  injection  to  be  returned. 

c.  Introduction  of  the  Forceps. — The  drill,  slipped  into  the  canula  of  the 
forceps,  and  fitted  with  its  box  to  receive  the  bow;  the  litholabe  in  turn 
introduced  into  the  common  sheath  and  furnished  with  a  box  at  its  outer 
extremity,  so  that  its  branches  closing  exactly  upon  the  grooves  in  the 
head  of  the  lithotritor,  which  represent  an  olive  made  smooth  with  some 
tallow,  are  then  passed,  united  into  one  instrument,  like  a  catheter  into 
the  urethra.  To  do  this,  the  operator  standing  on  the  right  side  of  the 
patient  lays  hold  of  the  penis  with  his  left  hand,  as  in  performing  the  com- 
mon introduction  of  a  catheter ;  raises  it  a  little ;  presents  perpendicularly 
to  it  with  the  right  hand  the  instrument  well  oiled  or  greased ;  enters  the 
meatus  urinarius  slowly,  by  gentle  rotatary  movements ;  speedily  arrives  at 
the  bulb ;  stops  for  a  second ;  powerfully,  yet  gently  depresses  his  hand  to 
get  underneath  the  symphysis,  through  the  membranous  and  prostatic  portions 
of  the  urethra;  and  so  clears  the  neck  of  the  bladder. 

d.  Finding  the  Stone. — Before  the  litholabe  is  opened,  he  is  to  find  the 
stone,  by  feeling  about  backwards  and  forwards  with  the  olive- shaped  extre- 
mity of  the  still  closed  metallic  instrument ;  1st,  from  before  backwards, 
upon  the  median  part  of  the  bas-fond  and  posterior  wall  of  the  organ ;  2d, 
from  behind  forwards,  as  if  to  complete  the  circle,  returning  by  the  right  or 
by  the  left  side ;  3d,  a  second  time  from  before  backwards,  returning  by  the 
side  opposite  to  that  last  passed  over,  coming  back  to  the  centre  into  which 
the  stone  may  have  fallen,  and  then  transversely,  so  as  Dr.  Ashmead  says 
to  leave  no  portion  of  the  floor  of  the  bladder  untouched.  If  we  can  find 
nothing  after  this  minute  search,  it  is  better  to  postpone  the  operation  than 
obstinately  persist  in  continuing  it.  Still  it  should  not  be  abandoned  until 
after  the  position  of  the  patient  had  been  varied  in  every  way,  and  we 
are  perfectly  sure  that  no  natural  excavation  or  depression  has  been  over- 
looked. 

e.  Opening  the  Forceps. — When  he  has  discovered  and  approached  the 
situation  of  the  stone,  the  operator  takes  and  holds  firmly  the  end  of  the 
litholabe  in  his  right  hand,  and  uses  his  left  hand  to  draw  towards  him  the 
outer  canula,  as  if  he  was  going  to  take  it  out  of  the  urethra,  and  thus  allows 
the  forceps  to  open  by  removing  the  restraints  upon  the  natural  elasticity  of 
the  branches.  The  bladder  runs  much  less  risk  in  this  way  than  if  he  slipped 
the  litholabe  forward  without  disarranging  its  sheath,  with  a  view  to  save  the 
urethra,  the  entrance  to  which  moreover  is  perfectly  filled  up  by  the  neck  of 
the  triploid  as  it  opens  in  the  urinary  sac. 

f.  To  find  the  Stone  again  and  grasp  it  is  often  much  more  difiicult  than 


■w 


OPERATIVE    SURGERY. 


is  supposed;  especially,  as  Dr.  Ashmead  says,  because  feeling  it  is  not 
always  sufficient  to  point  out  its  exact  situation.  This  search  for  it,  now 
requires  the  utmost  care.  The  difficulty  is  to  say  whether  we  are  touching 
it;  1st,  with  the  convexity  of  one  or  both  the  lower  crotchets;  2d,  by  the 
middle,  inner,  or  outer  part  of  one  of  the  branches,  and  if  so,  whether  the 
right  branch  or  the  left;  3d,  by  the  inferior  surface  of  these  same  branches 
near  the  prostate.  The  following  rules  on  this  subject  should  not  be 
neglected. 

If,  in  balancing  the  instrument  it  is  perceived  to  fall  upon  the  foreign  body 
with  the  sensation  of  a  double  clash,  the  stone  is  situated  beneath  the  two 
branches  and  behind  the  prostate. 

If  one  branch  descends  lower  than  the  other  when  turned  upon  its  axis, 
and  but  one  collision  occurs,  it  will  be  found  on  the  highest  side. 

If  it  lies  forwards,  and  the  two  hooks  alternately  and  not  simultaneously 
pushed  on  equally  detect  it,  it  may  be  said  to  correspond  to  the  space  between 
them. 

If  one  only  strikes  upon  it,  it  must  be  upon  one  side.  To  detect  whether  it 
be  the  right  or  the  left,  we  are  to  keep  one  crotchet  motionless,  whilst  the  other 
is  gently  made  to  advance.  Let  us,  instead  of  this,  suppose  it  to  be  outside 
of  the  left  branch;  then  taking  the  other  for  the  fulcrum,  it  is  to  be  raised 
and  lowered  by  rotatory  movements  which  describe  the  arc  of  a  circle,  and 
will  then  not  fail  soon  to  detect  it,  whilst  the  same  motions  performed  on  the 
opposite  side  will  cause  nothing  to  be  perceived. 

A  transverse  limited  movement,  first  to  the  right  and  then  to  the  left,  will 
in  like  manner  inform  us  if  the  stone  is  within  the  litholabe,  nearer  to  one 
branch  than  the  other,  or  in  the  centre.  These  different  manipulations,  done 
with  a  little  address,  will  not  leave  us  long  in  doubt  as  to  its  real  situation 
if  the  surgeon  has  taken  the  precaution  to  place  inferiorly  two  branches  on 
the  same  level. 

Such  being  the  state  of  things,  it  cannot  be  very  difficult  to  include  the  stone 
in  the  area  of  the  instrument,  nor  consequently  to  grasp  it.  Not  to  derange 
the  relative  situation  of  the  diiferent  objects,  the  surgeon  takes  the  free  end  of 
the  forceps  and  raises  it  a  little  with  the  right  hand,  so  that  its  branches  may 
be  kept  in  contact  with  the  floor  of  the  bladder;  after  which,  taking  hold  of 
its  leather  box  with  the  left  hand,  the  canula  or  chemise  is  pushed  down  upon 
it.  It  is  also  advantageous,  previously,  to  draw  the  drill  backwards  and 
forwards  in  the  tube,  and  between  the  divisions  of  the  litholabe,  until  the 
fraise  has  absolutely  touched  the  stone.  By  an  effort  in  a  contrary  direction, 
on  the  sheath  and  on  the  stone,  the  concretion  is  finally  fastened,  and  then 
nothing  remains  but  to  attack  it  with  the  lithotritor. 

g.  Applying  the  Lathe  and  the  Brill-bow. — This  is  now  the  time  for  apply- 
ing the  supports  and  agents  of  motion.  A  pressure  screw  first  prevents  the 
two  closed  instruments  from  reopening.  A  nwrtice  which  there  is  on  the 
top  of  the  lathe  then  embraces,  seizing  it  underneath  the  quadrilateral  extre- 
mity of  the  sheath  in  front  of  the  box,  which  extremity  is  furnished  with 
lateral  edges,  and  a  pressure  screw  fastens  them  at  once  in  this  position. 
The  little  cup  of  the  spiral  spring,  supported  by  the  puppet  of  the  lathe  is 
then  applied  to  the  tail  of  the  drill.  The  puppet  is  pushed  forward  with  a 
violence  proportioned  to  that  action  which  we  intend  to  exercise  upon  the 
105 


834  NEW  ELEMENTS  OF  ^^ 

drill  and  on  the  stone.  It  is  stopped  by  a  turn  of  the  screw.  If  the  pres- 
sure of  the  spring  appears  too  great,  a  fourth  screw  enables  us  to  suspend 
or  continue  it  at  pleasure.  The  apparatus  is  then  ready.  An  assistant 
turned  towards  the  pelvis,  and  standing  on  the  right  side  or  between  the  legs 
of  the  patient,  takes  charge  of  it,  and  seizes  it  by  the  handle  in  the  right  hand, 
and  near  the  curved  portion  with  his  left.  The  operator  takes  the  loosened 
cord  of  the  drill-bow,  passes  it  around  the  box  which  has  been  previously 
placed  upon  the  drill,  and  brings  back  the  buckle  to  be  attached  to  the  end 
of  the  elastic  arch,  from  which  it  had  been  for  a  moment  separated ;  always 
recollecting  that  the  string  tliough  it  should  be  delicate  should  also  possess 
great  strength,  and  work  with  as  little  friction  as  possible. 

h.  Friction, — This  being  done,  the  surgeon  still  standing  on  the  right  side, 
holds  the  instrument  firmly  with  his  left  hand  between  the  penis  and  the 
head  of  the  chevalet  or  easel ;  whilst  with  his  right  he  makes  the  drill-bow 
act,  carefully  inclining  the  effort  forward,  and  combining  pressure  against  the 
stone  with  rotation  unless  the  spring  seems  to  be  sufficient.  The  drill  box 
has  moreover  been  arranged  in  such  a  way  as  to  strike  against  the  drawing 
box  of  the  litholabe,  before  the  head  of  the  drill  can  reach  the  vesical  extre- 
mity, and  go  beyond  the  circle  of  the  forceps. 

Having  finished  this  preliminary  perforation,  we  are  to  draw  back  the 
puppet  of  the  lathe  so  as  to  bring  back  the  drill  towards  ourselves.  If  the 
stone  is  friable  and  small,  we  try  to  break  it  before  letting  it  go,  by  acting 
powerfully  on  the  two  cork  boxes  in  an  opposite  direction.  If  not,  we  open 
the  forceps  moderately,  and  then  by  striking  gentle  blows  on  the  free  end 
we  try  to  move  the  stone  and  to  change  its  position  ;  which  change  we  may 
effect  by  the  assistance  of  the  drill  directed  by  the  right  hand.  If  nothing 
will  succeed  in  effecting  it,  we  must  wholly  abandon  the  stone,  and  seize  it 
again  precisely  as  if  it  had  escaped  by  accident  from  the  operator.  For  fear 
it  may  not  present  by  exactly  the  same  diameters,  which  is  extremely  rare,  we 
push  the  drill  hard  against  it,  so  as  to  move  it  again  if  it  falls  into  the  same 
hole  ;  and  not  set  it  again  in  motion  with  the  bow,  except  so  long  as  it  meets 
with  a  solid  portion  of  substance  to  destroy. 

The  use  of  development  drills,  of  strawberry-shaped  files  with  shoulders 
(/raises  a  virgu/e),  and  files  with  single  or  double  wings,  is  subjected  to  simi- 
lar rules,  whether  originally  made  use  of,  or  only  after  the  first  perforation. 
In  the  first  case,  we  must  so  separate  them  as  that  they  will  turn  freely 
behind  the  stone,  without  touching  the  inner  surface  of  the  branches  of  the 
litholabe,  and  so  that  the  central  may  serve  as  the  axis  to  the  lateral  wings, 
whilst  they  are  acting  on  the  stone.  In  the  second  case  we  open  them  only 
by  degrees,  and  even  within  the  first  perforation.  The  name  of  "  echoppeur,^^ 
graver  or  exca^vator,  then  really  becomes  applicable  to  them,  since  they  serve 
to  reduce  the  same  to  a  shell,  and  to  hollow  it  out  into  a  conoidal  cavity  whose 
summit  removes  backwards.  ^  Spherical  stones  of  rather  large  size,  taken 
centre  for  centre,  are  best  adapted  to  it;  those  which  are  elongate,  which  are 
grasped  laterally  or  by  some  projecting  part,  and  which  leave  a  void  on  one 
side  between  the  branches  of  the  forceps,  render  their  action  difficult  and 
sometimes  dangerous,  owing  to  the  unequal  resistance  which  they  meet  with 
in  turning.    M.  Tanchou's  apparatus,  though  more  ingenious,  is  not  wholly 


OPERATIVE    SURGERY.  835 

free  from  this  inconvenience,  and  I  think  it  in  such  cases  most  prudent  to 
confine  oneself  to  simple  friction  and  crushing  combined.  When  the  stone  is 
entirely  powdered,  or  the  patient  is  too  much  fatigued,  say  in  five,  eight,  ten, 
and  at  the  utmost  twelve  minutes,  the  sitting  should  be  completed.  We  take 
oft'  the  bow ;  loosen  all  the  screws  to  take  oft*  the  chevalet  or  easel,  and  with- 
draw the  drill  as  we  keep  closing  the  forceps.  When  a  fragment  adheres  to 
their  branches,  it  is,  if  not  too  large,  drawn  out  with  the  remainder  of  the 
instrument;  but  if  there  be  any  cause  for  fearing  its  action  on  the  urethra, 
it  is  better  to  let  it  go,  and  allow  it  to  fall  into  the  bladder  again,  by  pushing 
it  back  with  the  lithotritor.  The  remains  of  the  injection  and  the  urine, 
which  the  patient  is  usually  very  anxious  to  void  directly  afterwards,  almost 
always  bring  with  them  pieces  of  calculi,  and  a  greater  or  less  quantity  of 
powder,  resulting  from  the  grinding,  which  are  the  best  proof,  so  far  as  the 
patient  is  concerned,  of  the  success  of  this  operation.  We  advise  a  bath  on 
the  same  evening  or  immediately.  In  general,  all  the  treatment  which  the 
case  requires  is  that  which  is  called  for  by  states  of  convalescence  of  any 
kind,  or  by  invalids  usually.  At  the  end  of  two,  three,  four,  or  five  days, 
according  to  the  agitation  of  system  produced  by  the  first  attempt,  we  begin 
again,  and  again  observe  the  same  precautions ;  and  so  on  until  no  further 
vestige  of  stone  exists  in  the  urinary  bladder.  One  or  two  examinations 
with  the  common  sound,  at  intervals  of  some  days,  are  necessary  to  produce 
certain  conviction  on  this  point,  and  ought  upon  no  pretence  whatever  to  be 
omitted. 

£rt  5. — Remarks  on  certain  Points  in  the  Method  of  Operation,  and  on  the 
Accidents  which  occur  in  Lithotrity. 

In  spite  of  the  leather  boxes,  and  the  accuracy  with  which  the  three  princi- 
pal pieces  of  the  apparatus  fit  into  one  another,  it  sometimes  happens  that  the 
injection  escapes  between  them,  or  else  between  the  outer  canulaand  the  walls 
of  the  urethra.  A  *'  tubulure,^^  or  neck,  placed  upon  the  back  of  the  chemise 
or  sheath,  and  made  to  communicate  with  the  bladder  hy  a  groove  hollowed 
out  upon  the  external  face  of  the  litholabe,  is  now  added  to  almost  every  new 
instrument  with  a  view  to  remedy  this  inconvenience.  The  pipe  of  a  syringe 
may  in  fact  be  added  to  it,  so  as  to  make  a  catheter  of  it,  and  renew  the  in- 
jection; but  the  irritability  of  the  organ  soon  brings  matters  to  the  same  point, 
though  happily  it  is  not  often  entirely  emptied. 

Lithotrity  before  puberty  is  not  so  easy  as  it  is  in  the  adult.  1st.  Because 
of  the  imperfect  development  of  the  genital  organs,  the  narrowness  of  the 
urethra,  the  unmanageableness  of  the  patients,  and  the  exquisite  sensibility  of 
the  parts.  The  instruments  should  not  be  more  than  two  lines  or  two  and  a 
half  in  diameter,  which  sensibly  lessens  their  power,  whilst  at  a  later  period 
of  life  this  may  be  extended  to  four  lines,  although  those  of  three  lines  or  three 
lines  and  a  half  are  generally  sufficient. 

They  are  still  less  adapted  to  early  infancy  for  the  same  reasons,  and  more- 
over because  the  bladder,  rising  too  high  in  the  pelvis,  augments  in  propor- 
tion the  curve  of  the  hinder  third  of  the  urethra,  and  thirdly,  because  cutting 
at  this  period  of  life  oft*ers  a  great  chance  of  success. 

The  prostate  gland  in  some  persons  makes  its  application  difficult,  owing  to 


836  KEW  ELEMENTS  OF 

the  crowding  back  of  the  urethra  behind  the  symphysis.  In  such  cases,  curved 
instruments  are  in  a  measure  necessary.  M.  Leroy  struck  with  this  want, 
and  desirous  of  doing  away  with  its  importance,  and  having  oftentimes  expe- 
rienced the  danger  and  impossibility  of  straight  instruments,  has  proposed  a 
measure,  in  appearance  a  very  simple  one,  which  he  calls  redresseur,  straight- 
ener  of  the  urethra;  composed  of  a  gumelastic  catheter  introduced  crooked, 
and  when  in  made  straight  again  by  a  straight  mandrin  which  is  pushed 
slowly  into  it  from  before  backwards  by  a  screw.  This  instrument  resem- 
bling tliat  which  M.  Rigal  has  contrived  in  the  same  view,  and  which 
might  well  be  superseded,  as  M.  Pravaz  remarks,  by  the  cylinder  of  the  litho- 
tritor,  carried  with  the  hand,  by  spiral  movements  through  a  large  flexible 
sound,  open  at  both  ends,  endangers  the  occurrence  of  serious  accidents,  such 
as  contusing  the  verumontanum,  and  tearing  the  urethra  by  means  of  the  screw 
or  the  nut  of  which  we  cannot  calculate  the  power ;  and  also  because  the  head 
of  the  mandrin  or  stylet  makes  its  way  by  striking  against  every  point  of  the 
inferior  wall  of  the  canal.  That  of  M.  Tanchou,  would  be  decidedly  prefer- 
able, if  straightening  the  urethra  were  a  precaution  really  necessary  to  be 
taken  in  such  cases,  as  it  is  formed  on  its  vesical  third  of  a  series  of 
small  jointed  pieces,  which  allow  of  its  being  introduced  curved,  and  straight- 
♦Mied  when  in,  without  the  slightest  friction.  But  if  rectilinear  catheterism  is 
not  practicable,  it  is  according  to  my  view  of  the  case  much  better  to  resort  to 
curved  instruments,  or  even  to  lithotomy,  than  to  rely  on  such  means. 

Extreme  development  of  the  prostate  brings  with  it  another  inconvenience  ; 
it  changes  the  bas-fond  or  trigone  of  the  bladder  sometimes  into  a  deep  exca- 
vation, in  which  the  stone  is  not  always  easily  seized.  The  fingers  of  the 
surgeon  himself  or  his  assistant  introduced  into  the  rectum,  would  I  think  be 
preferable  for  raising  and  offering  it  to  the  claws  of  the  litholabe  to  the  little 
bag  invented  by  M.  Tanchou  or  any  species  of  tampon  whatever,  which  could 
be  slipped  up  above  the  anus. 

Lithotrity  upon  females  is  infinitely  easier  than  in  man,  and  almost  without 
danger.  In  them  the  canal  being  wide,  distensible,  short,  and  not  curved,  free 
from  prostate  gland  or  seminal  orifices,  adapts  itself  admirably  to  the  pas- 
sing in  of  the  instruments  necessary,  neither  does  it  require  as  entire  a  pulve- 
rization of  the  calculus.  The  only  thing  is  that  they  have  somewhat  more  diffi- 
culty in  retaining  the  injections,  less  indispensable  however  in  a  naturally 
large  bladder,  supple,  and  so  to  speak,  beneath  the  eye ;  so  much  so,  that  in  a 
very  few  sittings  a  little  girl  of  three  years  old  was  relieved  of  a  large  calculus, 
notwithstanding  that  no  liquid  could  be  retained  in  the  unnary  reservoir. 

Curved  instruments,  either  those  of  Pravaz,  Pamard,  or  Leroy,  being  intended 
all  of  them  for  the  same  species  of  friction  as  that  apparatus  whose  application 
I  have  described,  demand  no  particular  detail  of  their  method  of  operation. 
The  principal  advantage  they  possess  is  that  of  fatiguing  the  urethra  less, 
causing  less  pain  consequently,  and  of  penetrating  into  the  bladder  more  freely. 
As  on  the  other  hand  they  are  less  convenient  than  the  others  for  sounding  the 
organ,  finding  and  seizing  the  stone,  it  is  useless  to  attempt  their  use  in  females. 
It  may  indeed  be  laid  down  as  a  principle,  that,  cseteris  paribus^  straight  instru- 
ments are  best  suited  for  performing  lithotrity  by  perforation,  excavation,  or 
concentric  friction ;  whilst  curved  instruments  answer  better  for  crushing  the 
stone. 


OPERATIVE    SURGERY.  837 

If  the  "  grinder"  [grugcoir)  of  M.  Rigaud  were  curved,  and  if  it  were  pos- 
sible to  lessen  its  size  a  little  without  decreasing  its  strength,  it  would  deserve 
frequently  to  be  employed,  and  would  be  equal  to  the  task  of  crushing  any 
stone  not  bigger  than  a  nut.  It  is  introduced  in  the  same  way  that  all  other 
instruments  are.  To  open  it,  it  is  held  towards  the  urethra  by  the  left  hand, 
whilst  the  right  acts  on  its  handle  by  an  effort  which  displaces  the  screw  and 
nuts.  When  it  is  ascertained  that  the  stone  is  between  the  claws,  it  is  closed 
by  an  opposite  effort,  after  which  a  see-saw  motion  and  circumduction  of  the  wrist 
suffice  to  set  in  action  the  friction  of  the  grasps  upon  the  foreign  body.  The 
shell  breaker  of  M.  Heurteloup,  whose  motions  are  very  much  the  same,  requires 
pretty  nearly  the  same  management,  except  that  the  spring-work  in  it  compels 
it  to  re-enter  its  sheath  at  the  same  time  with  some  violence ;  thus  crushing  the 
stone  rather  than  grinding  it.  Its  action  indeed  is  more  rapid,  but  is  attended 
witli  tlie  creation  of  splinters  and  fragments  which  have  afterwards  to  be  seized ; 
whilst  that  of  M.  Rigaud  cannot  let  go  its  hold  until  the  last  fragment  of  stone 
it  contains  is  reduced  to  a  fine  powder. 

Mr.  Jacobson's  instrument  being  one  of  the  easiest  to  manage  will  probably 
be  oftenest  employed.  None  less  exposes  the  bladder  to  injury.  A  mere 
jointed  loop,  having  neither  hooks  nor  free  points,  it  is  almost  impossible 
that  it  should  either  pinch  or  pierce  the  walls  of  the  organ ;  so  that  strictly 
speaking,  it  might  be  used  without  premising  an  injection.  Its  curve  renders 
its  introduction  as  easy  as  that  of  a  common  sound.  The  way  to  open  it  is 
very  easy.  The  nut  being  brought  back  to  the  end  of  the  screw  we  apply  the 
palm  of  the  right  hand  on  this  end  and  push.  The  jointed  branch  of  the  forceps 
opens  forthwith  in  the  bladder,  as  if  to  form  the  circle  of  a  rocket  or  battle- 
dore, rather  irregular,  owing  to  the  dorsal  concavity  preserved  by  the  other 
branch.  We  proceed  to  search  for  the  stone  according  to  the  rules  always 
given.  When  the  calculus  is  entirely  encircled  by  the  metallic  loop  we 
pull  upon  the  screw,  first  with  our  hand  as  if  we  were  closing  a  litholabe,  and 
then  with  the  screw  nut,  which  becomes  in  this  case  a  return  screw,  which, 
causing  the  two  halves  of  the  stone  breaker  to  act  like  two  large  files  rubbing 
upon  the  stone  in  opposite  directions,  concentrates  its  whole  action  upon  the 
latter,  and  scarce  can  fail  of  crushing  it.  The  numerous  fragments  which 
follow  it  are  submitted  to  a  similar  treatment  and  search.  The  surgeon  needs 
no  assistant,  and  the  patient  feels  but  little  Hitigue,  nor  does  any  thing  prevent 
the  sittings  from  recurring  at  brief  intervals.  To  conclude,  the  position  is 
the  sanTe  as  for  catheterism  in  general.  It  is  only  to  be  regretted  that  so  many 
advantages  should  be  counterbalanced  by  a  greater  difficulty  in  finding  and 
seizing  stones  of  small  size :  of  being  certain  that  we  hold  them  in  the  loop  of 
the  forceps,  and  by  the  impossibility  of  extracting  with  it  any  of  the  frag- 
ments. 

To  accomplish  the  extracting  of  fragments,  M.  Heurteloup  employs  a 
large  sound,  either  crooked  or  straight,  terminated  at  its  vesical  extremity  by  a 
sort  of  thimble,  called  the  magazine,  which  may  be  unscrewed  at  pleasure. 
Laterally,  and  at  about  an  inch  from  the  summit,  are  two  laro;e  apertures  front- 
ing each  other.  The  other  end  has  its  cork  box,  a  stop  cock  for  injecting, 
and  rings  that  it  may  be  held  by  the  fingers.  The  liquids  introduced  with 
its  assistance  itito  the  bladder,  bring  with  them,  as  they  flow  out  again  through 
the  apertures  all  such  fragments  of  stone  as  are  capable  of  entering  and 


838  NEW    ELEMENTS   OF 

passing  through  them.  Those  which  are  too  large  for  this  are  stopped  at  the 
orifices.  The  inventor  then  uses  a  jointed,  flexible  stylet,  like  the  lithotritor 
of  M.  Pravaz,  to  break  or  crush  the  point  which  projects  inwardly  into  the 
magazine,  and  press  it  to  the  bottom,  whilst  the  remaining  portion  falls  back 
into  the  bladder.  When  from  more  or  less  frequent  repetition  of  this 
manoeuvre  the  magazine  becomes  filled,  the  instrument  is  withdrawn  for  it 
to  be  unscrewed  and  emptied,  and  is  then  reintroduced  if  it  is  thought  advi- 
sable to  begin  over  again.  M.  Leroy  conceives  that  this  end  may  be  better 
accomplished  by  an  instrument  of  the  same  kind,  but  in  which  the  central 
stem  may  act  equally  by  pressure  as  by  rotation.  Without  absolutely  reject- 
ing the  assistance  of  similar  contrivances,  we  are  nevertheless  obliged  to  con- 
fess that  the  probable  advantages  to  be  derived  from  them,  are  not  evident 
enouL^h  for  practitioners  hastily  to  adopt  them,  or  to  supersede  by  them,  or 
add  them  to  other  instruments  of  more  acknowledged  excellence. 

Occidents. — Those  which  follow  lithotrity,  though  seldom  of  a  fatal 
nature,  are  varied  and  numerous.  The  pain  which  naturally  attends  the 
operation  is  sometimes  excessively  acute.  As  it  depends  more  particularly 
upon  the  traction  of  straight  instruments  upon  the  sub-pubic  portion  of  the 
urethra,  it  is  to  be  hoped  that  the  use  of  curved  instruments  will  diminish  its 
severity.  Every  sitting  is  succeeded  in  a  great  many  patients  by  a  paroxysm 
of  fever,  more  or  less  violent,  characterized  by  the  same  phenomena  as  an 
intermittent.  This  is  an  occurrence  to  which  even  simple  catheterism  gives 
rise,  and  obliges  frequently  to  prolong  the  interval  between  the  sittings.  In 
many  cases  we  shall  notice  engorgement  of  the  spermatic  cord,  epididimus, 
and  even  testicle  itself;  which  is  explained  to  be  owing  to  friction  and  con- 
tusion sustained  by  the  verumontanum  and  ejaculatory  canal.  Tears  or 
rents  of  the  urethra,  urinary  infiltrations,  abscess  of  the  perineum  and 
scrotum,  though  less  common,  have  nevertheless  occurred.  The  chief 
inconvenience  of  these  events  is  that  they  oblige  us  to  defer  to  a  later 
period,  the  date  of  the  next  operation.  It  is,  however,  but  just  to  say  that 
one  of  the  persons  lithotritized  in  my  presence  by  M.  Civiale,  was 
attacked  with  slight  engorgement  of  the  testis  from  the  first  sitting,  was  not 
prevented  by  it  from  coming  every  third  day  to  have  the  stone  triturated, 
and  without  having  reason  to  repent  of  so  doing.  A  bath  daily ;  venesection, 
if  in  a  plethoric  subject;  demulcent  drinks,  poultices,  leeches,  and  the  con- 
comitant items  of  an  antiphlogistic  regimen  if  the  symptoms  are  threatening, 
combined  with  rest  and  tranquillity,  are  the  means  to  be  adopted  for  mode- 
rating or  removing  them.  i 

HxmaUma  when  slight  and  unaccompanied  by  fever  demands  but  little 
attention;  cystitis  and  peritonitis,  which  M.  Marjolin  tells  us  he  has 
observed,  and  such  nervous  phenomena  a§  all  writers  on  litliotrity  mention, 
require  under  this  the  same  treatment  as  under  any  other  circumstances,  and 
afe  owing  either  to  the  pain  caused  by  the  introduction  of  the  instruments, 
the  friction  of  forceps,  or  of  the  stone,  when  it  has  become  angular,  against 
i\\^  bladder. 

The  same  remark  applies  to  incontinence,  partial  or  entire  paralysis  of 
the  organ,  and  to  the  weight  and  burning  sensation  felt  about  its  neck.  Frag- 
ments of  stone  may  become  arrested  in  the  urethra  in  such  a  way  as  to 
close  it  quite,   and  produce  retention  of  urine  and  frightful  agony.      The 


OPERATIVE    SURGERY.  839 

means  of  relieving  this  accident  will  be  found  in  the  previous  article — Stones 
in  the  Urethra. 

Punctures  of  the  Bladder,  on  which  many  persons  have  laid  much  stress, 
are  doubtless  possible,  for  M.  Brischet  witnessed  the  operation,  but  they  must 
be  infrequent  in  the  hands  of  cautious  operators.  I  need  scarcely  say  thaft 
the  aid  of  art  would  be  attended  in  such  a  case  with  little  hope  of  advan- 
tage, unless  the  perforation  were  without  the  peritoneum. 

One  of  the  accidents  about  which  we  are  justly  most  solicitous,  is  pinching 
the  organ.  Happily  it  is  one  which  we  can  almost  always  avoid.  To  do 
this  it  is  sufficient  to  be  careful  never  to  shut  the  forceps  hastily,  and  never 
to  approximate  their  grasps  until  we  have  felt  the  stone  between  tl^em, 
and  at  the  same  time  drawing  them  towards  the  urethra ;  all  which  are 
easily  done  when  the  bladder  has  been  previously  filled  with  a  certain  quan- 
tity of  liquid,  so  as  to  surround  the  stone.  But  where  the  bladder  contracts 
violently  and  will  retain  nothing,  when  the  patient  is  agitated  or  the  instru- 
ment is  directed  by  an  unskillful  hand,  it  is  easily  conceivable  that  the  inner 
walls  of  the  organized  sac  may  become  entangled  in  the  hooks  or  branches 
of  the  forceps,  and  run  a  great  risk  of  being  lacerated.  Of  this  the  operator 
is  admonished  by  the  cries  and  acute  suffering  of  the  patient.  Flakes  of  the 
natural  tissues  withdrawn  along  with  the  instrument  often  furnish  melancholy 
proof  of  the  fact.  Peritonitis  or  cystitis  is  the  almost  necessary  consequence 
of  such  an  injury,  and  requires  the  usual  remedies. 

Finally,  it  is  possible  for  the  instrument  to  break  in  the  cavity  of  the 
urinary  pouch.  If  the  fragment  remains  perfectly  at  liberty,  every  attempt 
to  extract  it  by  the  natural  outlet  will  be  evidently  useless,  and  our  surest 
course  is  to  perform  lithotomy  without  hesitation.  The  litholabes  invented 
bv  MM.  Meirieu,  Tanchou,  Recamier,  Jacobson,  and  that  of. M.  Pravaz, 
modified  by  M.  Segales,  being  kept  together  at  each  division  by  joints  or 
strings,  are  generally  safe  from  this  accident,  as  they  allow  the  separated 
portion  to  be  drawn  out  with  them. 

Art,  6. — A  comparative  Examination  of  Lithotrity  and  Litnotomy. 

Scarcely  was  the  breaking  up  of  the  calculi  known,  than  it  was  upheld  by 
its  partisans  as  a  perfectly  innocent  operation,  and  one  wholly  free  from  dan- 
ger. Others  have  gone  so  far  as  to  suppose  that  it  was  calculated  some  day 
or  other  to  do  away  with  any  surgical  operation  for  the  cure  of  calculus. 
The  public  upon  both  these  points  have  been  deceived,  Lithotrity  as  now 
performed  is  in  substance  a  longer  and  a  more  painful  operation  than  cysto- 
tomy, and  I  have  seen  persons,  among  others  one  who  was  cut  by  M.  Souber- 
bielie,  after  some  attempts  by  M.  Civiale,  declare  they  had  suffered  more  in 
one  sitting  from  lithotrity,  than  from  all  the  manipulations  of  cutting  for  the 
stone.  One  fourth,  if  not  one  third  of  those  who  submit  to  it,  suffer  some 
accident,  and  it  is  not  true  that  no  one  ever  dies  from  it.  It  vvas  clearly 
proved  by  M.  Heurteloup,  that  instead  of  one  in  forty  M.  Civiale  lost  eight 
patients  out  of  forty-eight.  Of  those  of  M.  Leroy  three  died  out  of  twenty- 
eight  ;  and  an  analysis  of  operations  performed  at  the  school  of  Abou  Zabel  in 
Bagdad ;  by  Mr.  Watteman  and  others  in  Germany;  in  England  by  Messrs. 
Liston,  Costello,  Heurteloup ;  in  France  by  MM.  Amussat,  Bancal,  Roux, 


640  NEW    ELEMENTS   OF 

Dupuytren ;  in  fact  by  different  surgeons  in  almost  every  country  in  the 
globe,  proves  that  this  is  about  the  best  result  which  has  as  yet  been  obtained. 
If  we  take  all  the  patients  with  calculus  who  have  presented  themselves  to 
lithotritic  surgeons,  and  on  whom  tlie  operation  of  cutting  might  have  been 
performed,  the  result  is  even  less  encouraging.  Of  the  eighty-two  spoken  of 
by  M  .Civiale,  thirty-one  were  dead  at  the  expiration  of  a  year,  and  nineteen 
others  recovered  only  after  having  met  with  some  accident  or  other.  M. 
-Leroy  was  able  only  to  cure  radically  twenty -five.  Out  of  ten  who  offered 
;  to  him,  M.  Bancal  was  enabled  to  operate  only  upon  two ;  so  that  among  those 
vAio  are  chosen  as  its  subject,  there  perished  one  in  ten  or  twelve  at  least ; 
and  in  a  given  number  of  patients,  some  being  subjected  to  lithotrity,  some 
cut,  and  others  left  to  the  resources  of  the  organism,  one-sixth  or  one-eighth 
at  least  are  lost.  Looking  at  lithotomy  under  this  aspect  alone,  it  is  quite 
alarming  enough,  and  it  was  unnecessary  for  the  enthusiastic  admirers  of 
lithotrity  to  have  darkened  the  picture  of  its  ill -success  to  disgust  the  public 
and  dissuade  the  greater  number  of  patients  from  undergoing  it.  Still, 
tiiough  there  be  authentic  records  proving  that  eight  hundred  and  twelve 
persons  cut  for  stone  in  Paris  at  the  Hotel  Dieu  and  La  Charite  two  hundred 
and  iifty-five  died  between  the  31st  December,  1719,  and  the  1st  January, 
1728;  others  again  demonstrate  that  Cheselden  lost  only  twenty-four  out 
of  two  hundred  and  thirteen.  While  M.  Sanson  tells  us  that  he  has  seen  six 
die  out  of  twenty,  M.  Dupuytren  on  the  other  hand  about  the  same  time  per- 
formed the  operation  on  twenty-six  persons  before  meeting  with  the  loss  of  a 
single  individual ;  and  Dr.  Dudley,  of  Transylvania  University,  Ky.  met  with 
a  like  success  in  seventy -two  cases.  Though  we  may  not  admit  the  wonderful 
success  which  is  by  some  persons  attributed  to  Raw,  or  believe  that  it  was  pos- 
sible for  this  surgeon  to  succeed  fifteen  hundred  times  in  succession,  whiph 
simply  means,  that  out  of  all  his  cases,  he  succeeded  in  curing  fifteen  hundred, 
it  seems  very  certain  that  Mr.  Martineau  of  Norwich  has  lost  but  two  in 
eighty-four;  M.  Pansa  of  Naples  five  in  sixty;  Ponteau  two  in  eighty; 
Lecat  three  in  sixty -three;  M.  Pajola  of  Venice  nearly  the  same  propor- 
tion; M.  Viricel  of  Lyons  three  in  eighty-three;  M.  Ouvrard  of  Dijon 
three  in  sixty;  Sancerotte  one  in  sixty;  and  that  of  Descharaps  at  one  time 
succeeded  nineteen  times  in  succession.  These  it  is  true  are  but  partial  data. 
The  same  operators  have  not  been  always  as  successful;  but  why  should  not 
the  same  thing  happen  in  lithotrity.^  Although  we  admit  that  in  1826  M. 
Civiale  had  lost  but  one  patient  out  of  forty,  must  it  not  likewise  be  con- 
fessed that  he  has  not  since  been  as  fortunate,  and  that  his  practice  at  the 
hospital  Necker,  according  to  M.  Larry's  report  to  the  Institute,  offers  a 
much  more  considerable  proportion  of  reverses.  Nor  is  it  possible  to  expect 
from  every  one  the  same  ratio  of  success  as  from  a  man  so  practised  as  is  M. 
Civiale. 

We  must  not  come  with  prejudices  such  as  these  to  the  consideration  of 
subjects  of  this  importance.  Senac  was  perhaps  justified  in  saying  that  most 
of  the  patients  operated  on  for  stone  in  the  Parisian  hospitals  died;  for  in 
the  year  1725  there  died  sixteen  out  of  twenty-nine  at  La  Charite.  Another 
person,  with  equal  propriety,  might  have  maintained  however  that  only  one 
perished  out  of  eight  or  nine;  for  twenty -two  recovered  out  of  twenty-five 
i:i  1727,  and  twenty-three  out  of  twenty-six  in  1720,  at  the  same  institution. 


I 


OPERATIVE    SURGERY.  841 

All  this  did  not  prevent  Morand  from  discovering  that  in  this  hospital  seventy- 
one  deaths  had  occurred  in  two  hundred  and  eight  cases  in  eight  years ;  and 
at  the  Hotel-Dieu  within  the  same  period  eighteen  out  of  five  hundred  and 
ninety-four  cases.  M.  Souberbielle  lost  eighteen  outof  fifty-two  in  1824  and 
1825,  but  his  mean  proportion  is  not  less  than  one  in  six  or  eight.  Notwith- 
standing M.  Richerand's  opinion  that  the  successful  and  fatal  cases  were 
about  equal  in  number  at  the  beginning  of  this  century,  MM.  lloux  and 
Dupuytren  have  established  them  in  the  proportion  of  five  to  six.  Lastly,  if 
figures  must  be  made  to  speak,  the  following  are  the  results  of  the  best  kept 
statistical  accounts  which  have  been  published  in  twenty  years. 

At  Norwich  in  five  hundred  and  six  cases,  seventy  deaths ;  at  Leeds  in 
one  hundred  and  ninety-seven  cases,  twenty-eight  deaths ;  at  Bristol  one,  in 
four  and  a  quarter  cases;  at  Luneville  one,  in  fourteen  cases. 

In  the  account  of  M.  Dupuytren,  which  includes  Paris  and  its  environs, 
there  have  been  in  ten  years  sixty-one  deaths  out  of  three  hundred  and  fifty- 
six  cases,  or  one  in  six.  Lithotrity  I  am  well  convinced  is  less  fatal  than  this  ; 
but  it  is  necessary  to  ascertain  how  much  less  it  is  so,  and  this  point  experience 
does  not  yet  enable  us  to  decide.  In  the  settlement  of  the  question  it  becomes 
conscientious  men  to  consider  that  those  persons  whose  cases  admit  of  litho- 
trity are  the  very  ones  in  whom  lithotrit^  would  best  succeed ;  whilst  all  those 
to  whom  trituration  is  inapplicable  have  likewise  not  much  chance  of  being 
cured  by  lithotomy.  The  problem  therefore  cannot  be  solved  definitively, 
until  a  certain  number  of  hundreds  of  calculus  persons  subjects  for  lithotrity 
shall  be  taken,  which  shall  be  divided  into  equal  parts,  and  one  half  litiiotrized, 
and  the  other  half  cut. 

Though  lithotrity  may  have  fewer  dangers,  it  is  not  in  every  case  possible 
to  practice  it.  It  is  absolutely  repelled  by  calculi,  the  nucleus  of  which 
consists  of  some  solid  body,  such  as  a  pin,  a  needle,  a  ball,  a  piece  of  wood, 
of  horn  or  ivory.  The  same  may  be  said  of  all  calculi  which  adhere,  are 
encysted,  or  in  any  other  way  made  immovable ;  of  such  as  are  extremely 
hard  which  are  larger  than  a  hen's  egg  upon  which  the  bladder  is  kept  habi- 
tually applied  ;  if  individuals  who  have  deformity  of  urethra,  either  congenital, 
such  as  hypospadias,  epispadias,  or  the  result  of  disease,  to  such  a  degree  as 
to  make  it  difficult  to  use  the  necessary  instruments.  The  existence  of  many 
stones,  considerable  enlargement  of  the  prostate,  a  protracted  state  of  ill 
fiealth,  or  horny  induration  of  the  bladder,  will  render  it  for  the  most  part  as 
dangerous  an  operation  as  lithotomy.  In  every  other  case  its  advantages 
appear  to  me  to  be  indisputable  except  in  children  :  more  particularly  if  the 
patient  is  endowed  with  patience  and  gentleness,  and  is  of  a  somewhat 
blunted  irritability,  so  as  fearlessly  to  undergo  the  various  manoeuvres- 
requisite  ;  if  he  dreads  cutting  instruments  so  much  as  willingly  to  submit  to 
be  a  longer  or  shorter  time  in  getting  rid  of  it,  and  to  suffer  as  often  as  is 
necessary  for  the  annihilation  of  his  stone  the  reintroduction  of  the  litho- 
tritic  instruments.  Although  a  return  of  the  disease  is  much  more  probable 
than  after  lithotomy,  owing  to  the  remnants  of  stone  which  often  evade  the 
most  cautious  researches,  if  it  appears  likely  that  two,  three,  four,  five,  or  six 
sittings  will  suffice,  we  can  have  no  hesitation  as  to  performing  it.  Lithotomy 
is  then  incomparably  more  alarming.  The  latter  it  is  true  allows  the  more 
speedy  and  complete  removal  of  the  stone,  and  the  pain  is  in  a  measure 
106 


842  NEW  ELEMENTS   OF 

instantaneous  only ;  but  the  patient  must  be  confined  to  bed  or  the  room  for 
twenty  or  thirty  days,  whilst  in  the  intervals  of  the  sittings  lithotrity  scarce 
disturbs  his  usual  habits. 


SECTION  III. 

The  Urethra. 

Art,  1. — Catheterism 

Catheterism  is  performed  for  the  purposes  of  giving  exit  to  urine ;  for  ex- 
ploring the  bladder;  the  cure  of  certain  diseases;  and  to  aid  in  the  success 
of  certain  operations,  such  as  the  various  operations  for  stone,  lithotrity,  &c. 
The  instruments  with  which  it  is  effected  have  long  been  known  under  the 
name  of  eathetet^s,  which  in  Germany  and  England  tliey  still  very  generally 
retain  :  but  in  France  are  more  generally  called  "5om/es"  or  ''  algalies^^ ;  the 
last  of  whicli  words  however  only  applies  to  hollow  tubes  of  a  metallic  nature. 
Solid  stems,  cylindrical,  conical,  probe -pointed,  or  buttoned  at  the  point,  of 
various  substances,  may  also  be  employed  for  this  purpose.  The  terra 
"  catheter^-  is  now  understood  to  mean  only  the  grooved  instrument  used  in 
sub-pubic  cutting  for  stone. 

The  object  of  the  surgeon  being  to  penetrate  into  the  bladder  of  urine  by 
the  natural  passage,  an  acquaintance  with  the  structure  of  the  urethra  becomes 
an  indispensable  preliminary,  without  which  catheterism  will  expose  the 
patient  to  very  alarming  dangers. 

§  1.     Anatomical  Remarks. 

The  urethra  at  the  adult  age  is  about  nine  inches  long,  sometimes  seven  or 
eight  only,  and  at  other  times  ten  or  even  eleven ;  two  lines  and  a  half  to  four 
lines  in  width,  but  not  of  equal  width  in  all  parts  of  its  extent.  Its  narrowest  part 
is  its  meatus;  so  much  so  indeed  that  some  surgeons  have  been  obliged  to 
cut  it  before  commencing  lithotrity.  Directly  behind  it  on  a  level  with  the 
frenum  we  find  the  fossa-navicularis,  which  in  spite  of  what  may  be  said  of 
late  years  in  most  subjects  forms  a  species  of  excavation  here.  Next  comes 
the  portio-spongiosa,  which  extends  as  far  as  the  root  of  the  penisj  and  con- 
tinues insensibly  increasing  in  diameter  as  far  as  the  portio-bulbosa,  which  is 
wider  still.  This  part  which  is  but  a  continuation  of  it  soon  contracts  itself 
very  much  to  become  blended  with  the  membranous  portion,  and  is  seen 
beneath  the  divergence  of  the  roots  of  the  corpora  cavernosa  penis  in  front  of 
the  sub-pubic  ligament.  After  the  membranous  portion  comes  the  prostatic 
portion,  encircled  as  it  were  by  the  horizontal  aponeurosis  of  the  perineum, 
situated  directly  beneath  the  symphysis,  and  where  the  canal  hollows  itself 
out  to  close  again,  and  finally  widens  anew  like  a  funnel  at  the  orifice  of  the 
urethra.  It  is  to  be  borne  in  mind  that  all  these  excavations  exclusively  re- 
side in  its  inferior  wall,  whilst  the  contracted  portions  are  nearly  circular  and 
comprise  its  entire  circumference.  Each  of  them  being  deeper  behind  than 
before  it  causes  them  to  form  folds  in  the  former  direction,  like  valves  before 


OPERATIVE    SURGERY.  843 

the  progress  of  the  instrument.  This  inconvenience  is  especially  felt  in  the 
fossa-navicularis,  and  the  excavation  of  the  bulb.  The  former  as  well  as  all 
the  spongy  portion,  contain  besides  small  veins  the  lacunae  of  Morgagni  (as 
they  are  called)  looking  in  the  same  direction,  and  equally  capable  of  impeding 
the  introduction  of  instruments.  The  prostatic  excavation  Is  still  more  im- 
portant because  of  the  verumontanum,  which,  of  a  crest-like  shape,  divides 
it  into  two  from  the  end  of  the  ejaculatory  canals  seen  on  the  summit  and 
sides  of  this  crest  and  the  numerous  ducts  from  the  prostate  which  terminate 
in  it ;  so  that  the  beak  of  the  instrument  frequently  encounters  here  a  double 
depression,  extremely  apt  to  lead  it  in  a  false  direction.  I  have  in  some 
subjects  met  a  little  further  on  before  entering  the  bladder  a  semilunar  fold 
whose  concavity  was  forwards  seemingly  dependent  on  an  extension  of  the 
lining  of  the  valve  of  the  bladder,  and  which  would  equally  prove  an  obstacle 
to  the  passage  of  the  sound.  To  understand  the  unequal  resistance  of  the 
urethra,  it  is  merely  necessary  to  observe  its  relations  and  the  structure  of  its 
different  parts.  Its  dorsal  side  forming  the  concave  edge  of  the  se^rment  of  a 
circle  is  on  that  account  shorter  than  the  other  and  less  disposed  to  form  plaits. 
Destitute  of  cavity,  and  strongly  adherent  to  the  lower  surface  of  the  penis,  it 
presents  much  regularity,  and  so  great  strength  in  its  spongy  portion  as  scarcely 
to  be  in  any  danger  from  catheterism.  The  corpora-cavernosa,  as  they  go  off 
opposite  the  bulb  to  fasten  on  the  ischio-pubic  rami,  leave  a  small  portion  of 
it  uncovered  almost  in  front  of  the  symphysis,  where  it  maybe  injured  by  the 
beak  of  the  catheter,  bruised  and  even  perforated  when  the  instrument  is 
'  parelessly  passed  and  tilted  up  more  than  is  necessary,  so  as  to  butt  against 
the  anterior  face  of  the  sub-pubic  ligament,  or  of  the  horizontal  aponeurosis 
which  prolongs  or  continues  it  below.  Behind  the  fascia  the  dorsum  of  the 
urethra,  strengthened  by  the  muscle  of  Winslow  and  the  upper  arc  of  the  pros- 
tate and  the  cellular  tissue,  has  nothing  to  fear  from  the  action  of  instruments, 
because  moreover  it  possesses  there  considerable  mobility,  rises  easily  against 
the  pelvic  surface  of  the  pubis,  and  passes  gradually  into  the  anterior  wall  of 
the  bladder. 

The  urethra,  which  in  the  fossa-navicularis  is  very  thin,  being  no  longer 
embraced  as  at  the  meatus  by  the  cavernous  tissue  of  the  glaiis  penis,  is  in 
some  measure  reduced  to  its  inner  and  outer  membranes ;  and  is  consequently 
very  weak,  easily  pierced,  torn,  and  ulcerated.  A  little  further  on  the 
spongy  layer  separates  its  mucous  tunic  from  its  outer  covering,  and  sensibly 
increases  its  thickness  and  its  strength.  But  in  the  bulb  this  layer  becoming  too 
much  attenuated  and  expanded  leaves  it  again  to  its  original  resisting  power; 
an  arrangement  the  more  to  be  regretted,  as  no  part  is  more  excavated, 
and  that  there  we  encounter  afresh  the  horizontal  aponeurosis.  The  inferior 
wall  of  the  membranous  portion,  instead  of  being  thinner  and  weaker,  is  on  the 
contrary  thicker  and  stronger  than  any  where  else  exclusive  of  the  prostate 
or  the  bulb.  Embraced  by  the  perineal  fascia  as  by  a  ferrule,  and  supported 
by  the  decussation  of  the  fibres  of  the  transverse  muscles,  it  is  in  itself  addi- 
tionally lined  by  a  layer  evidently  muscular,  and  surrounded  by  a  fibro- 
cellular  sheath  at  times  of  some  thickness.  It  is  therefore  more  common  to 
observe  lacerations  and  traumatic  perforations,  at  the  entrance  of  the  urethra, 
into  and  at  its  departure  from  the  bulb,  than  at  this  part  itself;  whilst  by  way  of 


844  NEW   ELEMENTS   OF 

retaliation  itis  the  chosen  seat  of  stricture.  Quite  behind  it  the  lower  wall  of  the 
urethra  is  as  it  were  decomposed  by  the  prostate,  which  seems  to  be  developed 
between  its  two  natural  layers.     It  follows  that  the  mucous  coat  is  now  its 
only  membrane  as  an  independent  wall;  that  this  membrane  makes  one  body 
with  the  gland,  and  can  neither  plait,  contract,  or  be  the  seat  of  spasm  or 
contraction ;  but  that  it  is  easy  to  perforate,  excoriate,  and  more  readily  takes 
on  ulceration  and  profound  disorganization,  or  forms  abscesses;  in  a  word, 
tliat  it  makes  common  cause  with  the  prostate  gland  as  respects  diseases  and 
pathological  alterations.     The  fleshy  fibres  between  the  prostate  and  the  bulb 
in  the  urethra,  which  anatomy  compels  us  to  acknowledge,  even  though 
practice  had  not  a  thousand  times  demonstrated  their  existence,  do  not  allow 
of  our  doubting  the  contractile  faculty  of  this  canal,  or  the  possibility  of 
spasmodic  stricture,  which  among  others  Mr.  Charles  Bell  denies.     These 
spasmodic  strictures  are  of  equally  indisputuble  occurrence  in  front  of  the 
membranous  portion,  and  even  to  the  forepart  of  the  penis.     I  have  seen  them 
in  two  dogs,  and  the  use  of  a  bougie  will  often  enable  us  to  study  them  in 
man.     It  has  now  happened  to  me  twenty  times  at  least,  to  push  a  conical 
2;umelastic  bougie  to  a  depth  of  five  or  six  inches  without  the  slightest  diffi- 
culty ;  then  directly  afterwards  to  find  it  so  strictured  that  it  required  an 
exercise  of  strength  to  withdraw  it;  that  in  its  withdrawal  it  was  easy  to  feel 
the  friction  and  that  the  canal  parted  with  it  in  a  measure  with  regret.     In 
some  instances  besides  these  contractions  have  been  evident  enough  to  expel 
the  foreign  body,  and  push  it  forwards  several  inches  before  my  eyes,  although 
no  effort  had  been  necessary  to  cause  its  introduction.     The  value  of  such 
facts  can  be  weakened  by  no  speculative  reasoning.     However,  the  presence 
of  fleshy  fibres  is  not  indispensable  to  their  explanation.     The  elastic  element 
of  the  bronchi,  the  outer  layer  of  the  ureter,  the  deep  envelope  of  the  scrotum, 
the  soft,  velvet-like  cellular  tissue  of  the  perineum,  &c.all  enjoy,  I  am  satisfied, 
a  species  of  contractility;  and  yet  we  may  assert  that  in  these  lamellae  there 
exist  no  muscular  fibres. 

The  direction  of  the  urethra  is  another  point  which  must  not  be  forgotten. 
While  the  penis  is  in  a  relaxed  state  the  canal  presents  a  double  curve;  the 
one  forward  and  its  concavity  downward  ;  the  other  behind,  and  its  concavity 
upward,  of  the  shape  of  the  roman  S.  During  erection,  or  when  it  is  raised 
towards  the  abdomen,  the  urethra  loses  the  former,  and  assumes  the  direction 
of  the  segment  of  a  circle  whose  concavity  is  downward  ;  much  more  concave 
behind  than  before,  and  very  much  the  shape  of  a  rib  in  this  respect.  The 
other  is  a  fixed  curve,  which  begins  in  front  of  the  symphysis,  ends  at  the  blad- 
der, comprising  the  bulbous,  membranous,  and  prostatic  porticms ;  and  depends 
upon  the  attachment  of  the  penis  to  the  anterior  surface  of  the  pubis  by  a  liga- 
ment of  slight,  extensibility,  whilst  another  fibrous  riband  keeps  the  prostate 
behind  the  symphysis,  and  also  upon  the  circumstance  of  the  bladder  being 
pushed  up  towards  the  abdomen  by  the  rectum  and  the  prostate,  whilst  the 
urethra  outw^ardly  is  obliged  at  the  same  time  to  rise  upwards  and  forwards  to 
gain  the  lower  face  of  the  corpora  cavernosa. 

From  all  this  it  follows  that  the  curvature  of  this  canal  is  not  invariably  the 
same ;  that  iu  extending  towards  theischia,  as  often  happens  in  man,  and  almost 
naturally  in  children,  the  sympliysis  and  sub-pubic  ligament  may  very  mucli 
increase  it;  and  that  enlargement  of  the  prostate,  fullness  of  the  intestine,  and 


OPERATIVE   SURGERY.  845 

thickness  of  the  perineum  must  produce  eifects  of  the  same  kind,  less  diffi- 
cult to  be  overcome. 

.  The  urethra,  therefore,  is  neither  straight  nor  almost  straight^  and  to  main- 
tain this  would  now  be  absurd.  Those  who,  along  with  Rameau,  Lieuteaud, 
Santarelli,  C.  Bell,  and  others,  asserted  it,  could  never«have  thought  so,  or  else 
their  eves  were  blinded  by  a  wish  to  discover  arguments  in  favor  of  rectilinear 
catheterism.  If  the  urethra  were  straight  it  wpuld  be  prolonged  in  the  direc- 
tion of  the  bulb,  following  a  line  which  would  fall  on  the  point  of  the  coccyx 
passing  over  tlie  anus.  Instead  of  this  what  does  it  do  in  reality  ?  It  is  seen 
to  separate  from  its  spongy  tissue  gradually  from  the  bulb  entirely,  to  pass 
through  tlie  aponeurosis  under  the  pubis,  enter  the  pelvis,  and  end  two  inches 
at  least  from  the  level  of  the  anus,  and  consequently  above  the  direction  of 
the  line  of  which  I  have  just  spoken.  This  mathematical  remark  leaves  no 
room  for  reply,  and  would  alone  suffice  to  establish  the  question,  should  any 
one  be  pleased  to  revive  it.  Still,  when  the  symphysis  is  short,  the  prostate  of 
no  great  thickness,  the  urethra  crosses  it  nearer  to  its  lower  than  its  upper 
surface,  and  the  pelvis  is  large,  tractions  upon  the  penis  do  in  a  great  measure 
cause  this  curvature  to  disappear,  and  allow  of  our  passing  straight  instruments 
v/ithout  any  great  obstacle  into  the  bladder;  which  in  turn  morie  or  less  for- 
cibly depress  the  floor  of  the  prostatic  portion  of  the  canal  and  cervix  vesicae. 

§  2.  Examination  of  Instt-umenis  and  Methods. 

Catheterism,  whether,  as  it  is  called  by  M.  Roux,  it  be  Evactmni^  Explorative, 
Directing,  or  Derivative,  is  performed  in  general  after  the  same  rules  in  every 
case. 

The  copper  catheters  (sondes)  which  were  once  used  were  attended  with  the 
inconvenience  of  becoming  oxidized,  and  covered  with  verdigi'is,  and 
are  now  universally  superseded  by  silver  ones.  Flexible  catheters  of  horn, 
leather,  and  spurious  metallic  wires,  having  been  used  only  in  default  of 
something  better,  equally  deserve  to  remain  in  the  neglect  into  which  they 
have  fallen  since  the  invention  of  elastic  catheters,  by  Theden,  Pickel,  and 
Bernard  the  goldsmith.  Silver  and  indian  rubber  instruments  then  are  the 
only  ones  worth  preserving ;  the  first  for  cases  in  which  their  solidity  is  de- 
sirable, and  in  which  the  catheter  is  to  remain  but  a  few  minutes  in  the 
urethra ;  the  second  for  those  in  which  after  the  operation  it  is  advisable  to 
leave  them  for  some  time  in  the  bladder. 

The  length  of  a  metallic  catheter  for  an  adult  man  is  about  twelve  inches. 
If  shorter  they  will  not  in  some  old  men  reach  all  the  way  to  the  re- 
servoir of  urine.  If  longer  they  will  expose  the  bladder  to  perforation  and 
the  organs  to  injury.  Their  diameter  should  vary  from  two  to  three  lines. 
Due  proportion  being  preserved  they  pass  better  the  greater  their  volume.  For 
children  they  are  made  of  a  line  or  a  line  and  a  half  diameter,  and  from  five  lo 
eight  inches  in  length.  If  their  sides  are  too  thin,  they  become  liable  to  bend,  get 
out  of  shape,  or  even  break  on  the  slightest  eftbrt.  A  contrary  construction 
makes  them  more  expensive,  usurps  room  in  their  cavity,  and  will  interfere 
with  the  flow  of  urine,  unless  the  caliber  of  the  instrument  is  otherwise  very 
large.  Their  free  end  is  generally  expanded,  of  a  funnel-shape,  and  has  a  small 
ring  on  each  side,  to  which  on  occasion  strings  or  ribands  may  be  attached. 
At  a  distance  of  a  few  lines  from  the  other  end,  which  is  blunt,  are  two  lateral 


846  NEW   ELEMENTS    OF 

elliptical  apertures,  instead  of  a  mere  slit  wliich  used  to  be  seen  in  them.  We 
now  scarcely  use  any  longer  than  those  which  instead  of  d  beak  have  a  stylet 
head,  which  is  pushed  forward  to  open  them  and  whicli  closes  them  when  drawn 
towards  ourselves  ;  nor  those  either  which  are  free  and  open  at  the  vesical  end. 
The  curve  which  has  been  given  them,  has  been  the  source  of  much  discussion. 
It  is  easy  to  push  on  a  straight  instrument  like  a  cylinder  by  making  it  revolve 
on  its  own  axis,  and  thus  overcome  obstacles  which  could  not  with  one  of 
another  shape  have  been  surmounted.  But  this  advantage  is  more  than  coun- 
terbalanced by  the  pressure  which  their  beaks  cause  against  the  floor  of  the 
membranous  and  prostatic  portions  of  the  urethra,  and  their  tendency  to  make 
a  false  passage.  Crooked  instruments  give  less  pain,  enter  better,  and  are  in 
every  respect  preferable. 

The  S  shaped  catheter  of  the  ancients  revived  by  J.  L.  Petit,  so  as  not  to 
fatigue  the  canal  so  much  when  permitted  to  remain  in  it,  has  become  useless 
since  the  addition  of  flexible  ones  to  our  science.  A  very  great  and  very  length- 
ened curve  does  no  good,  and  serves  to  impede  the  motion  of  the  hand.  That 
curve  which  is  confined  to  the  end  of  the  catheter,  as  Rameau  suggested,  and 
as  Mr.  Key  has  since  advised,  enters  more  easily  than  a  straight  catheter  does, 
but  pulls  quite  as  much  on  the  sub-pubic  portion  of  the  urethra.  The  most 
convenient  we  have  are  curved  only  in  the  posterior  fourth  of  their  length,  in 
such  a  way  as  to  form  an  arc  whose  string  is  but  three  or  four  inches  long,  and 
its  radius  not  more  than  two  or  three.  I  have  found  those  most  useful,  the 
axis  of  whose  beak  is  carried  to  the  point  of  crossing  the  supposed  continuation 
of  their  length  at  a  right  angle,  and  especially  incises  where  the  prostate  is 
enlarged.  The  more  it  projects  backwards  the  more  diflicult  is  it  for  it  to 
enter  the  bladder,  and  not  butt  against  the  lower  wall  of  the  canal  after  it 
leaves  the  perineal  aponeurosis.  The  silver  wire  which  they  are  supplied  with 
is  hardly  ever  of  any  use,  and  has  not  even  the  advantage  of  being  able  to  clear 
the  eyes,  or  clean  the  interior  of  the  instrument  when  stopped  up  by  any  fo- 
reign body. 

Position  of  the  Patient. — In  most  cases  it  is  a  matter  of  indifference  whether 
the  patient  be  standing  up,  sitting  up,  placed  upon  the  edge  or  foot  of  the  bed, 
or  table,  with  his  legs  hanging  down  or  supported,  or  else  lying  on  his  bed  as 
usual.  The  latter,  however,  being  the  most  convenient  position,  is  that 
which  is  most  commonly  adopted.  Semiflexion  of  the  limbs  and  separation 
of  the  thighs  which  are  recommended  are  not  of  miich  importance,  though 
they  give  more  ease  to  the  operator,  and  may  perhaps  contribute  to  stretch 
and  unplait  the  urethra.  The  same  remark  applies  to  the  s^tate  of  the  head, 
belly,  and  chest,  all  of  which  should  it  is  said  be  sedulously  relaxed. 

Position  of  the  Surgeon. — Unless  the  surgeon  be  ambidexter  he  stands 
necessarily  upon  the  left  side,  and  can  only  take  his  station  facing  the  patient 
or  between  his  legs,  if  it  is  his  wish  or  it  be  necessary  for  him  to  be  operated 
on  out  of  bed.  With  his  left  hand  half  supinated  he  seizes  the  sides  of  the 
penis  between  his  ring  and  middle  fingers,  and  with  the  forefinger  and  thumb 
pull,^  back  the  prepuce  so  as  to  uncover  the  glans,  or  at  least  the  meatus. 
His  right  holding  the  catheter,  held  like  a  pen,  its  concavity  being  towards  the 
abdomen  presents  its  point  to  the  orifice  of  the  urethra  perpendicularly,  and 
so  carries  it  on  without  raising  the  handle  to  the  bulb,  by  a  see-saw  motion, 
performed  from  right  to  left  or  from  the  abdomen  towards  the  space  between 


OPERATIVE   SURGERY.  847 

the  thighs,  a  circular  motion  in  which  the  two  extremities  of  the  catheter  seem 
pursuing  one  another.  He  then  introduces  it  into  the  membranous  portion  be- 
neath the  pubis,  causes  it  to  pass  the  prostate  and  all  the  crooked  part  of  the 
urethra,  so  that,  as  it  were,  it  embraces  the  posterior  surface  of  the  sym- 
physis, and  its  hollow  portion  is  in  the  axis  of  the  lower  straits  Urine  flows 
out  directly,  and  the  thumb,  opening  or  closing  the  orifice  of  the  artificial 
tube,  allows  it  to  flow  or  be  restrained  as  need  may  be. 

Difficulties  in  the  Operation. — Catheterism  is  not  always  thus  simple,  and 
by  times  presents  serious  difficulties.  It  is  a  thing  which  requires  custom 
and  skill,  accurate  anatomical  knowledge,  and  several  precautions.  If  the 
beak  of  the  catheter  bears  too  much  on  the  lower  wall  of  the  urethra  it  will 
glide  on  with  difficulty,  and  be  stopped  at  the  fossa  navicularis  at  the  bulbous 
cavity  or  in  the  prostatic  depression,  and  go  astray  in  some  one  or  other  of 
these  dilations.  These  circumstances  we  need  not  fear  if  it  be  made  to  fol- 
low the  upper  wall  uninterruptedly  unless  it  is  raised  too  much,  or  unless  its 
axis,  instead  of  corresponding  with  that  of  the  canal,  fall  at  a  greater  or  less 
angle  on  the  surface  over  which  it  is  to  pass,  and  even  this  improper  direction, 
unless  it  is  excessively  out  of  the  way,  will  have  no  real  inconvenience  until 
between  the  roots  of  the  corpora  cavernosa ;  and  when  it  an-ives  at  the  ante- 
rior face  of  the  symphysis  all  that  is  required  is  to  pass  the  catheter  along  in 
the  axis  of  the  urethra  from  the  meatus  to  the  bladder,  holding  it  gently 
pressed  against  its  dorsal  region.  No  fixed  rule  can  be  given  on  the  subject, 
because  the  relations  of  this  axis  with  that  of  the  body  are  never  constant. 
In  some,  the  handle  of  the  catheter  requires  to  be  held,  so  to  speak,  parallel 
to  the  walls  of  the  abdomen  whilst  it  is  passing  through  spongy  portions  of  the 
urethra ;  whilst  in  others  we  are  obliged  from  the  commencement  to  bring  it 
into  the  plane  of  the  lower  strait.  Violence  however  is  never  necessary.  The 
instrument  must  progress  as  much  by  its  own  weight  as  by  the  influence  of 
any  external  cause.  If  we  meet  with  resistance  to  it,  it  is  to  be  withdrawn 
a  little  way,  and  then  inclined  and  urged  on  in  another  direction.  By  adopt- 
ing the  advice  given  by  Le  Dran  and  many  other  authors  since,  that  of  draw- 
ing back  the  urethra  upon  it  from  below  upwards  and  from  behind  forwards, 
we  create  numerous  obstacles  instead  of  doing  any  away.  It  is  a  precaution 
which  can  only  be  useful  in  the  penis  portion  of  the  canal.  Further  on  it 
flattens  it,  tends  to  press  it  against  the  sub-pubic  ligament,  and  can  only  facili- 
tate its  laceration.  The  way  to  enter  the  bladder  safely  is  to  let  the  catheter 
descend  freely  to  the  commencement  of  the  membranous  portion ;  that  is  t» 
say,  down  to  the  level  of  the  lower  edge  of  the  symphysis,  so  that  it  may  nei- 
ther depress  the  upper  wall  nor  lower  wall  of  the  urethra  against  the  peri- 
neal surface  of  the  horizontal  aponeurosis;  then  suddenly  to  give  it  the 
see-saw  motion,  though  without  any  effi:)rt,  depressing  the  handle  from  before 
backwards  until  it  becomes  parallel  with  the  axis  of  the  thighs.  This  move- 
ment, unless  the  beak  is  on  this  side  of  the  pubis,  carries  it  at  once  into  the 
bladder.  If  not,  it  butts  against  the  symphysis,  the  penis  bends,  and  the 
instrument  springs  back  instead  of  advancing.  This  difficulty  is  generally 
to  the  operator's  being  afraid  of  depressing  the  outer  end  too  niuch,  scarcely 
fancying  how  very  much  its  point  must  be  raised  so  as  not  to  be  embarrassed 
by  the  posterior  tubercle  of  the  prostate. 

If  we  encounter  difficulty  in  approaching  the  symphysis,  we  are  to  employ 


848  NEW  ELEMENTS  OF 

the  left  hand  in  ascertaining  the  cause  by  raising  the  scrotum,  exploring  the 
perineum,  and  trying  to  detect  the  beak  of  the  catheter  through  the  canal  with 
the  fore  and  middle  fingers,  and  to  follow  its  movements.  If  the  instrument 
have  gone  on  a  little  further  the  forefinger  must  be  passed  into  the  intestine 
through  the  anus.  There,  as  above,  acting  as  a  guide  and  means  of  exploring, 
it  informs  us  precisely  in  what  direction  the  eiforts  of  the  other  hand  are  act- 
ing ;  and  if  we  are  still  in  the  membranous  portion,  or  in  the  prostatic,  we  feel 
through  the  thickness  of  the  interposed  tissues  whether  we  are  likely  to  create 
a  false  passage,  and  it  may  even  assist  us  in  tilting  the  catheter  towards  the 
bladder.  We  must  however  not  labor  under  any  error  as  to  the  value  of  this 
manoeuvre,  which  is  in  no  way  applicable  to  rectilinear  catheterism.  In  rais- 
ing the  prostate  the  finger  increases  the  curve  of  the  urethra,  presses  it-^et 
more  strongly  against  the  sub -pubic  ligament,  and  naturally  offers  the  soft  or 
lower  wall  to  the  beak  of  the  staff. 

To  derive  all  possible  benefit  from  it,  it  is  necessary,  as  soon  as  the  state  of 
parts  is  recognized  and  the  least  effort  is  about  to  be  made,  to  draw  the  pulp 
of  it  a  little  forward,  and  fix  it  on  the  convexity  of  the  instrument  at  a  short 
distance  from  its  end.  By  doing  this  that  portion  of  canal  which  has  yet  to 
be  passed  over  suffers  no  pressure  capable  of  increasing  its  curve,  and  the 
combined  action  of  both  hands  is  unattended  with  danger.  The  signs  which 
show  the  catheter  to  have  entered  the  bladder  are  so  evident  in  most  cases 
that  they  speak  for  themselves,  and  require  no  description.  But  in  many 
instances  several  may  be  wanting,  and  the  diagnosis  be  so  obscure  as  to  puz- 
zle a  surgeon.  If  thick  mucous  matters,  clots  of  blood,  &c.,  clog  up  the  eyes 
of  the  catheter,  urine  will  not  flow  out.  Instruments  which  are  very  much 
curved  keep  sometimes  so  closely  applied  to  the  anterior  wall  of  the  bladder 
that  they  remain  motionless  and  closed  even  above  the  upper  strait.  When 
the  urinary  pouch  is  empty,  contracted,  or  very  narrow,  we  can  penetrate  to 
so  little  depth,  and  the  movements  of  depression,  elevation,  and  rotation  to 
the  right  and  left  of  the  catheter  so  limited  that  one  is  really  led  to  doubt  its 
having  entered,  and  to  be  uncertain  as  to  the  place  it  occupies.  A  consider- 
able mass  of  blood  accumulated  in  the  anterior  part  of  the  bladder,  which  M. 
Mathieu  saw,  would  be  very  liable  to  deceive  one,  as  all  the  thickness 
must  be  penetrated  before  arriving  at  the  urine.  The  catheter  has 
besides  been  known  to  enter  deeply  the  thickness  of  the  recto-vesical  septum, 
and  perform  its  motions  with  almost  as  much  freedom  as  if  it  had  been  in  the 
bladder.  If  a  large  excavation  or  adventitious  pouch  of  greater  or  less  size, 
following  an  ulceration  of  the  floor  of  the  urethra,  become  hollowed  out  in 
the  thickness  of  the  perineum  in  front  of  the  rectum,  of  which  I  saw  a  re- 
markable example  in  a  young  man  who  died  in  1825  at  the  hospital  of  the 
school,  and  of  which  M.  Roux  says  he  has  seen  several,  the  error  becomes 
still  more  easy.  In  fact,  the  cavity  may  be  mistaken  for  a  diseased  bladder, 
more  particularly  as  the  catheter  on  its  entrance  gives  exit  to  a  small  quantity 
of  urine.  Hence  the  sensation  of  overcoming  a  resistance  beyond  the  pubis, 
the  freedom  that  we  perceive  directly  about  the  deep  extremity  of  the  instru- 
ment, the  possibility  of  moving  it  in  every  way  without  marked  pain  to  the 
patient,  the  road  and  direction  it  must  have  taken,  and  lastly  the  issue 
of  urine,  prove  that  we  have  entered  the  bladder ;  but  there  are  circum- 
stances in  which  many  of  these  signs  may  be  wanting,  and  others  simulate 


OPERATIVE    SURGERY,  849 

them  more  or  less  completely.  If  we  cannot  pass  it,  after  having  tried  ia 
various  ways,  it  is  well  to  take  another  instrument  with  a  dift'erent  curve, 
either  greater  or  smaller,  according  to  what  we  think  is  indicated ;  or  to  select 
one  of  larger  caliber,  which  by  opening  and  unfolding  the  canal  in  a  more  uni- 
form manner,  often  passes  where  a  smaller  one  had  been  stopped.  At  other 
times  we  succeed  better  with  a  catheter  of  a  sensibly  less  size;  or  then 
attempt  the  use  of  gumelastic  tubes.  The  position  of  the  patient  is  to  be 
changed  and  varied ;  and  when  the  difficulties  which  present  themselves  caa 
110  longer  be  attributed  either  to  the  operator  or  the  instrument,  we  proceed 
to  the  examination  of  such  as  may  arise  from  the  condition  of  the  canal  itself. 
The  obstacles  chiefly  encountered  in  this  part  are  the  following :  congenital 
or  acquired  tortuosity,  deviations  resulting  from  disease,  congestions,  tume- 
faction of  the  mucous  membrane  or  its  surrounding  tissues,  a  varicose  state 
of  the  prostatic  plexus,  an  excessive  development  of  the  verumontanum  or 
vesical  valve,  a  fibrous  or  any  other  tumor  upon  the  posterior  edge  of  the 
prostate  or  trigonal  space,  and  lastly,  spasmodic  contractions  of  the  peri- 
neum and  urethra.  Some  of  these  are  obviated  by  well-directed  motions. 
The  others  require  to  be  combatted  by  different  measures.  A  large  bleeding 
from  the  arm ;  leeches  between  the  scrotum  and  anus ;  warm  baths  continued 
for  a  long  while  if  the  patient  is  robust  and  suffers  much ;  opiate  draughts ; 
ointments  of  a  similar  nature,  such  as  belladonna  and  hyosciamus  placed  in 
the  anas,  and  along  the  course  of  the  urethra  when  the  irritability  is  very 
great,  and  there  can  be  no  doubt  that  the  movements  are  spasmodic,  consti- 
tute the  series  of  means  to  be  employed  on  such  occasions.  By  using  judi- 
ciously and  successively  each  in  its  turn,  a  well  informed  and  skillful  surgeon 
will  scarcely  ever  fail  to  succeed.  If  spasm  of  the  urethra,  properly  so 
called,  really  exist,  and  we  can  wait  for  some  hours  without  risk  to  the  patient, 
it  must  be  treated  as  I  have  just  described ;  but  in  urgent  cases  every  thing 
must  be  done  to  get  through  it,  and  I  have  my  doubts  whether  to  a  skillful 
hand  it  can  really  form  an  insurmountable  impediment.  It  is  so  convenient 
likewise  for  clumsy  people  to  assert,  as  they  do,  that  there  is  a  spasmodic 
contraction  merely  because  they  cannot  pass  the  catheter  into  the  bladder! 
As  a  constriction  of  this  sort  must  necessarily  be  of  short  duration,  and  does 
not  entirely  obliterate  the  canal  of  the  urethra,  it  must  with  patience  and 
small  instruments  be  in  the  power  of  art  to  overcome  it. 

Flexible  Catheters, — The  urethra  is  passed  with  flexible  catheters,  as  by 
the  preceding  ones.  Still  as  a  general  rule  it  is  correct  to  say  that  they  do 
not  pass  so  easily  as  silver  ones.  If  they  are  to  be  made  to  pass  a  tortuous 
canal  they  should  have  no  stylet,  so  that  they  may  bend  freely  in  every  direc- 
tion. In  an  opposite  case,  the  caliber  is  filled  up  by  a  metallic  rod  as  strong 
and  smooth  as  possible.  This  rod,  curved  as  catheters  generally  are,  becomes 
the  guide  of  the  instrument,  should  fill  it  quite  to  its  point,  and  at  its  handle 
end  exceed  it  in  length,  and  generally  terminates  in  a  ring. "  We  must  be 
extremely  careful  that  the  stylet  does  not  escape  through  tlie  eyes  of  the  flexi- 
ble sheath,  as  it  might  expose  the  urethra  to  a  very  dangerous  injury.  It  is 
best  before  introducing  it  to  give  it  the  proper  shape,  although  it  is  easy  to 
increase  its  curvature  after  it  has  passed  the  pubis,  by  slipping  the  finger  into 
the  rectum.  To  withdraw  the  rod  we  have  only  to  bring  it  towards  the 
abdomen  with  the  right  hand,  whilst  the  left  hand  holds  the  catheter  below 
107 


840  NEW  elements:  OF 

and  pushes  it  towards  the  bladder.  If  this  manoeuvre  is  sometimes  more 
painful  tlian  the  operation  itself,  it  is  because  it  has  been  badly  executed ; 
and  never  happens  when  the  stjlet  is  made  to  pass  over  at  its  exit  the  same 
segment  of  a  circle  which  it  traversed  at  its  entrance. 

Some  surgeons  at  the  instance  of  Dr.  Hey  have  approved  of  the  plan  of  no 
longer  using  the  stylet  after  reaching  the  pubis ;  but  to  hold  it  firmly  in  one 
hand  while  the  other  makes  uniform  pressure  on  the  catheter,  whose  blunt 
and  flexible  beak  passes  better  along  through  the  remainder  of  the  urethra, 
than  if  it  were  directed  by  the  stylet.  Others,  following  up  an  idea  of  Dr. 
Physick,  use  an  instrument  whose  summit  is  lengthened  out  in  the  shape  of 
conical,  flexible,  and  full  point,  which  goes  before  the  stylet.  Dr.  Hey  with  a 
view  to  fatigue  the  bladder  less,  contrived  to  give  the  catheter  a  fixed  curve, 
which  many  French  surgeons  have  adopted^  and  whose  only  inconvenience 
I  think  is  that  of  being  rather  too  prominent. 

Gumelastic  instruments  being  preferred  only  in  cases  in  which  it  is  useful 
to  leave  them  in  the  bladder,  call  for  the  utmost  attention  of  surgeons  on  this 
subject.  In  the  first  place  their  composition  should  be  such  that  no  bending 
can  break  them,  crack  them^  or  destroy  the  softness  and  polish  of  their  sur- 
face. If  this  is  not  attended  to  they  soon  become  rugous  in  the  urethra,  and 
are  soon  incrusted  with  urinary  salts;  and  if,  as  has  often  happened  unfortu- 
nately, a  piece  falls  off  into  the  bladder,  every  one  knows  what  the  conse- 
quences will  be.  The  best  way  of  trying  them  is  to  make  them  bend  and  twist 
suddenly  on  their  axis.  If  they  resist  and  do  not  alter  in  appearance  they 
may  with  confidence  be  employed.  If  otherwise,  they  should  be  refused. 
The  red  wax  edge  which  is  placed  round  their  free  extremity  is  useful,  not 
only  as  a  groove  for  the  strings  which  serve  to  fasten  them,  but  it  also  prevents 
them  from  being  lost  in  the  urethra,  and  from  slipping  towards  the  bladder, 
by  escaping  suddenly  out  of  the  hand.  It  does  not  at  first  sight  appear 
possible  for  a  catheter  ten  or  twelve  inches  long,  left  to  itself,  to  enter  wholly 
into  the  bladder ;  but  of  its  occurrence  we  have  proofs  the  most  incontestible, 
and  even  last  year  M.Rouxwas  called  upon  to  perform  cystotomy  for  an 
accident  of  this  kind. 

An  infinite  variety  of  methods  is  practised  for  fastening  a  catheter  in  the 
bladder.  Sometimes  the  ribands  which  go  round  the  head  are  led  up  and 
fastened  to  different  parts  of  a  T  bandage,  the  two  perpendicular  branches  of 
which  go  round  the  inner  surface  of  the  upper  parts  of  the  thighs.  Some- 
times they  are  attached  to  a  waistband  and  drawers,  at  others  they  are  tied 
to  little  strings  coming  froni  the  front  of  a  suspensory,  such  as  is  to  be  met 
with  readily  prepared  at  the  bandage  makers.  Instead  of  four  strings,  two 
Tip  and  two  down,  placed  at  equal  distances  from  the  root  of  the  penis,  some 
have  them  made  with  double  rows  of  button  holes,  others  with  small  rings 
formed  like  the  handle  of  a  basket.  In  hospitals  the  penis  is  first  passed 
through  a  hoop  covered  with  linen,  which  is  then  fastened  by  strips  of  bandage 
on  the  front  of  the  pubis  and  scrotum,  so  in  short  as  to  serve  for  a  common 
rendezvous  for  the  ribands  of  the  catheter.  All  these  methods  are  good,  in 
as  much  as  that  they  make  no  pressure  on  the  penis ;  but  they  all  are  more 
or  less  inconvenient,  and  have  the  objection  of  acting  both  on  the  pelvis  which 
i«  not,  and  the  penis  which  is  movable.  The  best  way  after  all  is  to  fasten 
the  catheter  on  the  body  of  the  organ  itself,  which  suffers  much  less  indeed 
than  has  been  a&serted  when  suitable  precaution  is  observed  in  doing  it.    With 


OPERATIVE  SURGERY.  ^51 

me  the  following  plan  has  always  been  effectual.    We  take  two  strips  of 
cotton,  rather  thick  and  half  a  yard  long.     Cotton  wick  will  answer  every 
purpose.    The  surgeon  makes  a  simple  open  knot  in  each  string,  places  each 
on  the  catheter  a  little  below  the  glands,  and  then  draws  the  knots  close, 
leaving  the  four  ends  separate  and  pendant.     He  then  takes,  adjusts,  and 
approximates  the  two  ends  of  the  first  string,  passes  one  end  within  the  other 
so  as  to  form  a  loop  an  inch  or  two  from  where  they  are  knotted,  applies  this 
loop  against  the  penis ;  passes  the  end  of  the  loop  round  it,  crosses  them,  brings 
them  back  again  to  the  side  whence  they  started,  and  ties  them  in  a  bow. 
He  then  does  the  same  with  the  second  string ;  carefully  arranging  the  whole 
so  that  there  are  four  strings  equally  tense  having  the  instrument  as  an  axis 
or  a  starting  point,  and  the  body  of  the  penis  for  a  basis  or  termination.    As 
from  the  suppleness  of  their  tissues,  they  scarcely  irritate  the  organ,  it  sup- 
ports them  very  well.     Instead  of  one  or  two  turns,  we  may  if  necessary 
pass  them  several  times  around  the  corpora  cavernosa,  so  as  in  a  measure  to 
cover  the  whole  penis  from  the  root  of  the  glands  to  the  pubis,  by  carrying 
the  cotton  wick  round  often  enough.     We  may  also,  as  M.  Roux  prefers, 
previously  surround  the  penis  with  a  piece  of  fine  linen,  so  that  the  strings 
may  not  be  in  immediate  contact  with  the  skin ;  but  these  little  changes,  as 
they  are  matters  of  choice  only,  do  not  deserve  discussing  seriously.     If  erec- 
tion or  swelling  of  the  organ  obliges  us  to  adopt  some  other  course,  any  one 
of  those  described  in  the  commencement  of  this  paragraph  may  be  pursued. 
A  precaution  which  it  is  not  less  important  to  attend  to  is  not  to  keep  the 
catheter  in  too  deep ;  for  though  a  flexible  one  it  may  create  inflammation 
and  ulceration  of  the  bladder,  and  even  perforation,  of  which  we  possess  many 
examples.     On  the  other  side,  if  its  holes  are  not  beyond  the  prostate,  urine 
will  not  enter,  and  the  instrument  will  be  useless.    It  is  better  upon  the  whole 
not  to  leave  more  than  an  inch  or  two  in  the  interior  of  the  bladder ;  and  to 
fasten  the  retentive  apparatus  near  the  glands  in  a  relaxed  state  of  the  organ 
and  not  on  the  handle  or  at  the  extremity,  unless  it  is  our  wish  that  the  urine 
should  issue  guttatim.     The  catheter  thus  arranged  is  stopped  up  with  a  little 
wedge  or  plug  of  wood,  a  sort  of  spigot  which  the  patient  takes  out  when  he  feels 
a  desire  to  urinate,  and  puts  in  again  directly  afterwards.  As  it  does  not  abso- 
lutely interfere  with  his  walkino;,  it  is  made  more  comfortable,  and  kept  in  more 
safety  by  being  cautious  to  have  it  gently  turned  up  with  the  penis  on  the  pubis 
by  means  of  a  bandage.     Prudence  requires  that  every  two,  three,  or  four 
days  it  be  taken  out  and  cleaned ;  and  that  it  be  changed  if  it  appears  in  any 
way  altered,  whicli  happens  every  eight,  ten,  twelve,  or  fifteen  days.     By 
keeping  it  in  longer  than  this,  we  run  the  risk  of  finding  it  coated  with  saline 
concretions,  which  may  lacerate  the  urethra  as  it  is  withdrawn. 

The  Masterturn. — In  former  times  lithotomists  and  great  surgeons  had  a 
peculiar  way  of  introducing  a  catheter.  To  do  it  they  turned  its  concavity 
downwards,  and  brought  it  towards  the  abdomen  by  a  semicircular  turn, 
only  at  the  moment  of  the  arrival  of  its  beak  beneath  the  sub-pubic  liga- 
ment. The  remainder  of  the  operation  was  not  different  from  the  pre- 
ceding ;  and  the  perfection  of  the  slight  of  hand  consisted  in  making  the 
circular  turn  end  insensibly  in  the  tilt  upwards,  which  alone  could  justify 
the  expression  "masterturn,"  or  {tour  de  maitre).  It  was  for  a  long  time 
supposed  that  the  only  object  of  this  method  was  to  conceal  the  true  mecha- 


95^  NEW  ELEMENTS  OF' 

nism  of  the  catheter  from,  the  eyes  of  their  assistant,  but  there  is  beneath  it 
I  think  something  more  than  this.  The  end  of  the  instrument  passed  in  this 
way  executes  a  rotatory  motion  in  the  curved  portion  of  the  canal,  which  must 
undoubtedly  aid  its  passage  beneath  the  symphysis;  and  which  thereby  com- 
bines the  advantages  possessed  by  straight  instruments  with  those  of  curved 
ones.  But  as  it  is  a  delicate  attempt,  which  in  every  one's  hands  would  not 
be  unattended  with  danger,  it  has  been  generally  discountenanced  or  reserved 
for  a  few  special  cases.  An  extreme  protuberance  of  abdomen,  for  instance, 
and  the  operation  for  stone,  when  we  stand  facing  the  patient  to  introduce  the 
instrument,  render  it  unnecessary.  It  is  not  even  then  indispensable,  for 
there  is  nothing  to  prevent  us  from  turning  the  handle  of  the  sound  to  one 
side  during  the  first  stage  of  the  operation,  if  the  size  of  the  belly,  and  the 
uneasy  forced  position  of  the  surgeon  do  not  allow  of  its  being  directed  as 
usual. 

Catheterism  in  the  Female, — The  female  catheter  is  but  from  five  to  seven 
inches  long  and  nearly  straight.  It  is  generally  an  exceedingly  simple  thing 
to  introduce  them.  The  canal  through  which  they  have  to  pass  is  so  shoct, 
so  regular,  so  easy  to  find  and  to  follow,  that  it  scarcely  resembles  that  of 
the  male  in  any  respect.  The  patient  is  more  conveniently  placed  when  she 
lies  on  her  back,  than  when  standing  up  or  seated  on  the  edge  of  her  bed» 
The  surgeon,  who  stands  on  the  right  side  rather  than  on  the  left,  desires  her 
to  flex  her  limbs  gently,  and  to  separate  her  thighs.  He  then  places  his  left 
hand  in  supination  on  the  pubis ;  opens  the  labia  minora  with  the  thumb  and 
middle  finger ;  raises  the  clitoris  and  vestibule  with  the  index,  the  nail  of 
which  is  kept  towards  the  meatus ;  takes  the  catheter  previously  greased, 
and  holds  it  in  his  right  hand  like  a  pen ;  passes  it  beneath  the  right  ham,  if 
the  breech  and  vulva  seem  too  much  sunken ;  offers  the  beak  with  its  con- 
cavity upwards  to  the  orifice  of  the  urethra,  lowers  it  a  little  to  get  it 
beneath  the  symphysis;  raises  it  again  immediately,  and  with  one  effort 
passes  it  into  the  bladder.  I  shall  not  here  repeat  the  means  for  maintaining 
this  instrument  in  its  place,  having  pointed  them  out  fully  in  the  article  on 
**  Vesico  Vaginal  Fistula."  This  is  an  operation  so  shocking  to  the  delicacy 
of  some  women,  that  we  should  be  happy  if  it  could  always  be  done  without 
exposing  their  persons.  Generally  this  is  possible  and  even  easy.  If  the 
left  hand  being  placed  as  above  described,  the  beak  of  the  catheter  is  carried 
to  the  nail  of  its  forefinger,  it  is  afterwards  only  necessary  to  slip  it  down- 
wards, following  the  median  line  on  the  vestibule,  to  fall  almost  certainly 
upon  the  meatus.  We  should  be  still  more  certain  to  succeed  by  passing 
the  instrument  from  below  upwards,  resting  its  extremity  against  the  pulp  of 
the  right  middle  finger,  whilst  the  ring  finger  of  the  same  acts  as  a  sort  of 
explorer  or  sentinel.  It  easily  detects  the  fourchette,  then  the  entrance, 
then  the  anterior  column  of  the  vagina,  the  termination  of  which  more  or 
less  swelled  like  a  tubercle,  is  found  immediately  below  the  urethral  orifice. 
At  this  point  the  ring  finger  stops.  The  others  then  slip  the  catheter  over  its 
fleshy  part,  using  it  as  a  director.  The  meatus  cannot  be  more  than  a  line 
or  two  off;  we  feel  about  a  little  and  almost  always  easily  enter  the  canal. 

In  women  who  have  had  many  children,  in  old  age,  and  during  pregnancy, 
&c.  the  urethra  is  at  times  pretty  difficult  to  find.  It  has  retreated  into  the 
pelvis  and  behind  the  pubis  and  becomes  very  oblique,  or  even  rises  quite 


OPERATIVE   SURGERY.  853 

against  the  symphysis.  In  such  a  case,  the  meatus  must  be  looked  for  deep 
under  the  pubic  ligament,  and  if  it  does  not  soon  show  itself,  we  try  to  bring 
it  into  view  by  pulling  upon  the  base  of  the  clitoris  and  the  vestibule 
upwards,  with  the  index  finger,  whilst  tlie  middle  finger  and  thumb  at  the 
same  time  pull  the  nymphze  strongly  outwards.  When  the  catheter  is  intro- 
duced the  handle  must  be  rapidly  lowered.  We  are  even  obliged  sometimes 
to  employ  one  with  a  more  considerable  curve,  or  even  to  resort  to  the  male 
catheter.  Even  when  the  points  are  in  an  unnatural,  distorted  condi- 
tion, as  in  the  few  first  days  following  delivery,  for  instance,  if  the  surgeon 
will  remember  that  the  meatus  urinarious  is  always  situated  on  the  edge  of 
the  vagina,  at  the  junction  of  the  circumference  of  the  opening  of  the  vulva 
with  the  base  of  the  vestibulum,  in  other  words,  at  the  base  of  the  small  trian- 
gular opening  bounding  the  inner  surface  of  the  labia  minora  and  lower 
surface  of  the  clitoris,  he  will  find  that  in  no  case  is  catheterism  really  a 
difiicult  operation  in  the  female  sex.  It  is  rendered  more  troublesome  in  early 
youth,  merely  by  the  intractability  of  the  patients.  The  catheters  require  to 
be  less  thick  (say  one  or  two  lines)  and  less  long,  (say  from  five  to  seven  or 
eight  inches)  but  to  be  prepared,  introduced  and  fastened  in  the  same  way 
as  is  done  in  adults,  only  it  is  well  to  have  the  curve  a  little  longer,  because 
of  the  symphysis  at  this  age  descending  lower,  the  bladder  beins  higher,  and 
the  prostate  less  bulky. 

Jlrt.  2. — Strictures, 

The  means  which  have  been  proposed  and  put  in  practice,  in  the  treatment  of 
organic  contraction  of  the  urethra,  are  catheterism,  forced  injections,  dilation, 
cauterization,  incision  from  without  inwards,  and  scarifications. 

§  1 .  Catheterism  hy  Force. 

When  there  exists  a  complete  ischuria,  and  the  obstacle  causing  it  can  by 
no  manipulation  be  done  away,  either  by  using  a  metallic  or  gumelastic 
instrument,  straight  or  crooked,  hollow  or  solid,  or  with  bougies  of  different 
kinds,  and  the  case  is  urgent,  no  choice  is  any  longer  left  the  surgeon,  but  to 
perform  puncturing  the  bladder  or  to  effect  catheterism  by  using  actual  force. 
This  operation  had  been  advised  since  the  time  of  Dease,  and  to  do  it  a 
catheter  ending  in  a  trocar  point  had  been  employed.  Now  those  persons 
who  venture  upon  performing  it,  use  a  conical  instrument  suitably  curved 
and  very  strong.  Credit  for  the  idea  is  given  to  MM.  Desault  and  Boyer ; 
but  Colfiniere,  who  violently  contested  their  claims,  declares  tliat  it  belongs 
to  him,  and  that  he  promulgated  it  in  1783.  According  to  M.  Boyer,  Mr 
Roux  is  the  only  person  in  France  who  has  taken  up  its  defence ;  and  except 
Dr.  Physick,  who  is  said  by  Borsey  to  have  used  a  similar  practice  since  17'95, 
it  has  found  only  undervaluers  in  the  surgical  world.  It  has  been  thought 
that  by  thus  forcing  a  way  through  the  impediment,  the  instrument  must  make 
a  false  passage  and  tear  the  canal  very  much  oftener  than  it  could  pass  the 
narrow  part  by  violence ;  and  to  those  who  know  the  dangers  which  attend 
urinal  infiltration,  the  idea  of  such  lacerations  has  been  extremely  alarming. 
Nor  do  I  think  that  it  is  a  point  upon  which  practitioners  generally  have  de- 


S54  NEW  ELEMENTS  OF 

•ceived  themselves.  In  spite  of  all  his  skill  and  all  his  practice,  M.  Roux  hasi 
more  than  once  demonstrated  the  dangers  of  his  method.  I  once  myself  had. 
occasion  to  open  the  body  and  dissect  the  urethra  of  a  man  who  had  been 
treated  by  him  in  this  manner,  and  who  died  of  urinal  abscess  caused 
hy  a  false  passage.  However,  the  danger  certainly  appears  to  have  been  ex- 
aggerated. A  well  conducted  instrument  does  not  always  swerve  from 
the  natural  course  on  clearing  the  resistance.  Besides  which,  when  it  really 
ruptures,  instead  of  doing  it  away  and  it  escapes  from  the  urethra,  it  generally 
re-enters  it  some  lines  further  on.  Lastly^  supposing  it  to  reach  the  bladder 
only  after  freely  ploughing  up  the  body  of  the  prostate,  this  accident  even  is 
far  from  always  proving  fatal.  The  catheter  remaining  in  may  change  the 
false  passage  into  an  accidental  canal,  and  yet  the  organism  scarcely  take 
notice  of  it,  as  I  saw  in  an  instance  in  1830,  at  a  hospital  in  Paris.  Neither 
is  it  uncommon  to  see  the  urine  resume  its  course  in  a  few  hours,  or  after 
some  days,  through  the  natural  channel ;  and  upon  the  whole  I  do  not  know 
whether  persons  sure  of  their  hands  and  of  their  anatomical  knowledge,  so  as 
not  to  fear  to  stray  in  going  through  the  perineum,  ought  not  to  prefer  forced 
catheterism  with  a  conical  sound  to  puncturing  the  bladder. 

Method  of  Operation. — The  patient  and  surgeon  take  their  places  as  for 
simple  catheterism.  The  more  weighty  and  solid  the  instrument  is,  the  better 
it  penetrates.  A  common  catheter  exposes  us  more  than  any  other  to  lacerate 
the  part,  nor  will  it  enter  the  urethra  easily  enough  unless  the  cone  which  it 
represents  be  prolonged  insensibly  up  to  the  handle.  Its  march  would  not  be 
progressive  enough  if  it  only  occupied  the  vesical  extremity ;  and  having  once 
left  the  canal,  it  would  advance  too  rapidly  into  the  adjacent  tissues. 
Generally  it  becomes  necessary  to  make  use  of  force  only  after  leaving  the 
bulb  and  level  of  the  symphysis.  From  that  time  the  surgeon  with  his  right 
hand  approaches  the  glans  penis ;  takes  hold  of  the  instrument  by  its  middle, 
and  not  its  handle,  that  it  may  vacillate  less,  and  so  that  he  may  with  greater 
ease  hold  it  with  all  necessary  firmness ;  pushes  it  accurately  onward  in  the 
known  direction  of  the  urethra,  not  allowing  it  to  deviate  in  the  least,  and  only 
urges  it  forwards  in  proportion  as  the  fingers,  one  or  more,  of  the  left  hand  on 
the  penis  or  in  the  anus,  follows  its  motions  and  can  appreciate  its  progress, 
and  make  him  certain  that  the  beak  scarcely  departs  from  the  centre  of  the 
membranous  and  prostatic  portions  of  the  canal  through  which  it  passes. 

False  or  New  Passages. — By  tearing  the  urethra  in  its  bulbous  portion, 
the  catheter  is  liable  to  plough  up  the  whole  extent  of  the  perineum  and 
recto-vesical  septum,  may  even  make  its  way  into  the  intestine  before  it 
again  finds  the  canal,  and  not  enter  the  bladder  at  all.  The  false  passage 
consequently  is  so  much  the  more  dangerous  as  it  does  not  even  give  exit  to 
the  urine. 

If  the  tear  has  taken  place  above,  and  the  point  of  the  catheter  has  got  up 
behind  the  symphysis  and  in  front  of  the  bladder,  the  misfortune  will  be 
greater  still ;  for  infiltration  having  to  attack  the  pelvic  cellular  tissue  ^/ould 
almost  infallibly  produce  death.  False  passages  through  the  prostate  are  in- 
finitely less  alarming ;  1st,  because  the  tissues  of  this  gland  resists  the  contact 
of  urine,  and  generally  prevents  infiltration ;  2d,  because  the  instrument  not 
being  far  away  from  the  organ  to  be  voided,  returns  to  it  almost  constantly 
before  much  damage  is  done,  or  a  great  space  outwardly  passed  over. 


OPERATIVE  surgery:.  855 

As  soon  as  we  are  conscious  of  having  met  with  this  misfortune,  we  must, 
unless  it  be  complete,  withdraw  the  catheter  towards  ourselves,  and  do  all  in 
our  power  to  find  the  urethra  and  re-enter  the  natural  passage ;  or  else  if  it 
communicates  with  the  bladder  leave  the  instrument  in  until  such  time  as 
it  can  be  replaced  bj  a  gumelastic  catheter,  which  must  be  left  in  for 
several  days.  When  infiltration  takes  place,  and  swelling  and  infiltration  are 
beginning,  whether  the  bladder  be  empty  or  not,  and  whether  or  not  it  be 
possible  to  place  an  instrument  in  the  uretlwa,  we  must  not  hesitate  ;  we  are 
freely  to  incise  the  presumed  course  of  the  laceration  and  to  endeavor  to  get 
to  the  canal.  It  is  the  only  means  of  limiting  the  extent  of  evil,  and  of  pre- 
venting mortification  of  the  tissues. 

§  2.  Forced  Injections, 

A  means  which  should  be  tried  before  paracentesis  vesicae  is  resorted  to, 
and  which  is  not  attended  with  the  same  dangers  as  catheterism  by  force,  is 
distention  of  the  urethra  by  a  liquid  pressed  in  from  before  backwards.  It 
was  first  mentioned  by  Tyre  in  1784,  who  says  that  he  has  derived  the  great- 
est advantage  from  it;  and  Soemmering  states  that  if  he  is  unable  with  the 
most  delicate  bougie  to  pass  the  stricture,  he  injects  oil  into  the  canal,  closes 
its  orifice  directly,  and  presses  upon  the  urethra  so  as  to  make  the  oil  pass 
from  before  backwards. 

Brunninghau  sen's  method  is  a  little  different;  he,  at  the  moment  when  the 
patient  attempts  to  make  water,  presses  upon  the  urethra  strongly  behind  the 
glans  and  compels  the  fluid  to  retreat,  thinking  thereby  to  overcome  the 
stricture.  About  ten  years  ago  M.  Despiney  de  Bourg  proposed  a  liquid  of 
a  purely  emollient  nature,  which  was  to  be  pushed  on  with  a  syringe.  M. 
Citadini  who  in  1826,  in  the  month  of  March,  published  a  work  upon  this 
subject,  carries  an  open  catheter  down  to  the  impediment,  keeps  the  urethra 
firmly  and  closely  applied  to  it,  and  uses  it  as  a  syphon  for  the  injection  of 
tepid  water  with  all  necessary  force,  or  of  any  other  appropriate  fluid  into  the 
canal.  M.  Amussat,  who  believed  himself  to  have  invented  forced  injections, 
does  very  much  as  M.  Citadini.  He  advises  the  application  of  a  compress 
around  the  penis,  so  that  no  void  may  remain  between  the  catheter  and  the 
parietes  of  the  urethra;  then  that  a  bottle  made  of  caoutchouc,  filled  with 
water,  be  adapted  to  the  top  of  the  catheter,  and  that  the  injection  be  thrown 
in  by  compressing  the  gumelastic  bag  with  a  tourniquet.  But  it  is  very  clear 
that,  if  the  principle  be  but  established,  it  can  be  of  very  little  consequence 
whether  the  liquid  be  projected  by  a  syringe,  gumelastic  bag,  the  fingers,  or 
in  any  other  way.  This  method,  though  a  rational  one,  and  one  which  in 
certain  cases  is  of  undoubted  efficacy,  is  still  far  from  deserving  all  the  praise 
which  some  persons  have  lavished  upon  it. 

If  the  urine,  which  is  a  kind  of  natural  injection  flowing  from  behind  for- 
wards, neither  can  break  through  the  stricture,  cause  it  to  disappear,  or 
prevent  its  occurrence,  how  can  we  hope  that  any  fluid  whatever,  merely 
because  it  is  forced  in  an  opposite  direction,  should  triumph  over  every  ob- 
stacle? It  is  therefore  very  probable  that  the  success  which  is  attributed  to 
it,  may  have  resulted  from  the  use  of  catheters  and  bougies  directed  judi- 
ciously; and  that  in  a  majority  of  instances   injections  might  have  been 


856  NEW   ELEMENTS   OF 

rendered  unnecessary,  by  a  most  skillful  employment  of  the  ordinary  means. 
Still  as  it  is  easy  to  use  them,  and  they  are  attended  with  no  inconvenience,  I 
see  no  reason  why  they  may  not  be  essayed,  even  without  waiting  for  the 
failure  of  other  methods. 


§  3.  Incisions  or  Scarifications  of  the  strichir eel  part. 

Although^'a  very  old  one,  the  idea  of  carrying  down  a  cutting  instrument  to 
the  bottom  of  the  urethra,  to  destroy  its  contraction,  lias  never  had  many  ad- 
vocates ;  and  I  wonder  that  it  should  ever  have  been  attempted  to  revive  the 
practice  in  our  own  time.  Besides  the  almost  utter  inability  to  cut  nothing 
but  the  strictured  part,  the  danger  of  cutting  healthy  and  not  diseased  struc- 
ture, and  the  dread  which  the  patient  must  feel,  another  inconvenience  about 
the  method  is,  that  it  offers  no  chance  of  a  permanent  cure,  and  that  it  renders 
the  stricture,  after  the  little  wounds  have  healed,  tighter  than  it  was  before.  In 
fact,  one  of  two  things  must  happen ;  either  we  must  leave  the  canal  to  itself 
after  the  incision,  and  in  this  case  the  wound  having  to  heal  by  first  intention 
will  be  closed  at  the  end  of  four  days,  or  else  it  must  be  kept  open  by  means 
of  catheters  and  bougies,  and  then  we  shall  have  mediate  cicatrization.  Now 
it  is  actually  demonstrated  that  these  secondary  cicatrices,  when  left  at  liberty, 
contract  invincibly  upon  themselves,  leaving  the  stricture  in  just  the  same  state 
in  which  the  knife  found  it,  if  it  be  not  even  much  harder,  and  much  more  diffi- 
cult either  to  overcome  or  to  destroy.  The  facts  which  are  arrayed  against 
this  reasoning,  prove  nothing;  because,  supposing  them  to  be  true,  the  dilation 
which  is  called  in  to  aid  the  incision,  is  of  itself  sufficient  to  explain  the  success 
which  is  obtained.  But  more  than  this,  most  generally  the  incision  has  not 
even  touched  the  stricture,  and  of  course  if  it  seems  to  give  way  directly,  it 
is  because  of  the  effect  of  the  dilator  instruments,  which  urethrotomists  never 
fail  to  pass  immediately.  Practice  daily  furnishes  evidence  that  after  the  in- 
cision, relapses  follow  as  after  simple  dilation.  I  have  beneath  my  eye,  at 
this  very  time,  two  remarkable  instances  of  this,  who  have  been  cut  each  of 
them  twice,  at  an  interval  of  a  year,  by  one  of  the  most  ardent  and  presuming 
scarifiers  in  Paris.  It  is  a  method  which  can  do  only  for  frsenum,  vulvular,  or 
semilunar  strictures,  if  any  should  be  met  with  in  the  anterior  third  of  the 
urethra  ;  but  which  beyond  the  bulb  will  be  attempted  only  by  the  inconside- 
rate, who  are  wanting  in  accurate  surgical  or  anatomical  knowledge — only 
empirics. 

The  Method  of  Operation. — As  it  is  possible  that  there  will  be  some  who, 
notwithstanding  the  above  remarks,  will  continue  to  practice  incisions,  and  as 
likewise  they  may  become  necessary  in  certain  cases  of  well  defined  stricture, 
too  hard  and  too  thick  to  yield  to  the  distending  efforts  of  a  bougie,  I  shall 
describe  the  method  of  doing  it. 

Dorner,  to  whom  the  credit  of  it  is  given  by  Siebold  and  Soemmering,  advises 
the  use  of  a  sort  of  lancet,  passed  through  a  catheter.  Dr.  Physick  highly  re- 
commends an  instrument  of  the  same  kind,  a  stem  ending  in  a  fleam  point,  en- 
closed in  a  canula  of  sufficient  length,  of  which  it  is  forced  out  by  pressure 
on  its  free  extremity.  In  the  work  of  Dr.  Dorsey,  two  of  these  urethrotomes 
may  be  seen ;  one  of  which  has  no  curve  whatever,  being  intended  for  strictures 
of  the  straight  portion  of  the  canal ;  the  other  rather  more  curved  near  its  beak 


OPERATIVE   SURGERY.  S3T 

than  a  female  catheter,  so  as  to  be  adapted  lor  attacking  strictures  of  the  bulb 
and  the  membranous  portion.  Dr.  Randolph  assures  us  that  Dr.  Gibson  has 
succeeded  with  it  in  cases  in  which  no  other  method  could  have  been 
successful.  But  every  one  must  see  that  the  cutting  edge  of  either  Dr.  Phy- 
sick's  instrument  or  that  of  Dorner,  no  matter  how  skillfully  used,  will  enter 
more  often  into  the  thickness  of  the  canal  than  into  the  middle  of  the  obstacle, 
and  in  many  cases  will  leave  the  stricture  wholly  untouched.  Dr.  Despinay, 
who  approves  of  incisions  only  in  cases  of  contractions  of  the  urethra  of  a  bri- 
dle shape,  in  its  anterior  part,  about  the  fossa  navicularis  for  example,  advises 
that  they  should  be  executed  with  a  straight,  very  narrow,  and  probe-pointed 
bistoury.  The  object  can  evidently  be  better  accomplished  by  the  bistoury 
contrived  by  Bienaise  or  M.  Civiales'  small  sheathed  urethrotome.  The  advan- 
tages of  this  plan  of  operating  over  that  pursued  by  Dr.  Physick  no  one 
can  dispute.  The  incision  being  made  by  a  lateral  effort,  and  from  behind  for- 
wards, gives  rise  to  no  exposure  to  a  false  passage,  as  that  one  does  which  is 
made  from  before  backwards,  beyond  the  conducting  instrument.  Dr.  Ash- 
mead  acting  upon  the  same  idea  as  M.  Despinay  de  Bourg,  has  had  an  instru- 
ment made  which  is  a  concealed  bistoury  like  that  of  Brother  Come,  the  sheath 
of  which  extends  to  a  point,  blunt  or  buttoned,  to  go  through  the  impediment; 
its  blade  cutting  only  for  an  extent  of  six  or  eight  lines  near  its  extremity,  so 
that  when  it  is  opened  it  incises  only  the  strictured  part,  which  is  thought  by  its 
inventor  adapted  for  any  region  of  the  urethra.  Others,  M.  Dzondi  first,  and 
afterwards  M.  Amussat,  have  contrived  a  sort  of  drill  with  four,  six,  or 
eight  cutting  edges,  or  crista,  parallel  to  its  axis,  projecting  for  half  a  line,  or 
a  line  at  most,  on  the  circumference  of  its  vesical  end,  which  for  a  distance  of  six 
or  eight  lines  should  be  somewhat  enlarged.  The  intermediate  grooves  are  filled 
up  with  tallow.  It  is  enclosed  in  a  straight  canula,  by  which  we  are  enabled 
to  carry  it  down  upon  the  obstacle.  When  it  reaches  this  part  we  begin  to 
push;  it  quits  its  canula  and  enters  the  stricture.  The  tallow  either  melts  or 
is  pushed  back  by  the  resistance.  The  little  edges  stand  out  isolated,  and 
cut  the  constricted  circle,  like  scarificators,  in  different  directions.  Then  it  is 
drawn  out,  a  catheter  or  flexible  bougie  immediately  enters  its  place,  and  is 
left  in  for  twenty-four  hours  at  least,  and  renewed  from  time  to  time 
until  the  cure  is  accomplished.  In  order  that  such  an  instrument  may  pene- 
trate, the  stricture  must  not  be  complete,  for  the  beak  which  does  not  cut,  and 
which  has  to  pass  first,  is  nearly  two  lines  thick ;  of  course  the  introduction  of 
a  pretty  strong  bougie  cannot  be  very  difficult,  and  we  seek  in  vain  for  any 
justification  for  the  performance  of  urethrotomy.  The  same  reproach  lies  against 
Dr.  Ashmead's  instrument  and  M.  Despinay's  procedure  ;  but  with  this  dif- 
ference, however,  that  as  it  may  assume  the  form  of  a  bougie,  or  a  stylet,  the 
latter  urethrotome  will  traverse  the  impediment  after  the  manner  of  a  catheter 
and  will  only  divide  it  secondarily  by  an  after  stroke.  It  combines  the  qual- 
ities of  an  urethrotome  with  that  of  a  conducting  catheter,  or  a  bougie  for  dila- 
tion ;  it  can  bear  upon  one  point  only,  or  it  may  cut  several  successively,  and 
at  different  depths,  at  the  pleasure  of  the  operator. 

It  is  this  instrument  consequently  which  answers  best,  whenever  it  is  abso- 
lutely requisite  to  practise  this  method  of  incision. 

108 


858-  JTEW  ELEMENTS  OF 

§  4.  Concentric  or  External  Incisions. 

Strictures  of  the  urethra  occur  so  frequently  and  give  rise  to  accidents  of 
so  serious  a  nature,  that  the  genius  of  surgeons  is  untiringly  employed  to  dis- 
cover some  remedy,  and  the  most  dangerous  and  painful  methods  have  beea 
proposed  for  their  removal.  Planque  has  given  us  the  case  of  a  surgeon 
who  fearlessly  opened  an  urethra  from  one  end  to  the  other,  so  as  to  cauterize 
and  cleanse  its  interior,  which  he  after  re-united  by  means  of  several  twisted 
sutures,  upon  a  catheter,  and  cured  his  patient ;  which  in  Solingen's  time  was 
the  method  in  use  at  Livourne.  Instead  of  thus  dividing  its  entire  length,, 
many  surgeons  determined  upon  merely  incising  the  strictured  part.  J.  L.  Petit, 
an  advocate  of  this  method,  permitted  the  wound  to  heal  upon  his  S  shaped 
catheter,  whilst,  according  to  what  M.  Dolivera  says,  Lassus  after  a  similar 
operation  replaced  by  a  gumelastic  catheter  in  1786.  M.  Levamier  of  Cher- 
bourg, who  was  stopped  by  an  almost  entire  obliteration  of  the  canal,  fearlessly 
revived  the  procedure  of  Petit  and  Lassus,  and  his  boldness  was  crowned  with 
complete  success.  But  that  in  our  own  time  several  surgeons  had  chosen  to 
adopt  the  same  operation,  and  had  striven  to  renew  the  popularity  of  a  method 
in  France  almost  forgotten,  a  few  words  of  mention  would  have  sufficed  for 
it.  But  for  some  years  past  it  has  been  too  often  attempted  for  me  to  pass  it 
by  in  silence. 

The  Method  of  Operation. — MM.  Eckstrom  in  Germany,  Arnott  in  England, 
and  Dr.  Jameson  in  America,  who  Have  derived  marked  advantages  from  the 
operation,  perform  incision  of  the  urethra  according  to  the  following  rules  z 
A  staif  or  catheter  with  a  groove  in  it,  is  passed  down  to  the  obstacle  and  held 
there  by  an  assistant ;  the  surgeon  raises  the  testicles  and  stretches  the  parts 
with  his  left  hand  ;  makes  with  his  right  a  large  slit  (buttonhole)  on  the  perineal 
wall  of  the  passage  with  a  very  sharp  bistoury ;  strikes  upon  the  staff;  with- 
draws it  a  little,  then  endeavors  to  find  the  continuation  of  the  urethra  at  the 
bottom  of  the  wound,  at  the  same  time  that  the  patient  makes  an  effort  to  uri- 
nate ;  attempts  to  pass  into  it  a  stylet  or  grooved  staff,"  which  he  uses  as  a  di- 
rector on  which  to  extend  the  incision  backwards  for  a  distance  of  some  lines 
beyond  the  stricture ;  and  he  concludes  the  operation  by  leaving  a  catheter  in 
the  canal  as  far  as  the  bladder,  upon  which  catheter  the  wound  speedily 
heals. 

Where  the  obliteration  is  very  complete,  or  it  is  very  difficult  to  discover 
the  opening,  we  are  advised  by  M.  Groninger  to  cut  at  random  almost  as  far 
as  the  prostate ;  to  plunge  either  a  narrow  bistoury  or  a  trocar  through  this 
gland  into  the  bladder,  so  as  to  create  an  artificial  canal,  afterwards  to  be 
kept  open  by  passing  into  it  through  the  meatus  urinarius  a  catheter  to  be 
left  in,  on  which  the  w^ound  is  to  heal.  Mr.  Cox,  who  advises  the  same  thing, 
quotes  a  case  in  support  of  it  which  he  looks  upon  as  quite  conclusive,  but 
which  in  fact  merely  shows  how  far  the  rashness  or  blindness  of  some  surgeons 
may  be  carried.  In  fact  the  urethra  is  never  completely  closed  in  an  organic 
stricture.  Even  supposing  that  the  simple  slit  be  sometimes  indispensably 
necessary,  and  that  forced  catheterism  should  not  receive  a  preference  over  it, 
when  passing  a  bougie  becomes  absolutely  impossible,  it  may  at  least  be  as- 


OPERATIVE   SURGERY.  859 

SBrted  that  such  an  incision  as  this  ought  always  to  be  sufficient  to  enable  any- 
well  informed  man  to  discover  the  continuation  of  the  canal.  It  would  assuredly 
be  much  easier,  more  rapid,  and  less  dangerous  to  puncture  tlie  bladder,  than 
perform  the  operation  advised  by  MM.  Gwneger  and  Cox,  and  twenty  times 
less  painful.  Besides,  I  doubt  very  much  whether  any  French  practitioner  of 
the  present  day  will  find  it  necessary  to  imitate  this  conduct,  and  even 
whether  they  will  not  constantly  avoid  making  even  the  simple  slit  in  the  peri- 
neum. 

§  5. — ^Dilation. 

The  treatment  of  stricture  of  the  urethra  by  dilation,  is  the  oldest  of  which 
we  possess  any  knowledge,  and  for  a  long  time  was  the  only  one  in  use. 
Leaden  bougies  formerly  used  and  cried  up  as  new  some  years  ago  by  M. 
Horzberg ;  those  made  by  Schmidt  of  a  composition  consisting  of  an  alloy 
of  tin  and  lead,  although  very  flexible,  were  too  hard  and  weighty  to  be  borne 
by  the  urethia  without  inconvenience.  Bougies  made  of  wax  and  of  gum- 
elastic  have  alone  been  retained  in  practice. 

The  former  of  these  instruments  were  formerly  constructed  of  several 
substances,  and  were  particularly  extolled  in  1551  by  Lamna,  and  by  Daran 
in  1745,  under  the  name  of  emplastic  bougies.  Since  the  possession  of  me- 
dicinal virtues  has  been  denied  them,  and  that  they  have  been  esteemed  on 
account  of  their  mechanical  properties  only,  red,  v/hite,  or  yellow  wax  made 
flexible,  has  been  substituted  for  the  various  component  compositions  of  a 
resolvent,  astringent,  or  desiccative  nature.  The  only  qualification  now  looked 
for  in  them  is  that  of  suppleness,  softness,  an  inability  to  melt  in  the  organs, 
a  capability  of  moulding  themselves  to  every  inflexion  of  the  canal,  and  an 
absence  of  all  brittleness  whatever.  The  leaden  wire  by  some  persons  intro- 
duced into  their  centre  to  add  to  their  solidity  is  useless.  A  delicate  and 
slender  piece  of  cat-gut  is  better,  if  we  are  absolutely  determined  not  to  use 
those  which  are  made  of  emplastic  cloth.  The  second  variety,  the  gumelastic 
bougie,  which  is  more  soft,  supple,  and  flexible,  and  still  less  irritating  than 
a  wax  one,  has  the  inconvenience  of  distressing  the  urethra  more  by  its  very' 
elasticity,  and  its  disposition  to  straighten,  particularly  if  it  be  of  any  size; 
whence  it  follows  that  as  mechanical  agents  they  cannot  be  substituted  in 
every  particular  for  emplastic  or  sear  cloth  ones,  as  Soemmering  and  most 
authors  of  modern  times  have  asserted.  Each  is  met  with  under  various  shapes. 
Some  are  cylindrical,  some  swelled,  some  conical,  &c.  Conical  bougies  grow 
larger  as  they  penetrate,  and  therefore  are  advantageous  in  dilating  the  canal 
more  rapidly  and  not  bending  up  as  readily  in  it;  but  they  have  the  disad- 
vantage on  the  other  hand  to  tend  to  escape  from  it ;  to  fill  it  up  too  accurately, 
and  consequently  to  distress  it  much  towards  its  base ;  moreover,  if  the  in- 
struments are  too  long  they  project  into  the  bladder  before  tliey  act  suitably 
upon  the  strictured  part.  It  is  necessary  that  their  point,  beginning  very  thin, 
should  not  be  more  than  twelve  or  eighteen  lines  from  the  body  of  the  cone, 
and  that  they  should  afterwards  be  cylindrical  up  to  their  head ;  it  being 
remembered  that  no  bougies  below  Nos.  8  or  6  require  this  modification, 
which  would  enfeeble  them  to  no  purpose. 

The  bougie  a  ventre^  or  which  bellies  or  swells  out,  will  often  deserve  a 


860  NEW  ELEMENTS  OF 

preference.  The  fusiform  (spindle-shaped)  enlargement  of  its  posterior  fifth 
when  it  is  long  enough,  is  no  obstacle  to  its  being  made  conical  on  that  side, 
and  the  sensibly  less  considerable  bulk  of  its  stem,  causes  it  to  concentrate 
almost  all  its  efforts  upon  the  stricture,  distress  the  urethra  very  little,  and  to 
be  kept  in  without  any  difficulty.  Led  by  this  idea,  M.  Desruelles  has  pro- 
posed to  substitute  for  a  bougie  a  metallic  canula  an  inch  or  two  long,  to  be 
left  in  the  strictured  part,  after  being  carried  down  by  the  assistance  of  another 
instrument,  and  so  as  to  be  kept  outwards  by  means  of  a  string.  But  the 
swelled  bougie  is  better ;  it  allows  us  to  carry  the  dilation  to  any  extent  we 
will,  and  gives  less  pain  than  conical  instruments. 

The  mode  of  action  of  bougies  upon  stricture  has  not  always  been  viewed 
in  the  same  light.  It  is  now  only  conceded  that  they  cause  ulceration  and 
dilation.  This  must  evidently  be  erroneous.  The  eccentric  compression 
which  they  cause,  bringing  about  interstitial  absorption,  may,  whilst  it  distends 
and  obliterates  strictures  in  the  urethra,  remove  the  phlogosis  which  so  often 
keeps  up  their  existence.  The  radical  cure  which  they  produce,  oftener  than 
from  the  testimony  of  some  authors,  one  would  be  inclined  to  believe  is 
indeed  explicable  only  by  this  remarkable  fact.  This  leads  us  moreover  to 
think  that  medicated  bougies  have  probably  been  wrongly  rejected  entirely, 
and  that  their  topical  action  is  perhaps  not  so  despicable  as  it  has  not  been 
well  understood. 

Ulceration. — Those  who  have  adopted  the  method  of  ulceration,  rest 
their  argument  on  this  ground,  to  wit :  a  stricture  which  is  merely  di- 
lated cannot  fail  to  return  as  soon  as  the  use  of  the  dilating  agent  is  dis- 
pensed with ;  whereas,  if  you  do  induce  a  loss  of  substance,  you  must  obtain 
a  permanent  enlargement  of  the  canal.  Home  recently,  in  professing  a  similar 
doctrine,  has  committed  a  double  error.  In  the  first  place  relapse  is  not 
inevitable  after  dilation ;  in  the  next,  ulceration  induces  a  loss  of  substance 
whose  very  cicatrization  will  reproduce  stricture  with  much  greater  certainty. 
There  is  moreover  nothing  to  prove  that  it  really  can  be  produced  at  will.  A 
bougie  forcibly  introduced  into  the  infundihulum  of  a  stricture,  or  pressed 
down  on  the  centre  of  the  circular  constriction,  irritates  and  dilates  sooner, 
but  does  not  ulcerate  and  rather  excoriates  the  part. 

Dilation. — The  medicinal  effect  of  bougies,  to  which  we  shall  probably  at 
some  future  day  return,  being  for  the  present  laid  aside,  the  only  thing  of  im- 
portance to  be  studied  is  their  effect  of  distension  in  its  different  degrees  or 
under  its  different  aspects.  It  is  a  sure  and  almost  an  unfailing  effect,  and 
yet  attended  with  the  serious  inconvenience  of  being  kept  up  with  unequal 
constancy,  and  of  acting  merely  as  a  palliative  to  the  evil  instead  of  curing  it 
radically  in  most  of  the  patients  who  submit  to  it. 

Still  to  these  objections  it  may  be  replied  that  their  weight  has  been  over- 
rated ;  that  strictures  which  consist  neither  of  frena  nor  valves,  nor  salient 
cicatrices,  nor  of  vegetations  of  any  kind  whatsoever,  but  which  depend  on 
pure  and  simple  thickening  or  phlegmasia  of  the  mucous  membrane  and  sub- 
jacent organic  layer,  sometimes  yield  beneath  a  well-directed  dilation; 
and  lastly,  that  it  suffices,  in  order  to  guard  against  relapses,  to  pass  a  bougie 
at  first  tivery  month,  then  every  two  months,  three  or  four  months,  and  keep 
it  in  for  some  hours;  a  precaution  which  must  be  the  less  annoying  to  the 
patient  as  he  can  do  it  very  well  for  himself. 


OPERATIVE   SURGERY.  8W 

Method  of  Operation, — la  a  firm  stricture,  passing  a  bougie  is  not  always 
an  easy  matter.  If  it  is  too  fine  it  bends  up  before  the  least  obstacle.  It  is 
easier  for  it  to  pass  if  it  be  somewhat  larger.  Cat-gut  ones,  which  are  stiffer 
and  possess  more  strength  in  a  small  compass,  here  offer  some  advantages. 
M.  Delpech  advises  us  to  flatten  and  chew  the  point  a  little  so  as  to  change  it 
into  a  sort  of  supple  and  delicate  pencil ;  he  then  passes  it  through  the  obstacle, 
takes  it  out  at  the  end  of  two  hours,  carries  in  a  larger  one,  which  he  removes 
after  a  like  interval  and  puts  in  another,  and  on  the  same  evening,  if  he  thinks 
it  practicable,  replaces  that  by  a  bougie  or  gumelastic  catheter.  The  swelling 
of  which  they  are  susceptible  makes  them  in  such  a  case  dilators  of  precious 
value ;  but  as  they  untwist,  soften,  and  grow  knotty,  if  we  delay  changing  for 
more  than  two  or  three  hours,  we  run  some  risk  of  their  breaking  or  scraping 
the  urethra. 

Small  Catheters,  Hollow  Bougies. — It  is  also  frequently  most  convenient 
to  begin  with  a  very  small  catheter  or  a  hollow  bougie.  The  stylet  with 
which  it  is  provided  should  be  well  curved  up  to  the  beak,  and  as  strong  as 
possible.  The  whole  is  then  introduced  into  the  bladder  according  to  the 
rules  of  catheterism.  Besides  which  it  is  prudent  to  be  provided  with 
catheters,  bougies,  and  cat-gut  bougies  in  one's  case,  so  as  to  be  prepared  to 
try  them  one  after  the  other  if  it  be  necessary.  For  the  patient  there  can  be 
no  fixed  position.  Sometimes  he  must  be  allowed  to  stand  up,  sometimes  to 
sit  down,  and  sometimes  to  lie  horizontally  upon  the  bed.  The  penis,  which 
in  general  is  raised,  requires  in  other  cases  to  be  slightly  lowered  and  drawn 
forward.  The  patient,  guided  by  the  sensation  he  experiences  and  the  resist- 
ance wdth  which  he  meets,  will  succeed  sometimes  where  the  most  skillful 
surgeon  had  failed.  The  want  of  success  in  a  first  attempt  is  no  argument 
against  its  renewal.  A  thousand  peculiarities,  of  which  practice  alone  can 
make  us  aware,  may  oppose  themselves  to  our  success  at  first,  and  permit  it  in 
a  moment  afterwards.  Upon  the  whole  the  procedure  is  very  much  the  same 
as  that  for  performing  catheterism.  The  penis  is  held  in  the  left  hand,  the 
bougie  is  pushed  on  with  the  right.  The  most  delicate  instruments  most 
readily  catch  on  the  bottom  of  the  lacunas  of  Morgagni,  or  of  the  slightest 
plait  in  the  canal.  The  moment  that  any  resistance  is  felt,  the  bougie  is  to  be 
turned  as  an  axis  between  the  fingers  after  having  been  withdrawn  a  few  lines, 
and  is  again  to  be  pushed  onwards  (as  it  is  being  turned)  to  the  obstacle.  A 
cul-de-sac,  a  fold,  a  wrong  direction,  a  rugosity,  an  elevation  caused  by  the 
stricture  itself,  may  arrest  its  progress.  It  is  then  particularly  that  it  must 
be  made  to  advance  gently;  it  must  be  drawn  towards  the  operator;  its  in- 
clination is  to  be  varied ;  it  is  to  be  turned  round  in  the  fingers  and  its  advance 
favored  by  means  of  the  fore-finger  applied  to  the  perineum.  It  is  known  to  have 
entered  the  stricture  when,  not  advancing  furtlier,  it  shows  no  disposition  to 
recede  and  seems  to  be  compressed  at  its  point,  as  it  were.  We  may  be  very 
sure  of  the  reverse,  so  long  as  it  springs  back  on  relaxing  the  pressure,  and 
offers  no  resistance  to  any  attempt  to  withdraw  it.  A  person  of  experience 
will  never  be  deceived,  and  will  feel  better  than  he  can  describe  the  diff*erence 
which  there  is  between  a  bougie  which  has  engaged  in  a  stricture,  and  one 
which  is  merely  stopped  in  the  urethra. 

In  the  former  case,  the  excess  of  its  bulk  alone  preventing  its  passing,  we 
have  but  to  replace  it  by  a  smaller  one,  or  else  fasten  it  at  the  point  at  which 


Bd2  new  elements  of 

it  has  entered.  In  the  second,  the  attempt  is  to  be  renewed  in  every  possible 
way,  by  taking  bougies  of  larger  and  smaller  size,  and  of  different  forms  and 
shapes.  As  a  last  resource,  the  bougie  may  be  fastened  at  that  part  of  the 
mrethra  to  which  it  has  descended,  provided  its  extremity  be  not  turned  up 
into  a  sort  of  brush.  It  is  by  no  means  an  impossible  thing  that  by  so  doing 
it  may  of  itself  clear  the  obstacle ;  and  that  in  half  an  hour's  time  nothing  may 
be  easier  than  to  make  it  advance  considerably.  This  conduct  which  has  been 
for  a  long  time  pursued  at  the  Hotel  Dieu,  at  Paris,  has  produced  numerous 
and  oftentimes  unexpected  instances  of  success.  If  the  canal  appears  to  be 
too  much  irritated,  too  painful,  if  it  bleeds  abundantly  or  is  spasmodically  con- 
tracted, we  must  suspend  the  operation  and  return  to  it  again  when  these  symp- 
toms shall  have  subsided.  Emplastic  bougies  previously  curved  at  the  point 
can,  it  is  true,  be  no  longer  rolled  between  the  fingers ;  but  they  accommodate 
themselves  better  to  the  direction  of  parts,  and  in  certain  cases  overcome  ob- 
stacles which  had  resisted  all  the  others.  That  which  seemed  to  be  impossi- 
ble, is  sometimes  rendered  easy  by  bathing  the  penis  in  cold  water ;  warming 
the  instrument  before  it  is  introduced ;  besmearing  it  with  cerate  moistened 
with  oil ;  or  by  charging  it  with  some  ointment  containing  opium  or  belladonna. 
A  long  probe-pointed  stylet,  having  a  ring  at  the  other  end,  introduced  by  a 
rotatory  motion,  has  succeeded  with  me  in  many  difficult  cases  quite  as  weU 
as  with  MM.  C.  Bell  and  Vanvelsuner,  who  proposed  it  in  1814  and  1821. 
The  button  at  its  end  is  an  excellent  means  of  clearing  the  most  irregular 
strictures,  and  as  M.  Segalas  has  pointed  out,  it  allows  the  extent  of  the  con- 
traction to  be  measured. 

I  now  suppose  the  bougie  to  be  introduced.  To  fasten  it  in,  it  is  only  neces- 
sary, when  it  is  an  emplastic  and  swelled  one,  to  bend  the  end  near  the  glans 
penis  in  the  form  of  a  hook,  or  of  a  ring.  When  cylindrical  or  merely  conical 
it  must  moreover  be  capped  by  a  condon,  or  bag  of  fine  linen,  which  encloses 
the  penis  at  the  same  time.  Elastic  bougies  require  similar  precautions 
to  those  given  when  we  were  speaking  of  catheters  permitted  to  remain  in  the 
urethra. 

The  time  which  the  former  are  to  be  allowed  to  remain  in,  varies  accord- 
ing to  a  variety  of  circumstances  ;  according  to  the  sensibility  and  irritability 
of  the  canal ;  to  its  being  otherwise  healthy  or  diseased ;  to  the  degree  of  suffer- 
ing experienced  by  the  person ;  to  the  date  and  state  of  the  stricture,  whether 
old  or  recent,  slight  or  serious  ;  and  lastly,  to  the  etfect  which  it  is  intended 
to  produce.  It  is  rare,  however,  for  it  to  be  less  than  half  an  hour,  one  or  two 
hours,  or  more  than  twelve  or  eighteen  hours,  which  is  usually  about  as  long  as 
the  patient  can  endure  it  without  too  much  suffering.  If  the  want  of  making 
water  is  very  acutely  felt,  and  the  urine  cannot  escape  between  the  walls  of 
the  urethra  and  the  foreign  body,  conical  bougies  have  this  advantage  more, 
that  by  withdrawing  them  a  little  the  urine  passes  easily,  and  they  can  be  re- 
placed with  facility  at  the  same  distance  which  they  were  at  before.  Flexible 
catheters,  either  conical  or  cylindrical,  are  valuable  in  this  respect,  for  it  is  not 
necessary  to  change  them  so  as  to  allow  the  bladder  to  be  voided,  and  there 
are  persons  who  cannot  retain  their  urine  for  more  than  an  hour,  or  even  as 
iong. 

Neither  can  there  be  anymore  certainty  as  to  the  time  of  each  application. 
We  are  sometimes  obliged  to  wait  two  or  three  days,  whilst  in  other  cases  the 


OPERATIVE  surgert.  86S 

organism  gets  so  rapidly  accustomed  to  it  and  the  patient  is  so  little  inconve- 
nienced, that  it  may  be  repeated  next  day.  At  each  new  introduction, 
we  employ  an  instrument  of  rather  larger  size,  as  soon  as  that  last  used  begins 
to  traverse  the  urethra  freely ;  but  conical  bougies  being  thicker  the  deeper 
they  are  made  to  penetrate,  do  not  so  absolutely  demand  this  change.  As  the 
cure  progresses,  the  sittings  approximate  and  are  made  to  last  longer.  As  a 
principle,  it  may  be  asserted  that  every  stricture  which  may  be  traversed  by  a 
bougie,  however  delicate,  is  curable  by  dilation.  The  treatment,  which  is  pro- 
longed always  in  proportion  to  the  hardness  and  resistance  of  the  stricture,  the 
susceptibility  of  the  patient  to  impressions,  and  the  facility  with  wliich  he  may 
be  managed,  is  sometimes  not  concluded  until  the  end  of  two  or  three  months ; 
but  I  am  certain  from  an  ample  experience  of  facts  that  we  may,  in  most  per- 
sons, at  the  end  of  twenty  days  or  a  month,  succeed  in  restoring  the  canal  to 
its  natural  dimensibns,  particularly  by  the  use  of  conical  bougies.  I  have  even 
succeeded  in  obtaining  such  dilations  in  the  space  of  six,  eight,  twelve  or 
fifteen  days,  in  patients  whose  strictures  had  lasted  for  years ;  and  in  some 
also  who  had  been  previously  treated  either  by  caustic  or  bougies,  but  in  whom 
the  cure  had  remained  incomplete.  I  have  no  faith  in  the  danger  to  which  it 
is  said  to  be  liable,  or  in  the  pain  which  by  some  authors  it  is  said  to  produce* 
Skillfully  applied,  I  have  never  seen  a  serious  accident  result  from  its  use.  The 
mucous  or  blenorrhagic  oozing  which  it  sometimes  induces,  almost  always  dis- 
appears of  itself  after  continuing  some  days. 

The  fever  preceded  by  rigors  and  ending  in  perspiration,  like  an  intermit- 
tent, which  is  caused  in  certain  cases,  has  in  it  nothing  alarming.  The  ner- 
vous sensations,  engorgement  of  the  testes  and  chord,  are  occasional  oc- 
currences, which  are  no  oftener  caused  by  using  bougies  than  by  simple 
catheterisra.  A  patient,  however,  whom  I  performed  it  upon  at  La  Pitie 
was  attacked  with  symptoms  which  it  is  proper  to  relate.  After  several  at- 
tempts, a  conical  bougie  had  been  passed.  One  morning  this  man  was  attempt- 
ing to  replace  it  of  his  own  accord,  in  which  he  could  not  succeed,  and  made  his 
urethra  bleed.  An  attack  of  fever  which  had  attended  the  first  trials,  recur- 
red, lasted  for  three  days,  and  yielded  on  the  fourth,  to  be  succeeded  by  a 
most  violent  and  painful  arthritis  of  the  right  tibio-tarsal  articulation,  inv/hich 
a  prodigious  abscess  formed,  and  afterwards  anchylosis.  This  leg  had  beeR 
fractured  above  the  malleoli  about  six  weeks  before.  Is  this  a  coincidence  ? 
or  is  it  an  effect  of  the  same  kind  as  that  which  blenorrhagia  often  pro- 
duces ? 

The  only  real  reproach  which  a  bougie  deserves  is  this :  relapses  may  follow 
its  use ;  and  we  are  obliged,  therefore,  to  carry  the  dilation  beyond  the  normal 
dimensions  of  the  urethra,  not  to  abandon  bougies  suddenly,  and  to  continue 
to  introduce  them  from  time  to  time  for  at  least  several  months. 

An  air  dilator  may  be  formed  of  a  little  fusiform,  or  a  cylindrical  bag  sup- 
ported by  a  stylet  and  carried  through  a  flexible  tube,  which  is  to  be  introduced 
flaccid  into  the  stricture, and  afterwards  inflated  with  the  breath;  which  Du- 
camp  says  ought  to  supersede  the  swelled  bougie,  and  offers  the  important 
advantage  of  distending  the  stricture  powerfully  without  at  all  acting  upon 
the  rest  of  the  passage. 

We  now  however  know  that  this  statement  is  not  correct ;  that  the  little 
bladder  necessarily  moulds  itself  upon  the  urethra,  and  presses  quite  as  much 


864  NEW  ELEMENTS  OF^ 

on  either  side  of  it,  as  upon  the  stricture  itself.  Mr.,  Arnott's  dilator  is  not  in 
reality  any  better.  .M.Castallat  showed  me  another  one  which  consists  of  a 
long  canal  of  fine  linen,  which  is  passed  down  into  the  bottom  of  the  urethra 
by  a  long  flexible  stylet.  This  tube,  which  ends  in  a  cul-de-sac  at  its  vesical 
end  and  is  open  and  burnished  with  a  ferrule  at  the  other,  is  intended  to  receive 
little  portions  of  lint  or  cotton,  which  are  crowded  down  into  the  stricture 
by  means  of  another  stem,  so  as  to  obtain  a  dilation  as  rapid  and  as  gradual  as 
may  be  desired.  However  great  the  ingenuity  of  these  contrivances  may  be, 
I  doubt  whether  they  will  preserve  a  place  in  practice.  Bougies  will,  with 
scarce  an  exception,  allow  the  same  end  to  be  accomplished,  and  by  their 
simplicity  deserve  that  preference  which,  in  all  probability,  will  always  be 
shown  them. 

§  6,  Cauterization. 

Under  the  belief  that  strictures  of  the  urethra  depended  upon  vegetations 
and  fungus  growths,  surgeons,  about  the  15th,  16th,  and  17th  centuries,  acquired 
the  habit  of  treating  them  by  caustic.    Verdigris,  vitriol,  savin,  &c.,  mixed 
up  with  emplastic  compositions,  and  made  into  bougies,  were  employed  for 
this  purpose.    Ferri,  Ambrose  Pare,  F.  de  Hilden,  Rivere,  &c.,  speak  of  it 
as  a  very  general  method,  and  often  dangerous,  and  it  is  well  known  that  Loy- 
seau  wa^  bold  enough  to  practice  it  upon  king  Henry  IV.    In  the  last  century, 
however,  it  was  scarcely  employed,  and  but  for  the  improvements  made  in  it 
by  Lemonnier,  Wiseman,  Roncali,  Hunter,  Sir  Ev.  Home,  Arnott,  Ducamp, 
and  several  other  practioners  in  France,  this  method,  which  ultimately  became 
general,  might  without  any  great  loss  have  remained  in  the  oblivion  into 
which  it  had  fallen.    The  use  of  the  nitrate  of  silver,  instead  of  sublimate 
and  other  caustics  originally  employed,  seems  to  have  removed  its  dangers 
and  has  procured  for  it  the  suffrages  of  many.    Since  then  the  demonstration 
of  the  possibility  of  touching  only  the  diseased  part  has  so  completely 
satisfied  men's  minds  as  to  render  the  practice,  in  a  measure,  a  common  one. 
It  would,  however,  be  incorrect  to  suppose  Ducamp  the  original  author  of 
these  changes.    Bougies  for  taking  an  impression  of  the  stricture  were  used 
as  early  as  the  16th  century.     F.  Germain  and  L.  Mazell  expressly  recom- 
mend that  the  seat  and  form  of  the  stricture  be  ascertained  by  the  beak  of 
an  emplastic  bougie ;  that  it  be  withdrawn  and  that  a  layer  be  removed  from 
its  point,  for  which  a  caustic  material  is  to  be  substituted,  and  then  that  it  be 
carried  down  again,  thus  armed,  into  the  strictured  canal.     The  procedure 
of  Sir  E.  Home,  which  consists  in  fastening  a  fragment  of  lunar  caustic  upon 
the  point  of  a  bougie  for  the  purpose  of  passing  it  down  to  the  stricture, 
evidently  differs  a  little  from  that  of  Germain  or  Mazell.    In  like  manner 
A.  Pare  anticipated  John  Hunter  in  inventing  a  canula  for  protecting  the 
canal,  whilst  the  bougie  armed  with  the  caustic  is  being  introduced  and  allowed 
to  act.    As  it  is  remarked  by  M.  Dezeimeris,  Lemonnier  was  also  acquainted 
with  the  method  of  seeking  for  the  impediment,  and  taking  an  impression  of 
it  in  wax,  before  proceeding  to  apply  caustic  to  it.    F.  Roncalli  moreover  had 
employed  the  very  same  caustic  as  Hunter,  or  the  same  procedure  as  Pare,  ever 
since  the  year  1720 ;  and  the  practice  of  Wiseman  was  so  far  from  being 
given  up,  at  the  period  of  the  experiments  of  his  countrymen,  that  in  1755 


OPERATIVE  SURGERY.  865 

AUies  complained  of  its  proving  so  frequently  fatal  at  Paris.  In  spite  of 
the  remarks  and  modifications  of  MM.Aberdom  and  Wathely,  the  method 
of  Sir  E.  Home,  adopted  in  France  in  1818  by  Petit,  was  so  violently  opposed 
by  Rawley  and  Carlisle,  amongst  others,  that  even  in  England  it  labored 
under  powerful  prejudices.  The  work  of  Mr.  Arnott  in  1819,  founded  upon 
principles  similar  to  that  of  Ducamp,  produced  scarcely  any  sensation  in 
London;  any  more  than  that  of  M.  Mcllvain,  published  in  1830.  will  do 
towards  establishing  the  use  of  potassa. 

Cauterization  from  before  backwards,  with  or  without  a  protecting  canuia, 
has,  since  MM.  Arnott  and  Ducamp  made  their  method  known,  almost 
entirely  disappeared  from  practice.  If  any.  should  still  be  disposed  to 
attempt  it,  tlie  armed  bougie  invented  by  Messrs.  Home  and  A.  Petit  being 
flexible,  ought  to  be  preferred  for  strictures  near  and  beyond  the  bulb.  If  it 
be  pushed  forward  rapidly,  it  is  difficult  for  the  caustic  wliich  occupies  its 
beak  to  touch  the  walls  of  the  urethra  before  it  comes  to  the  funnel-shaped 
constriction;  it  is  then  pressed  down,  a  little  of  the  nitrate  melts,  and  in 
about  a  minute  it  is  withdrawn.  When  the  obstacle  is  not  so  deeply  situated, 
Roncalll's  or  Hunter^s  canuia  maybe  employed  without  inconvenience.  Mr. 
Chas.  Bell  and  Mr.  Shaw  thought  that  the  beak  of  a  metallic  catheter,  curved 
or  straight  as  the  case  might  be,  with  a  central  aperture  if  the  obstacle  is 
central,  if  lateral  an  opening  on  one  side,  v/ould  answer  the  indication  better 
by  giving  an  opportunity  of  carrying  down  a  piece  of  caustic  and  projecting 
through  one  of  these  holes,  either  with  a  bougie,  a  long  forked  stylet,  on  any 
other  appropriate  instrument. 

Lanteral  Cauterizaiwn,  which  has  lately  attracted  so  much  attention,  re- 
quires more  caution  and  is  performed  by  divers  procedures,  all  belonging  to 
the  same  method.  The  apparatus  of  Ducamp  for  this  purpose,  consists,  1st, 
of  an  exploring  catheter,  made  of  gumelastic  and  graduated,  which  is  in- 
tended to  ascertain  the  depth  at  which  the  impediment  exists ;  2d,  of  a  bougie 
for  taking  an  impression,  which  is  another  graduated  stem,  having  a  certain 
quantity  of  ductile  wax  at  its  extremity;  Sd,  ofa  conducting  catlieter,  also 
graduated  and  flexible,  fitted  at  one  end  with  a  platinum  socket,  and  enclosed 
in  a  silver  tube  at  the  other;  4th,  of  a  caustic  holder,  consisting  of  a  small 
platinum  cylinder,  having  a  slit  hollowed  out  upon  one  of  its  faces,  a  transverse 
pin  towards  its  root,  so  as  to  prevent  it  from  going  beyond  the  beak  of  the 
conductor,  and  also  a  flexible  stem  with  which  it  screws,  and  wliich  is 
continuous  on  the  other  side  with  a  metallic  stylet  armed  with  a  ring. 

The  Method  of  Operation. — The  positions  of  the  patient  and  the  surgeon 
are  the  same  as  for  catheterism  or  the  application  of  bougies.  The  little  pla- 
tinum cup  is  filled  with  fragments  of  caustic  before  it  is  screwed  upon  the 
flexible  stem.  Holding  it  then  in  the  grasp  of  a  good  pair  of  forceps,  it  is 
placed  over  a  candle  or  a  wax  light,  the  flame  of  which  is  steady,  so  as  slowly 
to  melt  the  caustic,  and  not  allow  it  to  swell  up,  which  happens  when  it  is 
heated  too  rapidly,  or  when  the  cup  has  not  been  cleaned  or  dried.  It  tiien 
remains  only  to  make  the  whole  smooth  by  removing  the  roughnesses  and  ele- 
vations which  may  have  formed  upon  it  with  pumice  stone,  or  the  edge  of 
some  cutting  instrument.  We  are  then  ready  to  begin  the  operation,  after 
having  accurately  determined  with  the  exploring  instrument  the  depth  at 

109 


866  NEW  ELEMENTS  OF 

which  the  obstacle  is  to  be  found.  The  first  thing  to  be  introduced  is  the 
impress  bougie.  It  is  held  firmlj  for  a  moment  against  the  stricture ;  the 
wax  melts,  fills  it,  and  enters  the  narrow  part.  It  is  withdrawn  and  the  size 
of  its  lengthened  point  gives  the  measure  of  the  diameter  to  be  gone  through, 
whiUt  the  cast  on  the  wax  should  show  whether  the  stricture  is  central,  circu- 
lar, or  if  not,  in  what  part  of  the  urethra  it  exists.  We  then  pass  down  the 
conductor  to  the  same  depth,  where  it  is  kept  fixed  with  the  left  hand ;  then 
we  take  hold  of  the  ring  of  the  caustic  holder  in  our  right  hand,  and  push  it 
in  such  a  way  as  to  make  the  platinum  cylinder  loaded  with  nitrate  pass  out, 
by  turning  the  cup  towards  the  diseased  side ;  in  a  word,  by  making  it  enter 
the  diseased  circumference.  The  wings  of  its  pin  stop  within  the  socket  of 
the  conductor.  It  is  left  for  a  minute,  or  only  half  a  minute,  in  contact  with 
tlie  tissues.  Having  drawn  it  back  again  into  the  catheter,  we  withdraw  the 
whole  apparatus  and  the  operation  is  at  an  end.  By  this  procedure,  if  there 
be  more  than  one  stricture  existing  simultaneously,  w^e  cannot  attack  that 
which  is  farthest  off,  until  we  have  successively  destroyed  all  the  others. 
The  porte-caustique  being  straight  and  supported  by  a  very  feeble  flexible 
stem,  it  is  both  dangerous  and  difficult  to  enter  the  curved  portion  of  the 
urethra.  Besides  which,  the  fluids  secreted  by  the  organ  very  often  dissolves 
tlie  nitrate  before  it  can  enter  the  stricture. 

One  of  the  first  persons  who  endeavored  to  do  away  these  inconveniences 
was  M.  Lallemand.  His  caustic  holder,  which  ended  in  a  knob  or  button  of 
but  one  piece,  with  the  stem  which  makes  it  move,  is  straight  or  curved  accord- 
ing as  it  is  intended  to  penetrate  a  less  way  or  very  deep,  and  is  enclosed  in  a 
sheath  or  catheter  of  platinum,  having  the  same  direction  and  more  diameter 
than  is  necessary  for  it  to  apply  itself  accurately  upon  the  cylindrical  or 
swelled  portion  of  the  stylet.  A  sliding  ring,  armed  with  a  press  screw,  em- 
braces the  conducting  catheter  or  sheath.  The  stylet  has  at  its  other  end  a 
lenticular  button  or  a  nut,  which  is  not  put  on  until  after  the  instrument  has 
been  introduced  from  behind  forwards  into  its  sheath  or  canula.  In  drawing 
it  towards  one's  self,  the  small  enlargement  at  its  head  completely  closes  the 
beak,  and  makes  the  vesical  end  of  the  catheter  a  blunt  point.  It  is  carried  thus 
closed  as  an  explorer  into  the  bladder,  so  that  we  maybe  certain  whether  there 
is  or  is  not  more  than  one  stricture.  If  there  be  several,  we  may  begin  with 
the  last  as  well  as  with  the  first,  and  either  apply  the  caustic  from  behind  for- 
wards, or  vice  versa,  to  one  after  the  other,  or  all  at  one  sitting.  AVhen  it  is 
placed  in  contact  with  the  first  stricture,  the  sliding  ring  is  pushed  down  to  the 
meatus,  so  as  not  to  lose  sight  of  the  distance  of  the  stricture.  By  drawing 
the  sheath  towards  one's  self,  the  cup  of  the  stylet  is  disengaged,  and  falls 
covered  upon  the  altered  tissue.  To  close  and  withdraw  it,  to  push  it  for- 
ward or  bring  it  back  to  the  other  strictures,  it  is  nearly  indifferent  whether 
we  move  the  sheath  upon  the  stylet,  or  the  stylet  upon  the  sheath,  by  pushing 
the  one  or  by  drawing  back  the  other.  In  this  apparatus  it  is  necessary  to 
have  several  stylets,  if  it  be  a  curved  instrument ;  because,  being  wholly  me- 
tallic, they  cannot  turn  upon  their  axis  within  the  canula,  and  their  cuvette  or 
cup  necessarily  faces  a  fixed  point.  We  must  have  them,  therefore,  with 
cups  on  their  concave  edge,  others  with  the  cup  inferior,  and  others  again  in 
which  it  is  placed  laterally.  They  must  also  be  of  different  dimensions,  with 
.  slicaths  likewise  of  various  caliber. 


OPERATIVE    SURGERV.  86r 

M.  Segaias,  wishing  to  preserve  the  advantages  possessed  by  the  instru- 
ment of  the  professor  at  Montpelier,  without  relinquishing  those  in  Ducamp's 
apparatus,  uses  a  stylet  composed  of  small  chains  at  its  deep  part,  resembling 
the  lithotritor  of  M.  Pravaz,  which  easily  performs  all  the  necessary  rotatory 
motions,  and  can  turn  its  cup  to  all  the  different  points  of  the  diseased  circle 
successively.  He  encloses  it,  armed  with  its  sheath,  in  the  conducting 
catheter  of  Ducamp,  so  as  to  enable  it  to  penetrate  to  the  first  stricture. 

M.  Pasquier  has  caused  a  rim  of  a  circular  shape  to  be  placed  behind  the 
cuvette  or  cup  of  the  porte-caustique  instead  of  a  pin ;  so  that  it  might  not  be 
necessary  to  turn  the  stylet  containing  the  caustic  and  conducting  tube  at  the 
same  time,  as  in  the  instrument  of  Ducamp.  Some  other  modifications  have 
been  adopted  by  this  surgeon,  which  being  of  trifling  importance,  may  be 
retained  or  rejected  with  indifference.  Among  others,  he  has  done  away 
with  the  bougies  for  taking  impressions,  used  in  the  primitive  method,  and 
with  the  exploring  bougie ;  and  prefers,  according  to  M.  Racine,  to  com- 
mence the  treatment  by  the  common  bougie  and  by  dilation,  so  that  the  caus- 
tic may  be  applied  first  upon  the  stricture  which  is  furthest  off.  Some 
persons  have  thought  that  the  stylet  might  be  made  of  still  easier  management 
by  lengthening  its  outer  extremity — which  is  of  metal — by  cutting  it  angu- 
larly instead  of  its  being  circular,  so  that  the  pressure  screw  of  the  open  ori- 
fice of  the  conducting  canula  may  the  better  adapt  itself  to  it ;  and  have 
attempted  to  do  away  with  the  need  of  this  screw,  by  terminating  the  stylet 
in  a  forceps  head,  one  of  whose  branches  is  free,  and  provided  with  transverse 
grooves  which  fasten  it  conveniently  in  the  square  opening  of  the  wide  end  of 
the  sheath,  whilst  the  other  is  continuous  with  the  stylet  itself;  nor  have  I 
thought  these  slight  alterations  were  to  be  altogether  despised. 

The  stylet  to  which  I  give  the  jweference,  without  however  attaching  any 
great  importance  to  it,  is  made  of  silver,  with  a  platinum  cup,  has  no  rim,  and 
has  a  button  at  the  end  like  M.  Lallemand's.  Its  free  extremity  is  a  sort  of 
watch-spring,  from  twelve  to  fifteen,  lines  long;  it  fits  into  the  immovable 
branch  of  the  forceps  head  I  just  spoke  of,  in  such^a  way  as  to  be  held  there 
by  a  pressure-screw,  or  to  be  withdrawn  at  pleasure.  Its  sheath  is  the  same 
as  the  flexible  canula  of  Ducamp,  in  which  I  do  not  enclose  it  from  behind 
forwards,  until  I  have  curved  it  like  the  stylet  of  gumelastic  catheter,  when 
I  think  it  necessary.  The  forceps  head  being  placed  in,  we  have  only  to  pull 
upon  it  to  close  the  instrument;  and  then  to  apply  the  button  or  knob  at  its 
cauterizing  end  over  the  deep  opening  of  the  conducting  canula.  Its  flexibi- 
lity permits  me  by  curving  it  before  the  operation  to  turn  the  cup  upwards, 
downwards,  or  on  one  side.  Its  head  prevents  it  from  making  a  falee  passage, 
and  protects  the  caustic  against  the  moisture  of  the  canal.  To  make  it 
advance,  it  is  sufficient  to  approximate  the  two  branches  of  the  forceps  head 
with  the  thumb  and  fore-finger  of  the  right  hand,  to  pass  that  wliich  is  free  by 
the  side  of  the  other  into  the  wide  orifice  of  the  canula,  and  push  them  on 
together  whilst  the  left  hand  holds  the  instrument  firm  in  the  penis. 

Estimate  of  .the  Method, — The  principal  defenders  of  tlie  cauterizing  of 
strictures  lay  great  stress  upon  the  need  of  determining,  in  a  matliematical 
manner,  not  the  depth  merely,  but  the  length,  shape,  thickness,  and  situation 
of  the  stricture.    About  the  first  of  these  points  there  can  be  no  difficulty. 


'^68  NEW   ELEMENTS   OF 

Any  blunt  instrument  will  answer  the  purpose  iind  give  as  much  information 
as  the  explorer  or,  impression  bougie  of  Ducamp. 

It  is  not  so,  however,  with  the  second  point.  The  emplastic  or  gumelastic 
bougie,  pointed  with  doctile  wax,  which  the  same  writer  advised  to  be  passed 
down  upon  all  the  strictures  at  once,  with  the  idea  of  getting  several  casts  at 
one  time,  is  of  not  the  least  use  whatever.  A  long  stvlet  with  a  cylindrical 
head  is  of  infinitely  more  certainty.  This  is  passed  down  to  the  obstacle 
either  bare  or  enclosed  in  a  blunt  catheter  like  the  common  stylet.  The 
figure  which  then  corresponds  with  the  meatus  urinarius  is  noted,  unless  the 
meatus  be  at  the  top  of  the  catheter.  It  overcomes  the  stricture,  which,  how- 
ever, impedes  its  exit  a  little,  by  which  mechanism  it  becomes  very  easy  to 
measure  its  extent,  for  the  point  of  departure  and  that  of  its  return  outwardly 
may  both  be  marked. 

To  settle  its  thickness  and  shape  gives  more  trouble.  Ducamp's  impression 
bougie  is  a  deceitful  instrument  which  deserves  to  have  no  reliance  placed 
up-an  it,  and  is  fit  only  to  serve  the  purposes  of  empiricism  and  imposture. 
When  it  gets  into  the  urethra,  the  wax  yields  as  readily  beneath  the  action 
of  a  fold,  a  spasm,  or  a  momentary  flattening  of  the  canal,  as  beneath  that  of  a 
true  stricture,  and  I  have  never  known  a  practitioner  of  distinction  who  dared 
to  use  the  nitrate  of  silver  upon  no  other  authority  than  this.  How  many 
urethras  have  been  needlessly  cauterized,  because  of  supposed  constrictions, 
originating  in  Ducamp's  bougie  being  withdrawn  distorted  in  shape  .^  M. 
Pasquier  v/as  therefore  quite  right  in  proscribing  it,  and  I  think  it  is  an  in- 
strument which  should  be  banished  from  surgery.  M.  Amussat  has  proposed 
as  a  substitute  for  it  a  straight  canula,  which  has  a  stylet,  whose  end  has  a 
liead  which  is  nail-shaped,  or  of  the  shape  of  a  lentil.  This  head  closes  the 
opening  and  forms  the  beak  of  the  instrument,  but  is  so  arranged  that  the 
handle  is  inserted  a  little  without  the  centre  of  the  terminating  plate.  When 
the  canula  is  in  its  place,  it  is  held  or  caused  to  be  held  motionless  with  one 
hand;  and  the  stylet  pushed  forward  with  the  other.  The  rasp  clears  the 
obstacle,  it  is  turned  upon  its  axis;  immediately  its  cutting  edge  passes 
laterally  the  level  of  the  sheath  ;  on  being  withdrawn,  it  rakes  the  cor- 
responding wall  of  the  urethra,  which,  if  it  meets  with  nothing,  must  be  in  a 
sound  state;  on  the  contrary,  if  it  encounters  a  frenum,  a  projection,  or  the 
morbid  tissues  themselves,  which  arrest  it,  and  withdraw  it/rom  the  sheath, 
it  is  diseased  and  strictured.  This  instrument  which,  except  that  it  is  straight 
instead  of  curved,  does  not  differ  much  from  Fare's  urethrotome,  is  not  less 
defective  than  Ducamp's  bougies,  is  still  more  dangerous,  and  could  only 
succeed  in  very  large  strictures. 

We  shall,  by  and  by,  discover  what  necessity  in  reality  there  is  in  practice 
for  any  of  these  precautions. 

Amid  so  many  contrivances,  which  one  are  we  then  to  retain  }  The  appa- 
ratus of  M.  Lallemand  would  evidently  be  the  best,  if  it  were  indispensable 
that  every  stricture  should  be  passed  successively,  when  several  exist.  M. 
Scgalas's,  if  it  were  less  complicated,  would  possess  equal  advantages.  But 
I  must,  after  all,  give  the  preference  to  that  of  Ducamp,  altered  by  M.  Pas- 
quier, or  as  I  myself  use  it,  if  one  must  be  adopted  to  the  exclusion  of  every 
other.     But  it  is  with  cauterizing  the  urethra,  as  with  every  other  operation ; 


OPERATIVE    SURGERY.  869 

to  a  skillful  hand  ail  instruments  are  good;  to  an  unskillful  one,  there  are 
none  which  will  be  found  convenient. 

Effects  of  the  Caustic. — The  nature  of  the  eftects  produced  is  always  the 
same,  whatever  may  have  been  the  procedure  adopted.  Whilst  the  nitrate  is 
bare  in  the  Urethra,  the  patient  feels  pain  and  a  stinging  or  burning  sensation, 
which  in  some  is  obtuse,  in  others  very  acute ;  and  which  lasts  for  a  longer  or 
shorter  time  afterwards.  This  difterence  depends  on  several  causes ;  some 
of  the  cerate,  oil,  or  tallow,  maj  remain  round  the  caustic,  and  bjits  viscidity 
prevent  It  from  acting;  or  the  hardened  tissues  of  the  strictured  circle, 
may  have  lost  nearly  all  their  sensibility :  on  the  contrary  the  nitrate  may 
touch  some  sound  part ;  it  may  spread  behind  or  before  the  stricture;  or  the 
canal  may  be  at  the  time  the  seat  of  a  morbid  sensibility  and  irritation,  more 
or  less  developed.  When  there  is  no  false  passage,  nor  any  discharge,  the 
pain  speedily  subsides  usually,  and  the  blood  does  not  always  make  its  ap- 
pearance. However  a  bath,  either  immediately  or  in  the  course  of  the  day, 
is  always  useful  to  guard  against  accidents.  When  the  stricture  extends 
very  far,  or  the  cauterizing  has  been  severe,  it  may  happen  that  swelling  and 
congestion  may  cause  retention  of  urine ;  which  is  induced  also  in  other  cir- 
cumstances by  flakes  of  matter,  or  eschars,  wjiich  are  entangled  in  the  centre 
of  the  obstacle.  They  are  speedily  got  rid  of  by  a  fine  bougie,  a  warm  bath, 
and  tepid  injections.  If  we  are  threatened  with  inflammation,  we  must  apply 
leeches  to  the  perineum.  On  the  morrow,  or  the  second,  or  third  day,  flattened, 
grey,  blackish,  or  whitish  flakes  begin  to  issue  from  the  urethra  with  the  urine, 
the  exit  of  which  they  again  render  very  painful.  However  this  expulsion  is 
not  always  present,  but  sometimes  wholly  wanting,  notwithstanding  that  the 
caustic  may  have  had  a  very  powerful  eft'ect.  As  soon  as  irritability  has  subsided 
and  the  sensibility  and  tenderness  of  the  organ  permits,  say  in  three,  four, 
five,  or  six  days,  we  recommence  its  application.  Some  persons,  and  I  think 
tliem  right  in  doing  so,  pass  in  a  bougie  for  a  few  minutes,  from  time  to  time, 
during  this  interval.  Others  again  resort  to  dilators  only  after  the  destruction 
of  the  stricture,  which  in  that  case  demands  from  four  or  six  to  thirty  or  forty 
introductions  of  the  caustic ;  and  a  treatment  consequently  of  from  two  weeks 
to  three  or  four  months. 

The  Theory. — Tlie  last  question  which  remains  for  solution,  is  tliat  of 
the  advantages  derived  from  cauterization.  Its  advocates,  with  Hunter  at 
their  head,  maintain  that  mere  dilation  is  but  a  palliative  means  almost  in- 
variably followed  by  a  return  of  the  disease.  That  to  obtain  a  cure  which 
shall  secure  against  a  relapse,  we  must  not  merely  mechanically  remove  and 
dilate  the  stricture,  but  that  we  must  destroy  and  corrode  it,  as  is  done  by 
caustic  ;  after  which  bougies  come  in  to  smooth  the  surface  and  complete  the 
cure.  To  this  the  opposers  of  the  treatment  reply,  that  the  loss  of  substance 
which  the  caustic  causes  must  leave  a  hard,  elastic,  and  generally  a  rugous  or 
uneven  cicatrix,  which  will  almost  certainly  bringback  the  stricture;  that  on 
this  ground  cauterization  is  even  more  subject  to  relapses  than  dilation ;  ai^tl 
that  being  incomparably  more  dangerous  there  appears  no  reason  for  giving  it 
the  preference.  That  to  enable  it  to  act  at  all  the  caustic  holder  requires  a 
canal  a  line  in  width,  which  is  a  diameter  that  will  always  allow  of  the  use  of 
a  bougie,  and  that  this  latter  instrument  will  often  pass  where  the  caustic  cup 
cannot  enter.  ■  Arguing  from  the  first  of  these  objections  they  ask  M'here  is 


870  NEW   ELEMENTS   OF 

the  advantage  of  caustic  since  bougies  are  applicable  wherever  it  is  applicable, 
and  that  they  moreover  must  precede  and  follow  it  in  almost  every  case  ? 
These  arguments  never  were  and  never  could  have  been  triumphantly  replied 
to  by  those  to  whom  they  were  addressed.  To  destroy  force,  we  must  take 
another  view  of  the  mode  of  action  of  caustic. 

Nitrate  of  silver  alters  the  vitality  of  the  parts  which  it  touches  much 
more  than  it  consumes  them.     In  the  urethra  its  action  is  to  extinguish  a 
chronic  inflammation  which  produced  a  stricture,  and  by  which  it  is  almost 
always  maintained  and  established,  just  as  it  extinguishes  many  cutaneous 
phlegmasijE,  tetter,  erysipelas,  the  pimples  of  small  pox,  &c.;as  it  checks  the  pro- 
gress of  certain  anginas,  aphthae,  ophthalmiae,  &c.     By  this  agency  it  is,  and  not 
by  causing  ulceration,  that  it  dries  up  old  discharges,  the  seat  of  which  is 
sometimes  before,  sometimes  beyond  the  bulb  of  the  urethra;  that  it  has  been 
so  successful  in  the  hands  of  M.  Lallemand,  among  others,  in  many  aifec- 
tions  quite  independent  of  stricture.     But  according  to  this  hypothesis  it 
ought  to  be  our  aim,  instead  of  wishing  to  cauterize,  ulcerate,  and  destroy,  to 
effect  mere  touching  of  the  parts.     We  should  consider  the  nitrate  of  silver 
eriereiy  as  a  topical  application,  intended  to  sufflaminate  the  morbific  cause ;  to 
bring  about  resolution  of  the  lardaceous  congestion  and  the  absorption  of  the 
fluids  effused  or  accumulated  in  the  meshes  of  the  mucous  membrane  and  sub- 
jacent tissues ;  not  to  regard  it  as  a  true  caustic.     Therefore  potassa,  which  M. 
Whately  advises  us  to  substitute  for  lunar  caustic,  is  clearly  a  pernicious  agent, 
which  ought  never  to  be  employed  in  practice.     Upon  this  principle  we  should 
explain  the  good  effects  derived  from  the  medicated  bougies  of  the  ancients, 
and  also  how  it  is  possible  for  every  species  of  cautery  used,  to  have  succeeded. 
With  this  idea  the  use  of  nitrate  of   silver  becomes   extremely  simple. 
Impression  bougies  become  useless,  because  all  that  is  required  is  to  put  it 
into  the  stricture  with  some  instrument  or  other,  without  troubling  oneself 
whether  it  is  shorter  or  longer,  above  or  below,  provided  that  in  dissolving- 
it  spreads  at  once  over  the  whole  circumference  of  the  canal.     Conductors 
perforated  outside  of  the  centre  of  the  platinum  socket  which  caps  their  extre- 
mity, in  order  to  separate  the  caustic-holder  from  the  sound  wall  of  the 
urethra,  and  on  the  contrary  to  apply  it  more  accurately  upon  that  which  is 
diseased,  become  equally  destitute  of  importance.     Bougies  and  caustic  then 
'hold  the  first  rank  ;  the  first,  to  dilate  and  enlarge;  the  second,  to  cure  the 
structure  and  to  give  to  the  tissues  the  original  qualities  of  their  normal 
state.     Unless  I  am  greatly  deceived  the  treatment  of  the  great  majority  of 
organic  strictures  of  the  urethra,  may  be  reduced  to  the  following  rules :  first 
to  dilate  them ;  to  cauterize  them  for  the  first  time  only  after  four  or  five 
applications  of  the  bougie ;  to  recontinue  the  dilation ;  to  apply  the  caustic  a 
second,  a  third,  and  a  fourth  time,  at  varying  intervals ;  and  after  having 
restored  the  canal  to  its  utmost  diameter,  to  return  to  it  once  or  twice  more 
to  extinguish  the  last  traces  of  inflammation  and  morbid  irritation  which  may 
have  remained  behind. 

§  7.  Abnormal  Dilation  of  the  Urethra, 

in  the  case  of  a  patient  affected  with  incontinence  of  urine,  whose  urethra 
was   considerably  dilated,  it  occurred  to  M.  Habort  to  excise  partly  the 


OPERATIVE    SURGERY.  871 

walls  inferior  after  which  he  re-united  the  wound  by  means  of  suture,  and 
thus  succeeded  in  restoring  the  vesico  urethral  functions. 


SECTION    IV. 

Puncturing  the  Bladder 

It  is  now  so  rarely  necessary  to  interrupt  the  continuity  of  the  bladder  to 
give  issue  to  urine,  that  M.  Roux  and  several  other  surgeons  of  great  distinc- 
tion and  experience  have  never  encountered  this  operation.  Since  the  diseases 
of  the  prostate  and  urethra  have  become  better  known,  retention  of  urine  is 
of  very  rare  occurrence,  and  when  it  does  happen  the  accuracy  of  anatomical 
knowledge  possessed  by  most  surgeons  of  the  present  day,  enables  them 
almost  always  to  overcome  it  through  the  medium  of  bougies  or  simple  cathe- 
terism.  It  may  so  happen,  however,  that  every  other  means  may  fail,  and 
we  maybe  reduced  to  select  between  forced  catheterism  and  puncturing; 
between  two  operations  of  equal  danger,  but  the  first  of  which  it  is  not 
within  every  body's  power  to  perform.  The  second  may  be  practised  in  three 
ways;  through  the  perineum,  through  the  rectum,  and  through  the  hypo- 
gastrium. 

Art.  1. — Perineal  Puncture  of  the  Bladder, 

Opening  the  bladder  through  the  perineum,  as  a  means  of  remedying 
ischuria,  must,  to  the  ancient  lithotomists  who  admitted  no  other  way  of 
extracting  calculi,  have  appeared  a  very  simple  operation.  Consequently  it 
was  the  first  proposed  and  for  a  long  time  the  only  one  followed.  Latta,  to  whom 
Soemmering  gives  the  credit  of  it,  is  no  more  the  inventor  of  perineal  puncture 
than  Garengeot,  who  claimed  fifty  years  previously.  It  is  expressly 
advised  by  Riolan  and  Thevenin,  and  Toilet  had  performed  it  in  1681. 
Dionis,  besides,  describes  it  very  lengthily,  and  proves  that  it  can  be  per- 
formed in  two  ways. 

An  incision  upon  the  raphe  an  inch  long,  as  if  for  the  apparatus  major, 
permitted  a  long  bistoury  to  be  plunged  Into  the  front  of  the  anus,  quite 
into  tlte  bladder ;  a  catheter  to  be  slipped  into  it  on  withdrawing  the  knife,  and 
a  canula  to  be  left  in  the  wound,  through  which  to  evacuate  the  urine.*  But 
Dionis  thought  that  it  would  be  better  to  extend  the  incision  a  little  out- 
Vv'ardly  as  in  Brother  Jacque's  method  of  performing  lithotomy,  so  as  to  save 
the  prostate.  Juncker,  Lapeyronie,  and  Heister,  all  about  the  same  time 
conceived  the  idea  of  substituting  a  long  trocar  for  the  bistoury,  which  tliey 
supposed  had  very  much  simplified  the  operation.  Thus  conducted,  it  is 
reduced  to  the  first  period  of  Foubert's  lateral  cutting  for  stone,  and  is 
done  in  the  same  manner ;  that  is  to  say,  they  buried  the  instrument  in  the 
middle  of  the  space  which  separates  the  ischium  from  the  raphe,  directing  a 
little  forwards  and  within,  so  as  to  fall  almost  perpendicularly  upon  the  neck 
of  the  bladder.  A  dread  of  straying,  in  passing  through  so  many  tissues, 
gave  rise  to  the  idea  of  cutting  the  perineum  with  a  bistoury,  and  of  using 
the  trocar  only  after  the  distended  bladder  had  been  felt  fluctuating  with  the 
finger,  Sabatier  has  endeavored  to  cause  this  modification  to  be  associated 
with  perineal  paracentesis,  as  Garengeot  had  indicated  it  for  lateral  cut- 


872  NEW    ELEMENTS    OF 

ting,  the  result  of  which  would  be  to  blend  the  procedures  of  Dionis  and 
.Tuncker.    But  this  advice  has  been  generally  overlooked.     Whilst  authors  in 
France  have  continued  to  recommend  pure  and  simple  puncturing,  surgeons 
in  England  have  ever  adopted  incision;  and  it  seems  to  have  been  practised 
there  in  divers  manners.     Sir  A.  Cooper,  following  the  steps  of  Dionis,  cuts  a 
little  upon  the  left  of  the  raphe,  depresses  the  bulb  with  his  left  fore -finger, 
and  then  the  prostate  to  the  right,  whilst  with  the  other  hand  and  a  sharp 
scalpel,  he  divides  the  tissues  and  enters  the  bladder.     Mr.  Charles  Bell, 
v/hen  he  thinks  it  practicable  to  find  the  urethra  behind  the  stricture,  opens 
the  canal,  as  in  Cheselden's  operation,  and  says  that  vie  arrive  at  the  urinary 
bladder  with  less'danger  in  this  way.     Mr.  Brander  advises  us  to  come  down  to 
it  layer  by  layer  ;  but  Jones  and  Dorsey  do  not  see  the  necessity  for  so  much 
caution.     Indeed,  I  do  not  think  that  either  of  these  shades  of  difference  has 
much  advantage  over  the  others.     If  puncturing  with  a  trocar  be  more  speedy, 
it  is  less  sure.     The  instrument,  though  safer  perhaps  for  the  vessels,  the 
lireters  and  vesiculffi  seminales,  which  it  would  rather  separate  than  divide, 
escapes  more  readily  between  the  different  organic  layers,  and  more  easily 
misses  the  bladder.     With  a  long  and  narrow  bistoury  we  must  next  pass  a 
catheter  and  afterwards  a  canula  into  the  collection  of  urine.     Though  less 
probable,  a  false  passage  is  still  possible,  and  a  wound  of  the  organs  which  we 
have  to  avoid  is  much  to  be  dreaded.     Incision,  properly  so  called,  is  most 
ra.tiona],  most  prudent,  and  at  the  same  time  most  difficult.     It  is  rendered 
more  delicate  and  uncertain  than  in  lithotomy,  because  of  the  want  of  a 
director,  which  cannot  be  passed  through   the  natural  passages;  and  this, 
v/hether  it  is  attempted  to  save  the  prostate  as  in  tlie  lateral  method,  or 
whether  we  penetrate  through  the  urethra.     Still,  as  in  such  cases  the  blad- 
der is  always  2;reatly  distended,  and  its  excretory  duct  much  enlarged  behind 
the  stricture,  if  I  am  ever  obliged  to  open  an  artificial  passage  for  urine,  I 
will  confine  myself  to  searching  for  the  urethra,  and  making  a  slit   in  it 
between  the  stricture  and  the  anus,  though  I  should  include  the  top  of  the 
prostate  in  my  incision.     The  opening  thus  made  would  have  the  double 
advantage  of  o-ivins;  entrance  to  the  catheter  and  canula,  which  we  mii>;ht 
wish  to  introduce  into  the  bladder,  and  of  giving  us  an  opportunity  to  attend 
directly  to  the  diseased  canal,  from  behind  forwards.     The  slit  of  which  I 
speak  is  neither  more  nor  less  dangerous  than  that  in  ordinary  lithotomy,  and 
is  certainly  much  less  so  than  many  other  species  of  punctures  ;  and,  if  I  am 
not  deceived,  is  of  such  a  nature  as  advantageously  to  supersede  them  in  all 
cases  in  which  a  morbid  or  abnormal  state  of  the  perineum  does  not  interfere 
to  prevent  our  reaching  the  urinary  passages  in  this  region. 

Art.  2. — Puncture  through  the  Rectum. 

The  projecting  cyst  which  the  bladder  forms  low  down  upon  the  rectum 
when  distended  by  urine,  sufficiently  justifies  the  idea  of  recto  vesical  punc- 
ture. It  is  indeed  Surprising  that  it  should  not  have  sooner  given  rise  to 
it;  for  by  caryini2;  the  finger  into  the  anus  it  must  have  been  very  often 
noticed.  Fleurant,  who  imagined  himself  the  inventor,  and  Pouteau,  his 
successor,  as  a  means  of  preserving  the  trocar  canula  in  the  part,  so  that 
they  might  not  be  obliged  to  perform    the  operation  again  if  the  natural 


operati\t:  surgery.  8rs 

passage  was  long  in  regaining  its  functions,  iiad  the  spoon  of  tlie  canula  of 
their  trocar  bent  at  a  right  angle  with  the  concave  side  of  its  stem.  By 
this  means  it  becomes,  as  it  were,  reversed  upon  the  perineal  conduit  in  front 
of  the  anus,  where  it  is  easily  fastened  in  such  a  way  as  not  to  interfere  with 
the  patient's  walking  or  sitting,  nor  with  the  alvine  discharges.  Most  of 
those  surgeons  who  advise  the  leaving  of  a  catheter  in  the  wound,  have 
adopted  the  instioiment  invented  by  the  Lyonnese  surgeon.  Those  who 
think  with  Hamilton  that  it  is  better  to  withdraw  it  at  once,  even  at  the  risk 
of  having  to  renew  the  puncture,  require  nothing  but  a  trocar  of  the  usual 
curve.  Beyond  this,  it  is  a  matter  of  but  little  consequence  whether  its 
point  be  flattened  and  of  a  lancet  shape,  or  triangular,  like  that  which  Mr. 
Howship  has  endeavored  to  bring  into  use  among  his  countrymen.  Perhaps 
a  straight  bistoury,  narrow,  and  guarded  by  a  strip  of  linen  around  its  blade, 
would  answer  the  same  end  with  less  risk  of  producing  fistula,  and  would 
penetrate  better  ;  but  it  is  not  as  easily  managed,  nor  so  convenient  for  intro- 
ducing a  canula  afterwards.  The  patient  is  made  to  assume  the  same  atti- 
tude as  for  lithotomy.  He  might,  in  strictness,  lie  with  his  abdomen  on  the  edge 
of  a  bed,  with  the  legs  pendant,  unless  such  a  posture  added  too  much  to 
his  sutferino-s.  If  so,  the  surgeon  would  need  no  assistants,  and  would  be 
more  at  ease  for  piercing  perpendicularly  the  bas-fond  of  the  bladder.  In 
either  case  the  fore  and  middle  fingers  of  the  left  hand,  besmeared  with  cerate 
or  some  fatty  matter,  are  introduced  into  the  rectum  to  reconnoitre  the 
vesical  projection  and  the  prostate  gland  ;  stretch  the  parts  by  diverging  from 
each  other  a  little,  and  then  are  held  firmly  at  some  distance  from  the  gland, 
the  palmar  aspect  being  turned  forwards,  their  fleshy  parts  or  the  nails  butting 
on  the  distended  cyst,  to  serve  as  gorget  or  director  to  the  trocar.  The  latter 
is  carried  in  with  the  right  hand,  its  concavity  forwards,  to  the  intestinal 
surface  of  the  trigoifal  space,  between  the  peritoneal  cul-de-sac  and  the  base 
of  the  prostate ;  it  is  then  passed  suddenly  in,  as  if  it  were  intended  to  be 
carried  towards  the  umbilicus,  that  is  to  say,  forwards  and  upwards  obliquely. 
When  its  point  has  overcome  the  resistance  and  has  entered  the  bladder,  a 
few  drops  of  urine  escape  by  its  lateral  gropve,  which  gives  the  assurance 
that  no  error  has  been  committed.  The  blade  of  the  trocar  is  then  with- 
drawn. The  urine  flows,  and  as  soon  as  the  bladder  is  emptied  the  operation 
is  over,  unless  we  adopt  the  plan  of  fixing  a  tube  in  the  wound.  In  that  case 
a, very  elastic  and  flexible  catheter,  wrapped  round  with  lint  that  it  may  be 
kept  motionless  upon  the  perineum,  with  the  assistance  of  a  T  bandage  and 
some  compresses,  is  preferable  to  the  canula  of  the  trocar,  which  however  will 
serve  to  direct  its  introduction.  It  is  nevertheless  doubtful,  whether  such  a 
tube  be  necessary  at  all.  In  Hamilton's  patient  the  wound  re-opened  of  itself. 
Even  if  it  did  not,  a  second  puncture  would  be  attended  probably  with  less 
inconvenience  than  would  result  from  the  long  continued  presence  of  a 
foreign  body  in  the  bladder  and  rectum.  Finally,  it  would  be  useless  at  any 
rate,  to  leave  the  canula  in  longer  than  is  necessary  for  the  cohesion  of  tissues, 
that  is  to  say,  beyond  four  and  twenty  hours,  for  the  inflammation  which 
surrounds  the  little  wound,  although  it  puts  no  serious  obstacle  in  the  way 
of  the  issue  of  urine,  still  no  longer  allou^  of  its  infiltration  into  the  meshes 
of  the  recto-vesical  septum. 

110 


874  KEW   ELEMENTS   OF 


Jirt,  3. — Hypogastric  Puncturing  the  Bladder. 

The  very  opposite  statements  published  in  the  last  century  by  MM.  Hoin 
and  Noel,  on  the  subject  of  this  operation,  prove  that  puncture  above  the 
pubis,  which  ought  to  have  originated  about  the  same  time  as  hypogastric  cutting 
for  stone,  had  at  that  time  but  very  few  advocates.  Tolet,  Drouin,  Turbier, 
Mery,  Morand,  and  a  small  number  of  others,  were,  according  to  M.  Belmas, 
the  only  ones  who  had  performed  it.  But  the  authority  of  Brother  Come,  of 
Bonn,  Paletta,  and  of  Soemmering  especially  who  became  publicly  one  of 
its  most  strenuous  patrons,  ultimately  succeeded  in  bringing  it  into  vogue  in 
Europe,  in  spite  of  the  efforts  of  Murray  and  Mursinna  to  establish  that 
through  the  rectum.  In  France  it  is  the  only  one  which  for  a  long  time  past 
has  been  performed.  The  case  of  intestinal  puncture  which  is  contained  in 
the  thesis  of  M.  Duplat,  and  the  two  examples  which  have  been  contributed 
by  M.  Cabanell  from  the  practice  of  M.  Magnan,  are  rare  exceptions  which 
escape  attention. 

The  straight  trocar  originally  employed  being  liable  to  wound  the  organ 
behind  it,  and  the  beak  of  the  canula,  if  left  to  remain  in,  being  capable  of 
ulcerating  the  posterior  wall  of  the  bladder,  as  it  contracts  upon  itself  after 
the  evacuation  of  its  contents,  the  curved  trocar  of  F.  Come  has  been  gene- 
rally adopted,  whether  puncture  is  performed  without  previous  incision,  or 
whether,  after  the  method  of  Abernethy,  the  hypogastric  paries  is  cut  through 
with  a  bistoury  before  the  trocar  is  employed.  However,  the  operation 
is  really  so  easy  that  the  previous  incision  seems  an  unnecessary  complication 
of  it.  The  patient  is  made  to  lie  horizontally  upon  the  right  edge  of  his  bed. 
The  surgeon  feels  for  the  upper  edge  of  the  pubis  and  the  median  line;  applies 
the  point  of  his  trocar  at  about  an  inch  above  the  symphyses ;  plunges  it  in  at 
a  single  blow,  from  above  downwards,  and  from  before  backwards  to  the 
bladder,  which  it  reaches  after  a  course  which  varies  according  to  the  embon- 
point of  the  patient,  and  individual  peculiarity  of  structure.  The  blade 
of  the  trocar  being  withdrawn  urine  flows  out,  and  the  canula,  which  is  closed 
with  a  plug,  is  afterwards  fastened  around  the  body  by  means  of  strings  which 
are  attached  to  the  lateral  parts  of  its  handle.  But  the  canula  is  by  tkr  more 
dangerous  above  the  pubis  than  in  the  rectum.  When  it  is  too  long  it  causes 
ulceration  of  the  organ  ;  when  too  short  its  beak,  separated  from  the  bladder 
by  the  retraction  of  that  organ,  enters  the  surrounding  cellular  tissue  and 
remains  there.  If  it  be  not  often  changed  it  may  become  encrusted  with 
calculous  conci-fetions  and  is  not  easy  to  remove.  Having  withdrawn  it,  it  is 
not  always  easy  to  replace  it.  The  gumelastic  catheter  carried  into  the 
reservoir  of  urine  through  the  metallic  canula,  and  which  is  left  in  instead  of 
the  other,  being  of  smaller  diameter  does  not  completely  fill  the  wound,  and 
allows  of  urine  flowing  between  the  tissues  and  the  foreign  body.  The 
flexible  sheath,  acting  as  a  chemise  to  the  instrument  which  is  made  to  penetrate 
by  M.  Jules  Cloquet,  in  such  a  way  as  that  on  withdrawing  the  trocar  to  let 
the  urine  flow  out,  and  then  the  canula  afterwards,  it  is  alone  left  within  the 
solution  of  continuity,  is  but  an  imperfect  remedy  for  the  inconvenience.  It 
must  always  be  shorter  than  the  metallic  tube,  upon  the  outer  surface  of 
which  its  lower  extremity  always  forms  a  projecting  circle  of  more  or  less 


OPERATIVE    SURGERY.  875 

irregularity,  no  matter  what  be  done  to  thin  and  smooth  it.  Thence  originates 
a  series  of  elevations,  or  knobs,  which  it  is  more  difficult  to  act  on  through  the 
tissues.  It  would  be  erroneous  again  to  suppose  that  a  tube  will  long  remain 
in  close  contact  with  an  incision,  the  outline  of  which  is  precisely  the  same 
as  its  own  circumference.  Indeed  this  is  no  longer  so  after  the  lapse  of  a 
few  hours,  and  the  fluids  pass  readily  between  the  canula  and  the  wound. 
Of  this,  bougies  and  catheters  in  the  urethra  every  day  give  proof,  and  I 
saw  it  verified  at  the  hospital  St.  Louis  in  1822,  in  the  patient  whose  case 
gave  rise  to  the  above  change  in  the  instrument.  All  these  reflections  go 
to  favor  the  reasoning  of  those  who  advise  that  nothing  be  left  in  the  wound ; 
and  who  prefer,  in  case  of  necessity,  to  repuncture  the  bladder  after  it  has  a 
second  time  become  distended.  I  should  entirely  coincide  in  their  opinion 
were  it  not  that  the  more  speedy  approximation  of  the  puncture  in  the  abdo- 
minal parietes  than  that  of  the  bladder,  exposes  to  the  risk  of  the  filtration 
of  a  few  drops  of  urine  into  the  pelvic  cellular  tissue,  and  if  the  inflammatory 
state  of  the  wound  were  not  at  the  end  of  a  few  hours  changed  to  one  of  a 
fistulous  character. 

A  patient  upon  whom  I  performed  it  twice  in  three  days,  died  on  the  sixth 
of  peritonitis,  which  in  him  however,  evidently  existed  before  tha  puncture. 
A  blackish  abscess  of  limited  extent  was  visible  between  the  forepart  of  the 
bladder  and  the  bottom  of  the  hypogastrium. 

Art.  4. — Reciprocal  advantages  and  inconveniences  of  the  different  species 

of  Puncture. 

Each  species  of  the  vesical  paracentesis  has  in  its  turn  been  lauded  or 
proscribed  to  the  exclusion  of  either  of  the  others,  and  according  to  custom 
the  strict  truth  has  almost  always  been  exceeded.  Recto-vesical  puncture, 
thoujj-h  not  as  terrible  as  Soemmerins;  asserts,  is  far  from  beino;  as  safe  as  it  is 
pretended  by  Murray.  Tumors  in  the  neighborhood  of  the  anus,  the  thickness 
of  the  septum  at  the  entrance  to  the  intestine,  may  render  it  of  painful  and 
doubtful,  or  of  impossible  execution.  The  instrument  may  escape  into  the 
cellular  tissue  of  the  pelvis,  between  the  bladder  and  rectum,  and  open  the 
peritoneum  when  this  membrane  descends  considerably  towards  the  prostate; 
or,  when  tlie  puncture  is  made  a  little  too  high  up,  it  may  wound  the  vasa 
deferentia,  the  vesiculae  seminal es,  or  even  the  ureters,  if  it  be  made  laterally 
or  too  low.  The  organ  being  wounded  very  near  the  urethra,  and  con- 
sequently to  the  seat  of  disease,  werunin  this  respect  great  risk  of  increasing 
the  danger.  Lastly,  the  wound  may  remain  fistulous,  allow  of  the  entrance 
of  stercoraceous  moisture  into  the  bladder,  and  give  rise  to  symptoms  which 
may  prove  fatal.  It  is  true  that  the  greater  part  of  these  difficulties  will  be 
most  frequently  overcome  by  a  skillful  operator,  and  that  the  unpleasant  con- 
sequences of  which  I  have  just  spoken  are  not  all  unavoidable.  Fistula, 
however,  the  occurrence  of  which  no  skill  or  knowledge  on  the  part  6f  the 
operator  can  prevent,  as  is  proved  by  the  observations  related  by  Bonn,  Paletta, 
Angeli,  and  others,  is  of  itself  a  very  serious  aff*ection,  and  its  cure  is  too 
difficult  to  permit  us  to  incur  the  risk  of  inducing  it  whenever  it  is  possible 
to  avoid  it.  In  exchange  for  so  many  objections,  puncture  through  the  in- 
testine has  the  advantage  of  being  generally  easy,  of  bearing  upon  the  bladder 


876  NEW  ELEMENTS  OF 

at  its  most  depending  point,  of  passing  through  but  a  smali  extent  of  tissues, 
and  those  tissues  of  too  dense  a  nature  to  create  much  dread  of  urinal  infil- 
tration or  abscess,  which  have  nevertheless  been  sometimes  observed,  particu- 
larly in  one  patient  mentioned  by  M.  Nauche,  of  rendering  the  use  of  a  canula 
easy  and  of  not  confining  the  patient  rigidly  to  his  bed. 

Super-pubic  Puncture  is  unsuited  to  cases  of  retention  caused  by  bruises, 
inflammation,  or  tumors  of  the  hypogastric  region.  It  must  needs  give  rise 
more  than  any  other  to  infiltration  and  to  abscess.  The  bladder  being  opened 
upon  its  anterior  surface,  is  emptied  with  difficulty  and  does  not  bear  the 
presence  of  the  canula  as  well.  We  are  obliged  sometimes  to  go  to  a  great 
depth  to  find  the  organ,  and  the  peritoneum  is  not  entirely  sheltered  from 
danger.  But  there  are  no  fistula  to  be  feared,  for  even  if  the  wound  should 
assume  this  character  there  would  be  no  cause  for  anxiety.  The  peritoneum, 
crowded  over  from  the  pubis  by  the  sole  effort  of  the  distended  bladder,  it  is 
easy  to  avoid,  and  to  miss  piercing  the  bladder  with  the  trocar  is  next  to 
impossible.  The  operation  is  still  easier  than  that  per  rectum,  and  not  more 
painful  than  tapping  the  abdomen  ;  it  acts  upon  a  part  of  the  organ  which  is 
not  altered  in  structure,  irritable  or  irritated. 

Puncturing  through  the  perineum  is,  beyond  comparison,  more  uncertain 
than  that  through  the  hypogastrium ;  and  endangers  the  urethra,  or  vesicula 
seminales,  as  does  that  through  the  rectum.  It  may  be  done  too  far  forward, 
between  the  pubis  and  bladder;  or  too  far  backward,  and  enter  the  peritoneal 
cul-de-sac  or  the  intestine;  or  it  may  enter  the  bladder  by  lacerating  its 
parietes.  The  vessels  of  the  perineum  and  the  prostate  ghmd,  are  neither  of 
them  secure  from  injury  by  the  instrument.  Abscess  and  infiltration  are  not 
impossible,  and  the  presence  of  a  catheter  is  no  where  more  annoying. 

The  sole  advantages  of  this  puncture  are,  that  it  opens  the  bladder  in  a 
depending  part,  without  exposing  to  fistula?,  as  that  through  the  rectum;  it 
makes  an  easier  exit  for  urine,  and  does  away  with  much  of  the  danger  of 
urinal  inflammation,  incurred  by  that  above  the  hypo,2;astrium.  Tiiough  few, 
these  are  important  advantages,  and  but  that  they  must  be  bought  so  dear,  and 
if  they  were  real,  perineal  puncture  would  bear  away  the  preference  over  the 
other  two.  Now  to  me  it  seems  that  a  mere  slit  in  the  urethra  is  better  than 
either  of  them,  and  enables  us  to  avoid.neighboring  organs  with  every  certainty. 
As  it  is  no  otherwise  objectionable  than  that  it  is  rather  more  delicate  and 
rather  less  speedy,  I  think  it  preferable  every  time  that  the  shape  or  texture 
of  the  perineum  is  not  too  much  changed  from  a  normal  state,  and  where  the 
person  who  is  to  perform  it  has  some  experience  in  surgical  operations. 

In  other  cases  super-pubic  puncture  should  receive  the  preference,  and 
recto-vesical  tapping  be  reserved  for  occasional  exceptions,  and  for  circum- 
stances which  prevent  special  obstacles  to  the  passage  of  instruments  through 
the  natural  passage. 

As  to  penetrating  from  before  backwards  through  the  symphysis,  which 
Mr.  Brander  advises,  and  states  himself  to  have  performed,  it  is  a  method 
which  will  meet  doubtless  vvitli  but  few  defenders ;  first,  because  after  matu- 
rity it  would  be  often  next  to  impossible  ;  and,  secondly,  because  it  would  be 
no  safer  on  the  score  of  infiltration  than  hypogastric  puncture.  It  would  be 
rash  also  to  practice  puncturing  the  bladder  without  some  urgent  indication; 
as,  for  example,  for  a  retention  caused  by  a  mere  spasm  of  the  urethra,  of 


OPERATIVE    SURGERY.  S77 

%vhic]i  M.Racine  mentions  two  cases;  for  the  supposed  spasmodic  contrac- 
tion to  which  Mr.  Holbrook  has  recently  directed  professional  attention ;  but 
to  M'-ait  too  long  would  also  add  to  the  danger.  The  bladder  of  a  person  who 
has  not  made  water  for  twenty-four,  thirty-six,  or  forty-eight  hours,  being 
distended  to  an  excessive  degree,  may  give  way  and  even  burst.  Pain,  fever, 
and  a  partial  entrance  of  the  urine  into  the  circulation,  soon  throw  the  patient 
into  so  alarming  a  condition  that  puncture  can  no,  longer  avail  in  saving 
his  life,  nor  prevent  a  host  of  occurrences  which  a  few  days  before  might  have 
been  avoided.  The  observation  just  cited,  is  my  own,  and  furnishes  new 
proof. 


SECTION   V. 
Urinary  Fistulae. 

Recto-vesical  fistulae,  which  are  no  less  dangerous  and  still  more  unyield- 
ing than  those  in  the  vesico  vaginal  septum,  are  healed  in  the  same  manner  by 
similar  procedures.  The  surgeon,  however,  always  commences  by  restoring 
the  urethra  to  its  natural  dimensions,  when  it  is  strictured  ;  by  depressing  the 
prostate  gland  with  the  assistance  of  the  redressor,  an  instrument  contrived 
by  MM.Tanchou,  Pravaz,  and  Leroy,  when  its  size  is  such  as  to  impede  the 
iiow  of  urine;  and  by  destroying  all  obstacles  which  the  bladder  may  ex- 
perience towards  ridding  itself  by  the  natural  passage.  Desault  cured  recto- 
vesical fistula  following  cutting  for  stone,  by  incising  all  the  parts  situated 
between  the  wound  in  the  perineum  and  that  in  the  intestine,  including  the 
sphincter  ani,  so  as  to  lay  the  whole  into  one  incision.  But  if  the  first  incision 
had  long  been  healed,  either  this  procedure  would  be  applicable,  or  would 
require  some  modification.  We  might  in  such  a  case  advantageously  imitate 
the  method  of  Sir  Astley  Cooper,  who  re-opened  the  prostatic  portion  of  the 
urethra  upon  a  catheter,  through  the  perineum,  and.  from  before  backwards, 
so  that  the  urine  having  issue  anteriorly  might  allow  of  the  closure  of  the 
posterior  orifice  ;  and  entirely  succeeded  by  it  in  one  case.  Ai» incision  with  a 
bistoury,  drawn  out  from  the  fistula  to  the  perineum,  upon  the  groove  of  a  staft' 
as  in  the  recto-prostatic  operation  for  stone,  would  be  easier  and  surer  than 
Desault's  oblique  operation,  if  Sir  A.Cooper's  did  not  seem  likely  to  suffice; 
but  it  exposes  the  veru-montanum  and  ejaculatory  canals  to  injury. 

Fistulse  which  are  of  the  kidneys,  the  ureters,  the  top  or  face  of  the 
bladder,  which  do  not  open  exteriorly,  or  are  within  the  intestines  beyond 
the  reach  of  instruments,  can  derive  no  succor  from  surgery,  unless  they  de- 
pend upon  some  impediment,  such  as  a  calculus  or  a  stricture,  for  example, 
which  might  either  be  removed  or  destroyed.  Fistulae  at  the  umbilicus,  owing 
to  a  continuance  of  the  urachus,  are  of  the  same  kind. 

Spontaneous  Cure. — In  the  urethra  it  is  not  always  so.  In  the  pars  spon- 
giosa  they  rarely  fail  to  disappear  spontaneously,  after  care  has  been  taken  to 
restore  the  natural  dimensions  of  the  canal.  Towards  the  fossa  navicularis 
at  which  M.  Barthelemy  has  seen  them  open,  like  the  top  of  a  watering 
pot,  on  the  gland,  they  will  be  closed  almost  with  certainty  by  confining  the 
patient  to  urinating  for  several  days  through  a  catheter,  as  was  done  by  that 


878  NEW  ELEMENTS  OF 

surgeon ;  and  moreover,  by  taking  care  every  time  that  the  bladder  is  being 
emptied,  to  place  the  finger  firmly  behind  the  glans  so  as  to  keep  the  canal _ 
closely  applied  against  the  instrument. 

Injectiona.      Cauterization. — Fistulas  of  the  bulbous,  membranous,  and 
prostatic  portions,  usually  most  frequent  and  most  obstinate,  are  the  only 
ones  which  merit    special   attention.      The   first   and  only  course  to  be 
adopted,  whether  there  be  one  or  several  external  apertures ;  whether  they 
be   sinuous  or  straight;    whether  they  go  to  terminate  at  a  long  distance 
from  their  starting  point  towards  the  scrotum,  in  the  groin,  in  the  nates,  in  the 
anus,  on  the  inner  part  of  the  thigh,  at  the  extremity  of  the  labia  majora  in 
the  female ;  whether  they  stop  at  the  perineum ;  is  to  sound  the  urethra  and 
destroy  all  its  strictures.     If  they  resist  this  preliminary  treatment,  recourse 
must  be  had  to  irritating  injections  with  alcohol,  vinegar,  the  dilute  mineral 
acids,  to  caustic,  the  nitrate  of  silver,  to  troches  of  the  deutoxide  of  lead,  of 
nitrate  of  mercury,  to  compression,  and,  in  a  word,  to  the  different  medica- 
tions used  in  cases  of  fistula  generally,  and  which  properly  appertain  to  the 
science  of  chirurgical  pathology.     If  they  still  remain  incurable  and  sinuous, 
they  must  be  cut  into,  and  their  fundus  laid  bare ;  after  which  derivative 
catheterism,  a  re-application  of  caustic  and  suture,  can  alone  effect  their  cure. 
Some  few,  resisting  every  method,  end  in  time  by  getting  well  of  themselves. 
Of  this  I  have  just  seen  a  fresh  and  remarkable  example  in  the^case  of  a  dis- 
tinguished physician  who,  having  exhausted  every  means  of  treatment  pointed 
out  to  him  by  MM.  Boyer,  Dubois,  Dupuytren,  Richerand,  Marjolin,  Roux, 
Cloquet,  and  myself,  recovered  in  this  way. 

Derivative  Catheterism  succeeds  only  in  those  fistulas  in  which  there  is 
either  no  loss  of  substance  at  all  or  very  little,  whether  preceded  by  stricture 
of  the  urethra  or  not.     Neither  the  permanent  gumelastic  catheter,  the  S 
shaped  catheter  which  J.  L.  Petit  employed,  that  with  a  fixed  curve  such  as 
Mr.  Hey  recommended,  the  strongly-curved  instrument  advised  by  Dr.  Phy- 
sick  when  there  exists  engorgement  of  the  prostate,  nor  the  flexible  one  which 
maybe  directed  at  pleasure,  which  since  Desault  has  been  generally  employed 
in  France,  are  always  without  their  inconveniences.     If  they  remain  open  so 
that  the  urin%may  run  off  as  fast  as  it  is  deposited  from  the  ureters  in  the 
bladder,  the  point  resting  against  the  posterior  paries  of  the  organ  irritates 
and  ulcerates  it,  even  perforating  it  sometimes.    If  they  are  kept  closed  the 
small  quantity  of  urine  which  almost  always  passes  them  and  the  walls  of  the 
urethra,  suffices,  in  most  cases,  to  prevent  the  obliteration  of  the  fistula.    This 
fact  was  well  established  by  M.  Asselin  in  his  thesis  in  the  year  1803.    It  is 
better,  therefore,  to  pass  the  catheter  every  time  the   patient  desires   to 
urinate,  or  better  still,  let  him  learn  to  pass  it  himself,  giving  the  prefer- 
ence to  a  silver  instrument.     A  patient  whom,  without  success,  I  treated 
with  catheters  permitted  to  remain,  in  1830,  at  La  Pitie,  recovered  entirely 
in  three  days  after  I  began  to  have  tliem  passed  every  four  or  six  hours,  and 
afterwards  withdrawn.     Caustic  may  be  combined  with  catheterism ;  and 
indeed,  where  the  cure  is  protracted  for  a  week  or  two,  becomes  indispen- 
sable.    If  the  disease  continues  after  a  lapse  of  six  weeks  or  two  months,  we 
may,  without  incurring  censure  for  our  precipitation,  resort  to  the  last  chances 
left. 

Suture  is  performed  upon  this  as  upon  every  other  part  of  the  body.    We 


OPERATIVE   SURGERY.  879 

begin  by  making  a  slit  of  the  fistula  of  an  elongated  form,  more  towards  tlie 
integuments  however  than  towards  the  wall  of  the  urethra.  Having  stimu- 
lated the  edges  and  removed  their  callous  portions,  and  having  brought  them 
together  over  a  flexible  catheter,  destined  to  remain  permanent,  they  are 
maintained  in  the  most  perfect  apposition  possible,  by  means  of  a  suflicient  num- 
ber of  small  points  of  the  twisted  suture ;  the  points  should  not  be  more  than 
three  or  four  lines  apart,  if  we  do  not  wish  to  see  the  urine  oozing  through 
them,  and  should  for  the  same  reason  be  so  tight  as  to  effect  immediate  adhe- 
sion. We  then  apply  over  the  perineal  fissure,  some  lint  and  compresses, 
and  support  the  whole  by  moderate  pressure.  If  all  does  well,  we  take  out 
the  pins  on  the  fourth  or  fifth  day,  beginning  with  those  at  the  angles  of  the 
wound.  The  catheter  is  left  in  a  day  or  two  longer.  This  is  in  turn 
removed,  and  the  patient  is  cured.  M.  Cloquet  has  recently  been  success- 
ful in  a  procedure  of  this  kind.  Unfortunately,  as  the  fruitless  attempts  of 
Mr.  Charles  Bell  too  clearly  demonstrate,  one  is  not  always  so  fortunate.  It 
becomes  frequently  necessary  to  repeat  the  operation  often ;  nor  even  then 
is  it  rare  to  see  all  the  skill  of  the  surgeon  and  the  patience  of  the  patient 
terminate  in  an  increase  of  the  size  of  the  fistula. 

Urethraplastic  Method. — When  the  loss  of  substance  is  at  all  extensive, 
simple  suture  is  seldom  indeed  sufficient.  The  modification  invented  by  M. 
Dieft'enbach,  which  is  as  applicable  in  other  cases  as  in  this,  may  be  of  essen- 
tial service.  Proceeding  on  the  Celsian  precepts  for  the  hare-lip  operation, 
this  surgeon  makes  an  incision  longer  or  shorter  on  either  side,  an  inch 
or  half  inch  beyond  the  ulcer,  which  should  extend  as  far  as  the  apone- 
urosis. Then  having  performed  suture  in  the  usual  way,  the  result  is 
great  relaxation  of  the  old  sore,  the  agglutination  of  which  there  is  now 
nothing  to  impede.  When  this  is  aff*ected,  the  lateral  incisions  heal  like  any 
other  simple  wound.  In  this  way  M.  Dieffenbach  has  at  the  Charitc  of 
Berlin,  cured  fistulae  over  which  no  other  treatment  could  triumph,  and  I 
think  his  conduct  well  deserving  of  imitation.  But  it  would  be  wrong  in 
any  one  so  much  to  exaggerate  its  value  as  to  regard  it  as  of  never  failing 
success.  The  very  great  distinction  of  tissues,  such  as  we  see  consequent 
upon  gangrene  of  the  scrotum,  perineum,  certain  operations,  &.c.  will  continue 
to  require  something  more  than  this.  The  only  chance  of  recovery  then 
offered  is  from  the  recto  plastic  "method.  It  was  tried  in  London  once  by 
Sir  A.  Cooper  and  succeeded  ;  by  him  again  another  time  and  it  failed.  Mr. 
Earle  performed  it  twice  upon  the  same  individual,  who  ultimately  got  well. 
In  France,  I  believe  the  only  person  who  has  attempted  it  is  M.  Delpech ;  yet 
in  spite  of  his  acknowledged  skill  as  an  operator,  and  although  the  operation 
was  frequently  repeated  in  the  same  individual  at  different  times,  the 
fistula  continued  open.  Instead  of  taking  a  portion  of  integument  from 
towards  the  scrotum,  or  from  the  sides  of  the  penis,  as  has  been  done  by 
English  surgeons ;  or  borrowing  it  from  the  groin  or  inner  surface  of  the 
thigh,  as  the  professor  at  Montpelier  preferred  to  do,  which  he  might  turn 
over  and  fasten  to  the  re-animated  edges  of  the  fistula  by  means  of  simple 
suture ;  it  would  be  perhaps  better  to  follow  the  advice  of  M.  Roux,  for  the 
cheiloplastic  of  M.  Dieffenbach,  for  the  rhinoplastic  methods ;  to  act,  in  a 
word,  by  dissection  and  re -approximation,  rather  than  by  turning  over  of 
points.    If  so,  the  fistula  being  arranged  as  if  it  were  intended  to  perform 


880  NEW   ELEMENTS   OF 


common  suture,  its  two  edges  are  to  be  dissected  alternately  from  withir 
outwardly,  to  an  inch  more  or  less  towards  the  root  of  the  thighs  in  such  a 
way  as  to  form  flaps,  which  are  to  be  made  as  thick  as  possible.  The  edges 
are  then  to  be  stimulated  either  by  the  use  of  a  bistoury,  or  of  good  scissors: 
and  are  then  coaptated  either  with  simple  or  twisted  suture.  Graduated  com- 
pression exercised  laterally  upon  them,  will  keep  them  closely  applied  against 
the  subjacent  tissues,  and  will  guard  against  the  infiltration  of  urine.  Expe- 
rience, however,  has  not  yet  decided  in  favor  of  this  method  of  operation,  and 
consequently  I  shall  not  go  more  largely  into  its  detail.  I  must  say  the  same 
of  the  procedure  of  which  I  spoke  when  upon  the  bronchoplastic  method, 
and  afterwards  of  hernia  ;  because,  having  not  yet  practised  it  in  a  case  of 
urinary  fistula,  I  can  only  look  upon  it  as  one  very  likely  to  succeed. 

Congenital  Urethral  Fistulse,  near  to  the  glans,  admit  of  no  other  operation 
than  the  creation  of  a  new  canal  in  the  thickness  of  the  penis,  which  was  once 
performed  by  M.  Rublach,  and  with  success. 


CHAPTER    VI. 

THE  ORGAN  OF  DEFECATION. 
SECTION  I. 

Defects  of  Structure. 

Art.  1. — Imperforation, 

It  is  common  in  nevy'ly  born  children  to  see  the  rectam  open  into  the 
bladder  or  vagina,  into  the  perineal   portion  of  the  urethra,  or  towards  the 
posterior  part  of  the  vulva,  instead  of  ending  at  its  proper  aperture,  the  anus 
in  front  of  thp  coccyx.     Still  more  frequently  it  ends  in  a  cul-de-sac,  above 
its  natural  termination,  more  or  less  high,  up  in  the  pelvis.     The  first  cases 
belong  to  the  category  of  unnatural  anus,  and  are  coeteris  paribus,  less  inevi- 
tably fatal  than  the  second.    The  meconium  infused  into  the  bladder   is 
softened  there  and  diluted,  and  may  pass  from  it  for  some  days.     A  child 
vv^hom  I  saw  that  passed  it  per  urethram,  lived  nearly  a  week.     The  orifice 
of  the  receptacle,  and  the  size  of  its  excretory  duct,  are  so  small  however 
that  when  the  fecal   matter  acquires  mucii  consistency,  life    cannot  be 
supported,  because  the  urinary  organs  cannot  long  endure  without  danger 
the  immediate  contact  of  stercoraceous  substances.     Recto -vaginal  anus, 
recto-vulvar  anus,  and  indeed  all  external  anuses  resulting  from  defects  of 
conformation,  are  disgusting  infirmities,  but  do  not  necessarily  cause  death. 
But,  on  the  contrary,  where  the  intestine  is  devoid  of  opening  entirely,  or 
opens  into  an  organ  which  has  no  outlet  externally,  the  child  sinks  rapidly. 
In  either  case  art  has  but  two  resources  to  oppose ;  1st,  to  re-establish  the 
anus  in  its  natural  situation  ;  2d,  to  create  one  artificially  in  some  part  of 
i}iiQ  abdominal  cavity. 


OPERATIVE  SURGERY.  881 


§  1.  Re- establishment  of  the  Natural  Anus. 

To  re-establish  an  anus  which  is  closed  only  bj  the  integuments,  or  by  a 
layer  of  tissue  not  more  than  a  few  lines  thick,  is  not  an  operation  of  any 
difficulty.  A  projection  or  a  bluish  spot  usually  point  out  its  situation,  and 
the  obscure  fluctuation  which  is  at  times  perceived  by  the  fore-finger,  allows 
of  our  proceeding  fearlessly.  Instead  of  surrounding  it  by  a  circular 
incision,  as  Levret  advises,  the  surgeon  passes  the  point  of  a  straight  bistoury 
or  a  trocar,  in  at  the  middle  of  the  spot,  in  the  direction  of  the  rectum,  until 
he  comes  to  the  meconium  ;  then  enlarges  the  puncture  in  its  antero-posterior 
direction,  and  transversely  cuts  away  the  four  flaps  thus  made ;  places  in  the 
opening  a  pledget  or  tent  of  lint,  or  ^  suppository  of  some  sort,  to  prevent  it 
from  closing ;  and  continues  dressing  it  with  dilating  substances  until  it  has 
entirely  healed.  Many  successful  results  have  been  obtained  in  this  way, 
and  in  like  cases  no  one  should  hesitate  to  adopt  it.  The  same  operation 
would  be  required  if,  the  anus  existing,  the  rectum  were  closed  by  a  septum 
some  way  up.  Only  it  might  then  be  proper  to  surround  the  bistoury  with  a 
stripof  linen,  unless  we  preferred  J.  L.  Petit's  trocar  or  M.  Martin's  pharyn- 
gotome.  In  these  cases  it  is  not  practicable  to  excise  the  angles  of  the 
conical  incision. 

It  would  be  easy  to  re-establish  an  anus  opening  at  the  fourchette,  a  case  of 
which  in  a  little  girl  M.  Brachet  has  just  published.  All  the  tissues  which 
have  kept  up  the  deviation  from  the  natural  course  may  be  divided  by  a 
straight  bistoury  passed  into  the  intestine  through  the  fistula  upon  a  director, 
and  withdrawn  from  before  backwards,  or  from  the  perineum  towards  the 
coccyx,  and  from  above  downwards.  A  canula  fastened  in  the  rectum  and 
carried  up  as  far  as  into  the  posterior  angle  of  the  wound,  will  allow  the 
solution  of  continuity  to  heal  in  front,  and  enable  the  fecal  matters  to  re- 
sume their  normal  direction.  Vicq  d'Azyr  has  recommended  the  same 
operation  for  vaginal  anus;  and  the  advice  of  Mr.  Martin  is  to  divide,  first, 
the  whole  septum  from  above  downwards,  and  from  before  backwards,  as 
previously  mentioned  ;  then  to  place  the  canula  in  such  a  way  as  that  supe- 
riorly it  shall  go  a  little  beyond  the  fistula;  and  afterwards  to  re-unite  the 
wound  by  means  of  stitches  on  its  anterior  surface.  This  last  step  in  the 
operation,  by  far  the  most  difficult,  does  not  seem  to  me  to  be  necessary.  If 
the  tube  which  is  to  carry  off  the  fecal  matters  from  the  fistulous  orifice,  be 
suitably  placed,  the  divided  tissues  will  unite  very  well  without  (he  interven- 
tion of  stitches. 

There  exists,  moreover,  another  mode  of  avoiding  this,  and  arriving  at  the 
same  result  with  a  less  inconvenience,  viz.  to  ascertain,  by  means  of  a  blunt 
instrument  curved  like  a  crotchet,  introduced  into  the  fistula  from  above 
downwards,  how  low  the  intestinal  sac  descends,  and  to  enter  the  rectum  by 
puncturing  from  the  skin  towards  the  pelvis  without  any  division  of  the  recto- 
vaginal septum. 

In  children  of  the  male  sex  we  have  not  the  same  resource.  The  exit  of 
meconium  only  at  the  moment  of  the  flow  of  urine,  though  a  proof  of  the  ex- 
istence of  an  entero-vesical  anus,  neither  points  out  the  precise  '&^At  or 
direction  of  the  end  of  the  rectum.  If  it  escape  incessantly,  or  at  intervals, 
111 


8B2  NEW    ELEMENTS   OF 

without  any  ad  mixture  of  urine,  it  may  be  presumed  that  the  aperture  is  in  the 
urethra ;  and  although  it  may  not  always  be  discoverable  whether  it  be  a  short 
way  from  the  glans,  as  seen  by  M.  Cruveilhier,  or  more  deep  towards  the 
perineum  as  is  oftenest  the  case,  we  have  yet  some  right  to  expect  success 
from  methodically  puncturing  where  the  rectum  ought  to  be.  In  the  first 
case,  and  in  those  likewise  in  which  externally  nothing  exists  to  lead  to  any 
suspicion  of  the  state  of  parts  within,  the  operation  being  undertaken  in  a 
measure  at  random,  naturally  offers  a  less  chance  of  success.  It  would  be  a 
remedy  at  least  as  disgusting,  if  not  as  dangerous,  as  the  disease  itself,  to  cut 
into  the  perineum  and  neck  of  the  bladder  as  in  operating  for  stone,  for  the 
purpose  of  making  a  large  aperture  common  both  to  feces  and  urine,  in  cases 
where  the  intestine  had  its  outlet  with  that  of  the  bladder. 

The  child  upon  which  M.  Cavenne  of  Laon,  thought  proper  to  perform  it, 
died  the  same  evening;  and  M.  Martin  of  Lyons,  who  proposed  it,  never 
probably  reflected  that  as  the  operation  left  the  recto-vesical  anus  in  its  state 
of  original  contraction,  it  would  not  even  be  advantageous  in  prolonging  the 
life  of  the  new  born  infant. 

The  only  method  which  has  thus  far  been  attended  with  any  success,  is  to 
go  in  search  of  the  intestine  through  the  tissues  by  wliich  it  is  separated  from 
the  skin.  The  child  is  to  be  held  upon  the  knees  of  an  assistant,  or  on  a 
covered  table,  with  its  limbs  separated  and  bent.  The  surgeon  facing  it 
examines  the  groove  between  the  nates,  or  the  interperineal  fissure,  if  it  exists ; 
and  if  he  discerns  no  trace  of  intestine  or  anus,  endeavors  to  detect  the  point 
of  the  coccyx ;  places  the  centre  of  this  cut  about  ten  lines  forward  of  that 
bone  ;  first,  divides  the  skin  to  an  extent  of  from  ten  to  twelve  lines,  and  then 
successively  the  tissues  beneath  to  a  depth  of  one  or  two  inches,  that  is,  until 
he  comes  to  the  intestinal  cul-de-sac,  if  any,  or  until  he  abandons  all  hope  of 
finding  one.  The  left  fore-finger,  which  acts  all  the  time  as  a  guide  to  the 
paint  of  the  bistoury,  passed  down  to  the  bottom  of  the  wound,  occasionally 
for  some  moments  together  wiU  not  fail  to  percieve  the  projection  and 
fluctuation  in  the  distended  'organ,  and  will  serve  to  show  the  direction  in 
which  the  point  of  the  bistoury  or  trocar  should  be  passed.  This  dissection 
will  at  first  be  made  in  the  axis  of  the  body,  i.  e.  perpendicularly  nearly,  but 
it  must  afterwards  incline  towards  the  sacrum  by  degrees,  to  follow  the 
natural  course  of  the  rectum,  and  to  avoid  wounding  the  bladder.  In  this 
respect  a  trocar  is  a  less  certain  and  safe  instrument  tlian  a  bistoury,  for  as  it 
enters  blindly,  it  would  inevitably  pierce  the  bladder,  which  fills  nearly  the 
whole  pelvis,  if  there  should  prove  to  be  no  intestine.  Besides  which  it  gets 
too  easily  lost  among  the  soft  parts  to  be  here  deserving  of  much  confidence. 
Puncture  of  any  kind  could  supersede  dissection  without  disadvantage,  only 
when  the  cul-de-sac,  filled  with  fecal  matter,  is  perceptible  either  by  tlie  fin- 
ger or  to  the  eye ;  either  on  the  skin  or  at  the  bottom  of  the  wound.  Having 
once  entered  the  gut,  it  is  skillfully  to  be  enlarged  in  various  directions,  and 
in  that  particularly  in  wlftch  there  seems  to  be  most  space.  A  tent  of  lint 
or  linen  is  then  passed  in,  or  else  a  canula,  and  the  operation  is  at  an  end. 
We  have  then  only  to  keep  open  the  new  anus  to  give  it  size  enough,  and 
prevent  its  contraction  or  obliteration.  This  operation,  for  the  performance 
of  which  opportunities  often  occur,  is  rarely  followed  by  complete  success. 
Uoonhuysen,  F.  Hildanus,  de  la  Motte,  &c.  who  have  had  most  reason  for 


OPERATIVE    SURGERY.  883 

praising  it,  admit  that  their  patients  ultimatelj  perished  at  the  end  of  a  few- 
months,  or  one  or  two  years  ;  and  B.  Bell,  in  whose  hands  it  had  some  suc- 
cess, states  positively  that  it  is  almost  impossible  to  prevent  the  new  orifice 
from  closing.  The  cure  obtained  by  Wagler,  which  continued  unimpeded 
in  a  patient  whose  perineum  he  uselessly  incised,  and  on  the  following  day 
thinking  he  could  feel  the  rectum  at  the  bottom  of  the  wound,  passed  a  lancet 
into  it,  was  owing  doubtless  to  the  intestine  being  near  the  sphincter,  and  to 
his  not  being  obliged  to  go  deep.  I  must  say  the  same  also  of  the  case  of  a 
little  girl,  upon  whom  a  surgeon  operated,  who  is  mentioned  by  M.  C.  L. 
Lepine,  who  died  three  years  afterwards  of  a  totally  different  disease  ;  and 
of  a  more  fortunate  one  still,  reported  by  Mr.  Miller. 

The  reason  for  the  want  of  success,  is  but  too  easy  to  give.  The  absent 
portion  of  intestine  can  never,  otherwise  than  very  imperfectly,  be  restored. 
It  is  placing  of  a  fistula  in  lieu  of  a  natural  tube.  The  species  of  mucous  sur- 
face, which  is  at  length  formed,  represents  the  tunics  of  the  natural  organ  but 
very  imperfectly.  Though  the  organism  may  fail  to  close  a  stercoral  fistula 
entirely,  it  nevertheless  is  constantly  striving  to  diminish  their  size ;  so  that 
they  soon  become  mere  passages  for  the  escape  of  fluid  substances. 

The  absence  of  sphincter  is  another  hopeless  cause  of  its  failure,  especial- 
ly. When  this  is  the  case  it  becomes  extremely  improbable  that  the  opening 
artificially  made  can  be  l^ept  up  with  any  ease.  Still  it  is  not  to  be  sup- 
posed, with  Dumas  and  some  others,  that  in  every  case  an  artificial  anus  in  the 
side  of  the  abdomen  is  preferable.  This  is  no  other  than  a  fistula  Avithout  a 
sphincter,  and  whenever  it  can  be  made  in  the  perineum,  will  be  attended 
with  fewer  disagreable  occurrences  to  the  patient. 

§  2.  Tlie  Estahllshment  of  an  Artificial  Anus. 

The  first  person  who,  in  a  case  of  imperforate  rectum,  conceived  the  idea 
of  making  an  artificial  anus  in  the  iliac  region,  in  the  sigmoid  flexure  of  the 
colon,  was  Littre,  in  1720.  It  is  scarcely  conceivable  how  Dumas,  who  re- 
peated the  proposal  in  1797,  should  have  given  himself  out  as  its  inventor. 
M.  Dubois  had  performed  it  before  him,  in  1783,  upon  a  child  who  died  on  the 
tenth  day.  On  the  18th  October,  1793,  M.  Duret  of  Brest,  performed  it  with 
complete  success ;  and  Pilore  in  Rouen,  was  not  less  fortunate.  But  the 
child  upon  whom  Desault  operated  in  1794,  lived  only  four  days  afterwards. 
The  abnormal  super-pubic  anus,  noticed  by  Voisin  of  Versailles,  comes  in  aid 
of  the  hopes  raised  by  the  results  obtained  by  Duret  and  Pilore,  as  the  child 
lived  and  discharged  its  feces  by  this  passage.  It  is  true  that  they  have  since 
then  been  in  several  instances  disappointed.  M.  Ouvrard  of  Angers,  lost  his 
patient  as  quickly  as  Desault  in  1820 ;  and  M.  Roux  was  as  unsuccessful  last 
year  in  a  similar  case.  Where,  after  all,  is  that  operation  which  does  not 
sometimes  baffle  tlie  attempts  of  the  surgeon .'' 

The  little  patient  lies  upon  its  back,  its  thighs  extended,  and  is  held  by  one 
or  two  assistants.  The  surgeon,  conveniently  seated,  makes  an  incision  of 
about  two  inches  long,  a  little  above  the  Fallopian  ligament,  between  the 
anterior  superior  spine  of  the  ilium  and  the  pubis,;  divides,  layer  by  layer, 
skin,/asaa  superficialis,  the  aponeurosis  of  the  obliquus  externus  muscle,  the 
lower  fibres  of  the  small  oblique,  the  fascia  transversaliSytind  peritoneum,  the 


884  NEW   ELEMENTS   OF 

aperture  in  which  he  subsequently  enlarges  by  employing  a  grooved  director 
as  a  guide  to  the  instrument.  The  distended  intestine,  of  a  livid  or  greenish 
hue,  shows  itself  behind  the  wound,  and  may  be  known  moreover  by  the 
appearance  of  its  covering,  and  the  disposition  of  its  fibres.  The  fore-finger 
seeks  for  it  and  brings  it  outwardly  by  acting  as  a  hook,  or  else  by  assisting 
the  thumb  to  lay  hold  of  it.  A  loop  of  thread  is  then  passed  through  its 
mesentery  by  which  it  is  prevented  from  returning.  It  is  opened  in  the  direc- 
tion of  the  wound  in  the  belly.  Feces  escape ;  it  becomes  empty.  A  tent  or 
pledget  is  then  placed  in  it,  if  there  is  any  fear  of  its  closing  too  soon.  Ad- 
hesions are  soon  formed  between  the  surface  of  the  colon  and  the  walls  of  the 
wound  in  the  abdomen.  The  loop  of  thread  is  withdrawn  from  the  mesentery 
on  the  third  or  fifth  day,  and  tlie  new  anus,  then  definitely  established,  requires 
no  other  care  than  any  new  formed  anus  whatever. 

2.  Procedure  of  Callisen. — This  consists  in  piercing  the  side  to  get  at  the 
left  lumbar  colon  between  the  two  portions  of  its  mesenteric  fold,  without 
opening  the  peritoneum,  but  has  never  been  performed  upon  the  living  sub- 
ject. I  am  wrong.  M.  Roux  once  applied  it  to  a  little  patient  who  died  in 
two  hours  afterwards.  It  does  not  deserve  to  be  rescued  from  the  oblivion 
into  which  modern  surgeons  have  thrown  it.  It  would  be  incomparably  more 
difficult,  and  not  less  dangerous  than  the  preceding,  as  well  as  being  much 
more  inconvenient. 

3.  Procedure  of  M.  Martin. — The  project  attributed  by  M.  Paris  to  M. 
Dubois,  and  which  served  as  the  text  of  M.  L.  A.  Martin  in  his  thesis,  of  car- 
rying in  at  the  iliac  opening  of  the  intestine  made  according  to  the  procedure 
of  Littre,  an  exploring  instrument  from  above  downwards  for  the  purpose  of 
seeing  whether  it  might  not  be  possible  to  re-establish  the  natural  anus  by 
perforating  the  perineum,  has  also  hitherto  been  attempted  only  on  the  dead 
body.  It  would  be  unjust,  however,  entirely  to  despise  or  reject  it.  If  a 
mistake  should  by  chance  have  been  made,  and  the  rectum  should  have 
descended  low  enough  to  be  continued  as  far  as  the  skin  without  too  much 
difficulty,  we  should  be  still  better  enabled  to  perform  the  operation.  A 
flexible  catheter,  or  one  conveniently  curved,  would  first  point  out  the  state 
of  things.  I  would  not,  however,  advise  either  the  large  flexible  canula,  nor 
the  enormous  trocar  recommended  byM.  Martin,  to  transfix  the  parts  from 
within  towards  the  exterior.  It  would,  in  my  opinion,  be  better  to  penetrate 
through  the  perineum  in  search  of  the  beak  of  the  catheter;  or  if  it  were 
found  practicable  to  pass  into  the  pelvis  the  sonde-a-dard,  the  dart  and  stylet 
of  which  pushed  towards  the  surface  in  the  direction  of  the  anus,  might  serve 
as  the  guide  to  the  bistoury  during  the  rest  of  the  operation.  But  as  it  might 
be  somewhat  imprudent  thus  to  multiply  incisions  at  one  time,  and  as  there 
would  always  be  time  enough  afterwards  to  emplpy  this  resource,  it  might  be 
as  well  to  wait  until  the  health  of  the  child  is  restored  to  its  natural  state,  and 
to  choose  some  apparently  more  convenient  time  for  its  performance. 

If  experience  had  sufficiently  demonstrated  the  innocence  of  Littre's  me- 
thod, its  advantages  would  not  be  confined  altogether  to  new-born  children. 
It  might  be  likewise  applied  to  remedy  the  many  cases  of  intestinal  oblitera- 
tion which  show  themselves  after  birth.  As  every  stricture  of  this  kind  is  of 
a  fatal  nature,  we  can  see  no  reason  why  an  artificial  anus  should  not  be 
established.    The  difficulty  would  evidently  be  to  acquire  the  certainty  that 


OPERATIVE    SURGERY.  88^ 

there  exists  any  obliteration  at  all,  and  next,  to  be  sure  that  it  is  situated  in 
the  rectum  or  lower  portion  of  the  sigmoid  flexure  of  the  colon,  or  in  the 
large  intestine  at  least,  so  that  by  making  the  anus  in  the  right  fossa  iliaca  it 
might  be  above  the  disease.  This,  however,  may  often  be  arrived  at. 
Brail! et  entertained  no  doubt  of  it,  in  the  patient  whose  case  he  has  commu- 
nicated, nor  was  M.  Martin  Solon  deceived  in  the  fact  quoted  hy  M.  Paris. 
The  circumstance  was  equally  clear  during  the  illness  of  Talma.  I  might 
say  the  same  of  the  case  of  a  woman  whom  I  examined  after  death  at  the 
Clinique  Externe  in  1825. 

The  procedure,  moreover,  would  require  no  other  alteration  save  that,  in- 
stead of  being  always  carried  to  the  left,  it  might  become  indispensably 
necessary  to  direct  the  action  of  the  instrument  upon  the  right  fossa  iliaca,  if 
the  transverse  or  ascending  colon  were  attacked  by  the  stricture.  After  all, 
how^ever,  the  operation  exists  not  in  theory  only.  Surgeons  have  been  bold 
enough  to  perform  it  upon  the  living  human  subject,  and  M.  Martland,  who 
first  attempted  it  1814,  was  fortunate  enough  to  cure  his  patient. 

*^rt.  2. — Strictures, 

Strictures,  whether  congenital  or  artificial,  v^hich  are  not  cancerous,  but 
merely  organic  contractions  of  the  organ  of  defecation,  may  be  overcome  by 
operations  similar  to  those  performed  upon  the  urethra.  Their  great  fre- 
quency at  the  upper  part  of  the  anus,  is  explicable  by  the  species  of  fold  or 
valvular  border  seen  within  the  rectum  a  little  above  the  sphincter,  which 
represents  a  species  of  pylorus,  and  upon  which,  before  Mr.  Houston  of  Dub- 
lin, no  one  had  ever  laid  any  stress.  Higher  up  than  this,  they  are  almost 
always  consequent  on  ulceration,  and  upon  degeneration  of  a  kind  difiicult 
to  be  restrained,  and  therefore  they  yield  less  frequently  than  the  former  to 
surgical  remedies. 

§  1.  Dilation. 

The  use  of  dilation  in  stricture  of  the  lower  portion  of  the  rectum,  so 
highly  lauded  by  Desault,  and  since  him  by  a  majority  of  surgeons,  do^s  in- 
deed deserve  a  good  deal  of  the  praise  which  it  has  received. 

All  those  indurations,  results  of  chronic  inflammation,  which  involve  the 
mucous  membrane  only  or  the  subjacent  cellular  tissue,  and  even  some  larda  - 
ceous  degenerations,  admit  of  the  application  of  this  means  of  cure.  Dilation 
here  acts  by  the  same  meclianism  as  does  compression  in  external  congestion. 
The  excentric  pressure  which  it  causes,  forces  the  effused  solidified  sub- 
stances in  the  natural  organic  meshes  of  the  tissues  to  re-enter  the  general 
circulation,  thus  bringing  back  the  intestine  by  degrees  to  its  original  thick- 
ness and  increasing  its  size ;  and  by  extinguishing  its  principle,  often  remov- 
ing the  morbific  process.  This  result  is  not,  however,  attained  with  equal 
facility  on  all  parts  of  the  rectum,  nor  in  all  species  of  stricture.  Dilation,  in 
all  cases  where  the  disease  consists  of  irregular  tumors  extending  more  out- 
wardly than  within  the  canal,  in  which  it  occupies  a  point  too  badly 
surrounded  to  allow  of  accurate  pressure,  or  if  the  apparatus  is  ill  applied, 
generally  does  more  harm  than  good.     It  is  performed  with  rolls  or  tents  of 


886  NEW  ELEMENTS  OF 

lint,  spread  with  cerate  or  some  medicated  pomatum,  renewed  every  day,  and 
gradually  increased  in  size. 

These  tents,  for  which,  in  fact,  any  other  supple  or  flexible  cylindrical  body 
may  be  substituted,  do  very  well  for  affections  of  the  rectum  high  up,  and 
for  those  of  the  anus,  properly  speaking.  But  for  such  as  are  between  the 
sphincter  and  concavity  of  the  sacrum,  another  course  must  be  adopted. 
A  little  linen  bag  introduced  empty,  like  a  purse  with  its  bottom  upwards, 
filled  with  lint,  so  as  to  effect  pressure  from  above  downwards,  as  well  as  all 
around,  when  an  attempt  is  made  to  withdraw  it,  seems  then  to  be  better  indi- 
cated, and  should  have  a  preference  over  bladders  distended  with  air,  water, 
or  any  other  fluid.  These  two  methods  possess,  however,  the  common  incon- 
venience of  arresting  the  progress  of  fecal  matters,  and  thereby  in  many 
patients  give  rise  to  much  uneasiness.  It  would,  therefore,  be  well  to  follow 
the  advice  of  M.  Bermond  of  Bordeaux,  and  employ  his  apparatus  instead  of 
the  tents  or  purse  I  have  mentioned.  This  apparatus  consists  of  two  concen- 
tric canulse,  about  six  inches  long,  the  inner  one  smooth,  and  endin<»;  superiorly 
in  a  cul-de-sac,  the  outer  one  open  at  both  ends,  and  having  circular  grooves 
at  intervals  on  its  exterior  surface  to  admit  of  the  adaptation  of  chemise.  They 
are  sheathed  in  each  other,  and  so  carried  up  into  the  organ.  Lint  is  then 
passed  up  by  means  of  a  long  forceps  between  them  and  their  linen  envelope,- 
so  as  to  press  this  out  into  an  annular  projection  on  a  level  with  the  top  of  the 
instrument,  and  so  as  to  bear  more  in  this  and  less  in  the  other  direction  as 
may  be  requisite.  The  whole  is  fastened  outside  very  firmly.  When  it 
becomes  necessary  for  the  patient  to  discharge  the  contents  of  the  bowels,  the 
inner  tube  is  withdrawn  without  interfering  with  the  other,  which  may  have  a 
diameter  of  six  lines.  The  lamp-bottom  formed  by  the  chemise  above, 
necessarily  causes  the  fecal  matters  to  accumulate  there,  which,  if  required, 
may  be  dilated  and  made  fluid  by  glysters.  The  central  canula  is  afterwards 
replaced,  which  catches,  by  a  spur  on  its  side,  in  a  groove  which  exists  in  the; 
enclosing  canula  near  its  free  end. 

When  the  disease  is  not  within  reach  of  the  finger,  neither  the  tents,  the 
linen  bag,  bladders,  or  the  double  canula  of  M.  Bermond,  are  applicable  any 
loriger.  For  these  particular  cases,  M.  Castallat  has  contrived  a  little  ap- 
paratus which  may  be  pushed  up  a  distance  of  more  than  a  foot,  and  which  in 
other  cases  also  would  not  deserve  to  be  slighted.  I  have  already  spoken  of 
it  when  upon  the  subject  of  strictures  of  the  urethra.  It  also  consists  of  a  che- 
mise, shaped  like  a  condom^  preceded  by  a  long,  probe-pointed,  or  buttoned 
stylet;  it  is  carried  up  by  a  gumelastic  catheter,  and  made  into  a  tent  by 
means  of  cotton  passed  up  within  it  by  a  forked  stylet.  The  author  assures 
me  that  he  has  used  it  with  great  advantage  upon  a  patient  whom  several  dis- 
tinguished surgeons  had  pronounced  to  be  incurable.*  It  is  to  be  regretted 
that  it  is  too  complicated  to  become  general,  for  the  idea  is  an  ingenious  one ; 
and  it  is  very  desirable  to  have  it  so  much  simplified,  that  every  one  should 
be  able  to  use  it. 

*  The  patient  has  since  called  at  La  Pitie,  where  I  had  an  opportunity  of  examining  him. 
The  stricture  in  the  intestine  has  relapsed  into  its  orig-inal  state  of  contraction. 


OPERATIVE    SURGERY.  887 


§  2.  Incision, 


Before  dilation  was  proposed,  and  even  since  it  has  been  in  general  use,  in- 
cision into  strictures  of  the  rectum  was  practised,  either  as  a  principal  remedy 
or  as  an  accessory  means.  Wiseman  recurred  to  it  three  times  on  the  same 
individual,  Foi-d  had  the  good  fortune  to  see  his  get  well  without  a  relapse, 
and  Mr.  Copland  states  himself  to  have  been  as  successful.  The  ope- 
ration, unless  it  be  necessary  to  go  to  a  considerable  depth,  oiFers  but  few  diffi- 
culties. 

The  probe-pointed  bistoury,  carried  flatwise  on  the  forefinger,  and  intro- 
duced within  the  constricted  circle,  is  the  only  instrument  we  want.  Its  edge 
turned  towards  the  parietes  of  the  intestine,  divides  the  stricture  in  one  or 
several  places,  taking  care  not  to  pass  the  thickness  of  the  viscus.  A  large 
tent  is  then  introduced  to  just  above  the  wound,  and  the  case  is  treated  as  a 
simple  dilation.  The  kiotome,  or  the  instrument  invented  by  Desault  for  cut- 
ting frena,  here  finds  an  application,  if  any  particular  instrument  is  thought 
necessary ;  or  the  pharyngotome  may  be  used,  as  was  once  successfully  done  by 
M.  Duplat.  The  incision  becomes  too  dangerous  when  the  finger  can  no  longer 
accompany  the  knife,  for  us  ever  to  think  of  venturing  upon  it.  Annular  stric- 
tures of  a  semilunar  shape,  or  like  a  frenum,  alone  authorize  its  being  prac- 
tised ;  and  it  can  only  be  seriously  advised  as  preparatory  to,  and  as  a  means  of 
assisting,  the  operation  of  dilating  instruments. 

§  3.  Cauterization. 

It  is  rather  surprising  that  strictures  of  the  rectum  should  not  have  been 
treated  with  caustic  as  well  as  those  of  the  urethra.  Every  thing  leads 
to  the  belief  that  it  would  have  a  like  eftect;  that  the  nitras  argenti  em- 
ployed as  a  topical,  or  catheteric  application,  would  very  much  assist  the  suc- 
cess of  dilation,  by  destroying  the  principle  of  chronic  phlogosis  upon  the  mu- 
cous membrane  of  the  intestine,  as  it  so  often  has  done  in  the  excretory  canal 
of  the  urine.  But  I  do  not  know  that  it  has  yet  been  used  in  such  a  case,  and 
having  no  data  but  theory  and  analogy,  I  cannot  devote  to  it  any  long  detail. 
I  find,  however,  a  very  conclusive  instance  of  it  in  a  thesis  sustained  in  1 823, 
at  Strasbourg,  by  M.  Duplat. 


SECTION   II. 

Acquired  Lesions 

^rl,  ] . — Foreign  bodies  in  the  Jinus, 

So  various  are  the  shades  of  difference  in  the  shape,  size,  and  nature  of  the 
foreign  bodies  which  become  stopped  in,  or  are  introduced  into  the  lower  part 
of  the  rectum,  that  no  settled  operation,  nor  fixed  rule  of  procedure  can  be 
laid  down  for  extracting  them,  which  has,  so  to  speak,  to  be  changed  for  each 
particular  case.       The  fingers  and  thumb,  dressing  or  lithotomy  forceps  or 


888  New  elestents  op 

the  whole  hand  when  it  can  be  introduced,  are  the  means  which  first  suggest 
themselves.  The  hand  of  an  intelligent  child,  as  was  used  in  the  case  of  a 
patient  mentioned  bj  Nollet,  who  had  pushed  a  phial  of  eau  de  cologne  above 
the  sphincter,  or  that  of  a  midwife  should  be  used,  if  the  hand  of  the  surgeon 
is  too  large.  If  the  substance  is  wood,  or  vegetable,  or  animal  matter,  solid 
and  not  flexible,  a  gimblet  or  a  screw-ring  [tire-fond),  will  be  found  of  impor- 
tant assistance,  as  the  facts  related  bj  Saucerotte  and  M.  Bruchman  prove. 
A  pig's  tale  introduced  bj  its  base,  the  hairs  of  which  previously  cut,  butt  and 
rise  against  the  intestine  at  every  attempt  to  withdraw  it  by  traction,  should 
be  managed  in  the  way  that  Marchettis  treated  the  prostitute  who  was  made 
the  victim  of  their  malice  by  the  students  at  Gottingen.  By  means  of  a  string 
tied  to  its  lower  end,  he  succeeded  in  slipping  over  the  foreign  body  a  reed  ca- 
nala  from  below  upwards,  which  separating  it  from  the  sides  of  the  intestine, 
and. acting  as  a  sheath  for  it,  enabled  him  to  withdraw  it  directly  without  any 
difficulty. 

A  patient  once  passed  a  sweetmeat  pot  into  his  rectum,  its  small  end  going 
first.  Violent  irritation  succeeded  to  this  extraordinary  proceeding,  and  the 
intestine  very  soon  turned  over  from  above  downwards  into  the  vase,  like  a 
red  tumor  filling  up  its  cavity.  Desault  could  only  succeed  in  removing  it  by 
applying  two  very  strong  forceps  to  opposite  points  in  one  of  its  diameters,' 
one  after  the  other.  Instead  of  two,  four  might  be  employed  if  it  were  neces- 
sary to  pull  still  more  strongly,  or  to  separate  the  circumference  of  the  anus 
in  more  places  at  once.  A  large  ring,  a  ferule,  or  a  metallic  goblet,  would 
not  probably  resist  such  treatment.  If  it  were  of  glass,  of  crystal  or  porce- 
lain, or  any  brittle  substance,  it  might  be  broken  with  forceps,  if  it  could  not 
be  brought  avv^ay  in  one  piece.  A  narrow  saw  guarded  by  a  gorget,  and  the 
forefinger  ought  to  be  tried  in  case  apiece  of  wood,  horn,  or  ivory,  should  have 
become  fastened  crosswise  between  the  two  walls  of  the  gut;  whilst  a  body  of 
steel,  iron,  silver,  &c.,  will  sometimes  call  for  the  use  of  cutting  nippers,  or  of^ 
true  shears.  Biliary  calculi,  and  that  species  of  aegagropili  which  is  met  with 
in  the  intestines  of  man,  as  well  as  in  animal,  require  to  be  crushed  by  strong 
forceps,  or  broken  into  fragments  by  long  and  powerful  scissors,  if  they  can- 
not be  overpowered  by  the  hand,  hooks,  the  screw  or  gimblet. 

Hardened  feces,   concrete  balls,  and  stercoral  calculi,  which  in   many 
persons  become  sources  of  symptoms,  the  nature  of  which  is  never  suspected, 
often  require  the  use  of  blunt  hooks  or  the  finger,  of  wooden  spoons  of  greater- 
or  less  length,  or  the  delicate  hand  of  a  child  or  woman. 

Divisions  and  incisions  either  of  the  anus,  or  intestine,  on  elevated  portions 
of  its  parietes,  are  never  to  be  had  recourse  to,  until  the  inutility  or  insuffi- 
ciency of  such  measures  has  been  fully  established.  Then,  as  in  the  preceding 
cases,  we  are  to  employ  the  speculum  brise,  or  else  the  simple  speculum,  made 
incomplete  by  a  slit  of  two  or  three  lines  in  width,  which  divides  it  in  its  whole 
length  on  its  fuee  side,  as  advised  by  M.  Barthelemey,  either  as  a  means  of 
dilating  the  anus,  or  to  assist  the  action  of  other  instruments.  The  incisions 
tliemselves  are  sometimes  made  with  a  straight  bistoury  wrapped  round  with 
a  strip  of  linen,  sometimes  with  a  probe-pointed,  straight  or  crooked  bistoury 
guided  on  the  finger,  and  thirdly,  with  good  scissors. 

Upon  the  whole,  foreign  bodies  in  the  rectum,  are  treated  in  no  way  dilffer- 
ently  from  those  lodged  in  the  vagina.    To  the  means  above  specified,  we  may 


OPERATIVE    SURGERY.  889 

add,  I  think,  as  appropriate  in  either  situation,  lithotritic  instruments ;  and  it 
may  be  borne  in  mind  that  the  litholabe,  the  perforator,  and  the  stone-breaker, 
are  much  less  dangerous  to  manage  in  the  rectum,  or  vagina,  than  in  the  blad- 
der and  urethra. 

Art.  2d,— Polypi. 

Polypi  of  the  rectum,  though  not  very  uncommon,  are  still  not  seen  very 
frequently.  If  they  exist  at  a  distance  of  six  or  eight  inches  up,  it  is  next  to 
an  impossibility  either  to  reach  or  detect  them.  If  seated  lower  they  are  easier 
to  get  at,  and  require  to  be  treated  much  as  those  which  are  situated  in  the 
sexual  organs  of  the  female.  It  is  too  easy  to  excise  them  to  render  it  necessary 
to  advise  tearing  them  away,  or  the  use  of  caustic,  while  ligature  is  in  scarcely 
any  case  applicable  to  them.  When  above  the  sphincter,  they  are  to  be  hooked 
with  crotchet  forceps,  or  a  double  hook,  held  by  an  assistant.  If  the  anus 
offers  any  resistance,  a  speculum  brise  must  be  introduced  into  it.  The  sur- 
geon then,  with  a  pair  of  long  scissors,  rather  curved  on  their  flat  surface, 
protected  by  the  left  foreftnger  cuts  off  their  peduncle.  If  still  lower,  the 
method  of  excising  them,  is  the  same  as  that  of  haemorrhoids,  which  we  shall 
presently  describe ;  and  in  either  case  the  measures  hereafter  to  be  mentioned 
for  guarding  against  hoemorrhage  are  to  be  pursued. 

t^rt.  Sd. — Hemorrhoidal  Tumors. 

Haemorrhoidal  tumors,  cushions,  or  tubercles,  which  are  sometimes  concealed 
within  the  anus,  and  only  visible  when  the  patient  strains  on  going  to  stool — 
sometimes  salient  externally — are,  when  they  continue  in  spite  of  the  me- 
thodical use  of  pressure,  and  the  employment  of  antiphlogistic,  detergent, 
astringent,  and  catheteric  topical  applications,  sources  of  many  dangers 
and  inconveniences.  Nitrate  of  silver  would  triumph  over  them  in  the  begin- 
ning only,  or  when  they  were  yet  of  small  size.  The  red  hot  iron,  so  much 
extolled  by  the  ancients,  which  M.  A.  Severin  was  so  much  displeased  at 
not  being  allowed  to  apply  to  a  patient  of  high  rank,  because  of  that  persons 
cowardly  physician's  obstinacy,  w^ould  answer  doubtless  oftener  and  better ; 
but  the  means  possessed  by  art,  of  a  surer  and  less  alarming  nature,  have  long 
ago  caused  it  to  be  forgotten.  At  the  present  day,  in  spite  of  the  arguments 
urged  by  M.  Mayor  in  its  favor,  ligature,  even  though  easy,  is  generally 
abandoned.  Tumors,  such  as  the  mere  cushions,  which  have  no  peduncle, 
do  not  allow  of  it  use;  and  the  cases  mentioned  by  J.  L.  Petit,. show  that 
under  other  circumstances  it  may  give  rise  to  very  serious  symptoms,  such  as 
violent  pain,  syncope,  convulsions,  inflammation  of  the  intestine  and  perito- 
neum ;  and  this,  too,  whether  the  morbid  growth  was  allowed  to  fall  off  spon- 
taneously, or  whether,  as  Galen  had  advised,  it  was  excised  directly  this  side 
of  the  ligature. 

The  only  operation,  then,  to  which  they  should  be  subjected  is  excision. 
This  of  itself  seldom  ofters  any  great  difficulty.  The  only  alarming  thing 
about  it  is  the  bleeding  which  may  follow ;  and  that  process  is  consequently 
the  best  which  least  exposes  to  the  occurrence  of  this  accident,  and  most 
safely  opposes  it. 

112 


890  NEW   ELEMENTS   OF 

The  patient  lying  on  the  edge  of  a  bed  or  covered  table,  one  thigh  (the 
under  one)  being  stretched  out,  the  other  flexed,  so  that  the  anus  may  be  per- 
fectly free,  is  to  be  held  by  several  assistants.  The  surgeon  facing  the  affected 
part,  is,  according  to  M.  Boyer,  successively  to  take  hold  of  every  tumor,  be- 
ginning at  the  lowermost  ones,  and  proceeding  to  those  which  are  highest,  with 
good  dissecting  forceps  or  a  hook,  and  to  detach  them  one  after  another  with 
a  bistoury  or  a  pair  of  strong  scissors.  If  they  do  not  project  outwardly,  an 
effort  like  that  on  going  to  stool  will  make  them  protrude ;  but  it  is  important,  as 
the  pain  of  the  removal  of  the  first  always  occasions  considerable  retraction  of 
tlie  anus  by  which  the  others  recede  into  the  rectum,  to  fix  them  all  with  as 
many  hooks  or  forceps,  or  by  a  thread  before  cutting  any  of  them.  It  is  wholly 
superfluous  to  follow  the  advice  of  some  authors,  and  dissect  them  out  like 
cysts,  so  as  to  remove  as  little  as  possible  of  the  mucous  membrane  or  skin. 
It  is  much  easier,  besides,  to  give  such  advice  than  to  follow  it.  Loss  of  sub- 
stance can  here  be  no  source  of  disquietude ;  the  wound  heals  well,  and  after 
the  cure  the  organ  regains  its  original  flexibility.  All  the  dressing  required 
Is  merely  the  introduction  of  a  large  strong  tent,  spread  with  cerate,  carried 
in  for  a  depth  of  some  inches,  supported  outwardly  by  lint,  compresses,  and  a 
T  bandage. 

If  less  of  blood  is  to  be  feared,  the  dressing  is  not  quite  so  simple.  M. 
Boyer  begins  it  by  introducing  very  deeply  a  long  tampon  of  lint,  almost 
cylindrical,  hard,  embraced  by  two  strong  ligatures,  crossed  on  its  upper  end, 
knotted,  and  firmly  fixed  upon  its  lower  extremity,  and  the  ends  of  which 
gathered  two  by  two,  remain  hanging  out  of  the  anus ;  then  he  pushes  in 
several  balls  or  fresh  loose  tampons  below  this;  keeps  them  firmly  in  with  a 
strong  roll  of  lint  placed  between  the  buttocks  over  the  anal  opening ;  draws 
on  the  ends  of  the  two  ligatures ;  knots  them  over  the  roll  of  lint  sufficiently 
tight  to  draw  down  the  lint  contained  in  the  intestine  between  the  bleeding 
surfaces,  whilst  the  outer  tampon  tends  to  crowd  it  back  from  below  upwards. 
After  this  a  soft  mass  of  lint,  a  compress  and  T  bandage,  complete  the  whole 
apparatus.  In  this  way,  it  is  nearly  impossible  for  the  blood  to  escape, 
whereas  mere  tamponing  would  serve  only  to  make  it  pour  into  the  intestine, 
since  it  could  not  show  itself  outwardly,  making  an  invv^ard  of  an  outward 
hemorrhage,  which  would  be  more  dangerous  still.  But,  on  the  other  hand, 
if  the  pressure  is  not  even,  nor  powerful  enough,  if  the  apparatus  of  Boyer 
or  J.  L.  Petit  is  not  in  good  order,  or  illy  applied,  the  same  accident  may 
occur.  Besides  which,  it  sometimes  causes  great  suffering,  an  insurmount- 
able desire  to  go  to  stool,  a  weight  which  cannot  be  endured,  colic,  fever,  and 
other  symptoms  which  render  its  use  very  distressing.  It  is  indispensable, 
therefore,  in  many  cases,  to  have  an  assistant  to  hold  it  up  for  many  hours 
with  his  hand,  to  exhort  the  patient  to  make  no  effort,  to  resist  with  all  his 
moral  firmness  the  desire  to  push  which  he  feels,  which  seldom  fail  to  diminish 
in  violence  after  a  few  hours. 

I  need  scarcely  add,  that  if  the  belly  swells,  paleness  and  syncope  occurs, 
with  smallness  of  the  pulse,  indicating  a  continuance  of  the  flow  of  blood  ; 
the  whole  dressings  must  be  removed,  in  order  that  they  may  be  better  re-ap- 
plied ;  nor  that  the  sensation  of  weight,  and  of  the  presence  of  a  foreign  body, 
which  are  felt  so  acutely,  even  though  no  dressing  be  applied,  will  be 
increased  ioSvead  of  bettered  by  attempts  at  defecation  to  which  the  patient 


OPERATIVE  SURGERY.  891 

is  urged  in  spite  of  himself  almost,  but  from  which,  at  any  sacrifice,  he  must 
refrain.  I  would  willingly  advise  the  canula  and  chemise  devised  by  M. 
Bermond,  if  it  had  ever  been  tried  under  such  circumstances.  (See  Dilation 
of  the  Anus.)  With  it,  pressure  might  be  increased  and  diminished,  and  the 
dressings  changed,  modified,  and  renewed,  without  undoing  the  whole  appa- 
ratus ;  whilst  the  removal  of  the  inner  canula  would  allow  us  to  ascertain 
whether  there  was  any  eSusion  of  blood  into  the  intestine,  and  permit  the 
feces  to  escape  as  often  as  is  required,  and  this  for  days  together  if  neces- 
sary. 

The  procedure  of  M.Dupuytren  does  away  with  all  such  precautions.  This 
surgeon  almost  exclusively  employs  scissors  which  are  curved  on  their  flat 
surface  for  the  removal  of  hemorrhoidal  excrescences ;  and  whenever  he  sees 
reason  to  be  alarmed  about  hemorrhage,  directly  applies  the  red  hot  iron  upon 
the  wounds  which  he  has  made.  He  then  places  a  very  small  pledget  in  the 
anus,  which  is  supported  and  protected  as  I  have  before  mentioned.  By  this 
procedure,  accidents  scarcely  ever  happen.  Neither  intestine,  bladder, 
nor  circumjacent  parts  are  distended,  pulled  upon,  or  irritated  by  any 
thing.  The  congestion,  which  by  the  ordinary  dressing  is  made  so  exces- 
sive, is  by  this  means  rendered  very  inconsiderable,  and  hemorrhage,  con- 
sequently, has  no  exciting  cause.  In  this  respect,  the  red  hot  iron  has 
the  effect  of  making  the  operation  extremely  speedy,  and  is  not  productive  after 
all  of  more  pain  than  the  use  of  tampons.  The  inflammation  which  has  muc 
less  disposition  to  extend,  and  to  be  perceived  at  a  distance  from  its  seat, 
does  not  attack  the  veins  which  open  on  the  fundus  of  the  wound,  and 
the  establishment  of  purulent  foci,  caused  by  phlebitis  and  re-absorption, 
which  I  saw  fatal  in  two  patients  in  1824  and  1825,  at  the  hospital  of  the 
School,  is  maxie  much  less  probable.  I  do  not  know,  indeed,  whether  tlie 
cautery  is  really  indispensable.  The  branches  of  arteries  divided  are  so 
small  that  at  first  sight  it  would  not  appear  that  opening  them  could  prove 
dangerous.  When  left  to  themselves  these  vascular  mouths  will  probably 
very  soon  cease  to  flow  ;  and  I  should  not  be  surprised  if  the  very  precau- 
tions taken  to  guard  against  hemorrhage,  were,  in  very  many  cases,  the  causes 
of  its  production.  I  certainly  think  that  they  might  be  dispensed  with  in  a 
great  many  cases ;  and  that  to  prescribe  them  at  first  before  the  loss  of  blood 
seems  likely  to  be  abundant,  is  an  excess  of  prudence.  What  is  there  to  pre- 
vent us  from  resorting  to  it  at  a  later  period,  if  the  bleeding  should  continue  in 
such  a  way  as  to  create  uneasiness  ^  Nothing  is  easier  when  the  wounds  are 
external.  If  they  are  deeper,  the  patient  by  a  little  straining  will  bring  them 
into  view  of  the  operator,  who  may  then  cauterize  them  without  any  difficulty. 
Lastly,  the  use  of  the  tampon  should  be  a  final  resort,  which  there  will 
always  be  time  enough  to  call  to  our  assistance.  Two  patients  whom  in 
18S1  I  treated  in  this  manner,  had  no  cause  to  regret  its  having  been 
adopted. 

jirt.  4. — Falling  doivriy  Procidentia,  or  Prolapsus  of  the  Rectum. 

Falling  down  of  the  fundament  is  an  occurrence  not  to  be  confounded  with 
psTcidentia  through  the  anus  owing  to  intus  susceptio  of  a  higher  or  lower 
portion  of  the  bowel  of  greater  or  less  extent.    The  one  depends  on  relaxa- 


oyZ  NEW  ELEMENTS  OF 

tion  of  the  mucous  membrane  of  the  rectum,  the  latter,  on  true  intestinal  inva- 
gination. The  former  alone,  calls  sometimes  for  the  aid  of  particular  operative 
proceedings.  In  children  with  whom  it  is  very  common,  the  progress  of  age 
and  the  use  of  proper  topical  applications,  will  generally  overcome  it.  Not 
so  in  adult  age.  Its  obstinacy  then  often  becomes  a  source  of  trouble  to  the 
surgeon  and  of  despair  to  the  patient.  When  the  tumor  only  shows  itself 
after  every  stool,  and  then  easily  returns  afterwards,  it  becomes  certainly  an 
extremely  distressing  complaint,  though  it  does  not  endanger  existence; 
whilst,  if  the  patient  cannot  succeed  in  reducing  it,  it  may  become  strangulated 
by  the  action  of  the  sphincter,  inflame,  sphacelate,  and  give  rise  to  most 
alarming  symptoms. 

Reduction. — To  reduce  this  tumor,  we  act  precisely  as  in  cases  of  inverted  ^ 
uterus  and  vagina.  The  patient  lies  upon  his  back,  the  breech  being  raised 
higher  than  the  abdomen,  and  all  the  muscles  in  a  state  of  relaxation ;  the 
rectum  is  to  be  wiped  off  with  tepid  water,  then  rubbed  over  with  a  mixture 
of  oil  and  wine  ;  it  is  then  wrapped  up  in  a  piece  of  fine  linen,  and  then  com- 
pressed gently  from  circumference  to  centre,  from  above  downwards  with  the 
palms  of  the  hands,  or  the  fleshy  parts  of  all  the  fingers  ;  whilst  the  patient  is 
prevented  as  much  as  possible  from  making  any  eftbrt.  Sometimes  we  suc- 
ceed better  by  pressure  on  the  centre  of  the  mass  with  the  tips  of  several  fin- 
gers united  to  form  a  cone,  as  if  to  enter  the  anus,  pushing  before  them  the 
compress  with  which  the  tumor  has  been  capped,  and  which  is  held  on  by  the 
other  hand.  The  operation  is  not  over  when  the  tumor  is  replaced.  A  large 
pledget,  with  or  without  a  chemise,  is  frequently  used  as  a  means  of  keeping 
up  the  reduced  part.  A  tampon  of  lint  contained  in  a  linen  purse,  a  globe  or 
oval  of  ivory,  wood,  or  gumelastic ;  in  the  female  a  pessary  in  the  vagina, 
astringent  glysters  and  hygienic  cures,  are  the  means  to  be  essayed  for  pre- 
venting its  return. 

Division  of  the  Sphincter. — If  the  reduction  of  the  prolapsus  be  absolutely 
impossible  in  the  ordinary  way  and  danger  threatens,  we  must  not  hesitate  to 
divide  the  sphincter  ani  on  one  or  both  sides  of  the  root  of  the  tumor.  This  is 
to  be  drawn  on  one  side  with  the  left  hand,  whilst  with  the  right  hand  and  a 
straight  bistoury,  the  integuments  first  and  then  the  fleshy  ring  are  to  divided, 
beginning  nearest  the  intestine,  that  is,  from  within  outwards.  An  operation 
of  this  kind  by  M.  Delpech  on  a  young  person  in  18S0,  was  attended  with 
complete  success.  ' 

Excision. — When  nothing  prevents  the  parts  from  reascending,  and  yet,  in" 
spite  of  every  endeavor  they  refuse  to  do  so,  the  only  remedy  known  thirty 
years  ago,  and  the  only  one  now  known  by  many  authors,  as  able  to  be  per- 
formed for  the*  affection,  is  removal.  It  is  an  excision  or  a  resection,  which  in 
itself  is  easy  enougli,  and  is  performed  in  the  same  way  as  the  removal  of 
degenerated  piles,  a  polypus,  or  any  other  tumor  with  a  tolerably  large  base. 
It  is  unnecessary,  however,  to  take  out  the  tumor  from  quite  within  its  root. 
If  the  two  upper  thirds  are  destroyed,  the  remainder  will  inevitably  re-enter. 
It  is  possible  that  the  success  of  the  operation  would  be  equally  certain  if  the 
mucous  membrane  of  the  rectum  were  alone  attacked  and  its  muscular  one 
respected. 

The  dressings,  and  the  consequences  of  this  operation,  are  scarcely  different 
from  those  which  have  been  detailed  under  the  head  of  hemorrhoids. 


OPERATIVE   SURGERY.  89S 

This  is,  as  may  be  seen,  a  cruel  procedure,  and  one  which  is  very  far  from 
always  succeeding.  Happily  modern  surgery  almost  always  avoids  it:  sub- 
stituting for  it  a  method  much  less  alarming  and  less  painful,  and  on  the 
whole,  quite  as  certain ;  the  only  objection  to  which  is,  that  it  is  not  applica- 
ble to  irreducible  procidentia,  and  can  be  exerted  only  upon  the  tumor  after  its 
restoration  has  been  once  effected. 

Procedure  of  M.  Dupuytren, — This  consists  in  the  excision  of  the  radiated 
folds,  which  are  observed  upon  the  margin  of  the  anus,  whether  they  be,  or 
be  not  the  seat  of  hemorrhoidal  tumors.  In  a  majority  of  cases,  it  certainly 
appears  that  dilation  of  the  sphincter  is  the  great  obstacle  to  the  cure,  or  else 
the  very  great  relaxation  experienced  by  the  mucous  membrane  and  integu- 
ments which  follow  it  outwardly.  The  cellular  tissue  which  lines  them, 
acquires  such  looseness  after  a  time,  as  to  allow  them  to  slide  with  wonderful 
ease  over  the  layers  which  they  cover  naturally ;  and  whose  motions  in  a 
st;ate  of  health,  they  are  content  to  follow.  The  removal  of  a  certain  portion 
of  the  cutaneous  layer,  surprisingly  rectifies  this  anomaly  and  defect,  and 
thus  becomes  almost  an  infallible  remedy  for  the  evil  which  is  its  frequent 
sequel. 

The  idea  of  the  operation  first  occurred  to  Mr.  Hey  of  Leeds,  in  1788,  in 
the  case  of  a  Mr.  W.  of  Hull,  who  had  previously  been  a  patient  of  Sharps, 
and  in  whom  the  anus  continued  to  be  surrounded,  after  reduction  of  the  pro- 
lapsus, by  a  thin  pendulous  cutaneous  flap,  which  was  eight  or  twelve  lines 
long,  and  had  at  its  base  and  within,  several  bluish  and  soft  tuberqles,  such 
as  are  seen  in  persons  who  have  long  labored  under  piles.  '*It  appeared  to 
me,"  said  he,  "  that  the  prolapsus  depended  on  the  laxity  of  the  very  lowest 
part  of  the  intestine,  and  of  the  cellular  membrane  which  connects  it  with  the 
surrounding  tissues."  For  the  author  this  remark  was  a  ray  of  light.  He 
conceived  that  to  cure  his  patient,  he  had  only  to  increase  the  adhesion  of  the 
tissues  surrounding  the  anus,  and  the  action  of  the  sphincter  itself.  The 
surest  way  of  accomplishing  his  object  seemed  to  him  to  be  to  excise  the 
tegumentary  flap  with  its  appended  tubercles.  He  was  in  hopes  of  causing 
thereby  an  inflammation  which  should  be  capable  of  producing  a  firmer  adhe- 
sion of  the  rectuHLto  the  circumjacent  tissues,  entertaining  no  doubt  that  a  cir- 
cular wound  must  bring  with  it  a  more  powerful  constriction  of  the  sphincter 
ani.  Mr.  Hey  accordingly  removed  the  pendant  rim  and  the  bluish  tumors 
by  a  bistoury.  This  operation  he  performed  on  the  IStli  November,  and  in 
March  1789,  M.  W.  wrote  him  word  that  his  cure  had  continued  uninter- 
rupted. A  second  patient  operated  on  in  1790  in  the  same  way,  recovered  in 
three  weeks  ;  in  him  excision  was  performed  only  on  one  side.  In  the  month 
of  April  1791,  Mr.  Hey  a  third  time  put  his  plan  in  execution,  removing  the 
pendant  flap  and  encroaching  about  a  quarter  of  an  inch  upon  the  red  mem- 
brane which  covered  the  anus.  His  success  was  as  great  in  this  as  in  the  two 
other  instances.  He  treated  a  lady  in  the  same  way  in  1799,  except  that  he 
removed  the  two  soft  tubercles  seen  on  either  side  of  the  anus  at  different 
intervals  of  a  certain  time.  She  also  recovered,  and  in  as  short  a  time.  Yet 
even  at  home,  the  success  of  Mr.  Hey  remained  unremembered,  and  Mr. 
Saml.  Cooper,  who  mentions  it,  speaks  of  it  too  vaguely  for  any  one  to  derive 
much  benefit  from  it;  and  but  that  M.  Dupuytren  entertained  similar  ideas, 
devised  a  method,  and  made  that  method  general,  it  would  probably  have 
excited  no  more  attention  in  France  than  it  had  before  in  England. 


894  NEW  ELEMENTS  OF 

Tlie  Operation. — A  gljster  and  some  mild  purgative  is  to  be  given  the  pre- 
ceding night.  The  patient  is  placed  as  for  tlie  excision  of  hemorrhoids.  The 
surgeon,  with  good  forceps,  successively  seizes  each  radius  which  he  means 
to  remove,  and  excises  it  with  verj  sharp  scissors  from  below  upwards,  begin- 
ning at  the  margin  of  the  anus,  at  about  an  inch  from  the  sphincter,  to  end 
some  lines  above.  According  to  the  account  given  of  it  by  mj  old  fellow  stu- 
dent, M.  Paillard,  in  the  Journal  Hebdomadaire,  M.  Dupuytren  states  that 
four  radii  are  sufficient  to  remove ;  one  before,  one  behind,  and  two  laterally. 
I  have  thought  proper  to  remove  six  in  one  case  on  which  I  operated,  and 
eight  in  another,  because  of  the  relaxation  of  parts  and  great  dilation  of  the 
anal  opening.  Of  course,  every  ribbon  cut  away  may  be  made  larger  or 
smaller.  The  solution  is  begun  more  or  less  low,  and  ended  at  a  greater  or 
less  height,  according  to  the  state  of  parts.  One  of  Hey's  patients  had 
hemorrhage.  I  do  not  know  that  any  of  Dupuytren's  met  with  this  accident. 
The  English  surgeon  having  left  us  no  detail  of  his  proceeding  or  his  subse- 
quent dressing,  &c.  we  are  left  in  ignorance  whether  the  bleeding  was  owing 
to  the  operation  itself,  or  the  way  in  which  it  was  performed. 

The  Professor  at  the  Hotel  Dieu  merely  covers  the  wounds  with  a  soft  mass 
of  lint  spread  with  cerate,  and  either  places  no  tent  at  all  in  the  anus  or  a 
very  small  one.  Twice  I  have  pursued  a  different  course.  I  passed  in  a  tent 
as  thick  as  the  finger  to  some  depth  in  the  rectum.  I  separated  several  little 
fasciculi,  placed  them  between  the  edges  of  each  wound,  and  kept  them  apart 
by  means  of  lint,  thin  compresses  and  a  T  bandage.  My  intention  was  to 
prevent  an  immediate  union  of  the  small  wounds,  to  compel  them  to  suppurate 
that  I  might  obtain  a  modular  cicatrix  of  more  firmness  and  elasticity,  and 
more  solid  adhesion  than  would  have  followed  the  original  union.  I  have  had 
no  cause  to  repent  of  having  done  so.  The  recovery  was  complete;  but  I 
must  admit  that  M.  Dupuytren's  method  which  is  more  simple,  must  be  al- 
most quite  as  good  a  one,  for  his  patients  have  all  equally  been  permanently 
cured  of  their  infirmities. 

But  any  one  who  knows  the  difliculty  of  prolapsus  ani  and  the  trouble 
which  it  gives,  this  operation,  which  I  have  now  described,  must  be  consi- 
dered a  valuable  triumph  of  modern  surgery.  One  of  the  things  which  made 
a  great  impression  on  me,  when  I  arrived  in  Paris  in  1820,  was  a  successful 
case  of  this  kind.  I  could  scarcely  conceive  how  it  could  be  possible  that  a- 
woman  then  lying  in  one  of  the  surgical  wards  of  the  Hotel  Dieu,  who  for 
fourteen  years  had  never  gone  to  stool  without  having  the  rectum  to  prolapse 
under  the  form  of  a  red  livid  tumor,  as  large  as  the  two  fists,  should  be  imme- 
diately cured  by  the  removal  of  a  few  folds  of  integuments.  It  was  done, 
however,  and  to  my  great  surprise.  M.  Paillard  states  that  this  operation  has 
now,  in  fifteen  years,  been  often  performed  by  M.  Dupuytren,  and  has  failed 
but  once:  and  even  that  single  failure  may  be  attributed  to  the  course 
adopted.  For  my  own  part,  I  have  performed  it  but  twice  upon  two  women, 
at  the  Hospital  St.  Antoine ;  and  its  effects  were  no  less  satisfactory. 

When  the  prolapsus  recurs  at  the  first  stools,  which  are  discharged  after 
excision,  it  is  seldom  so  decided  as  before,  re-enters  of  itself  with  more  or  less 
difficulty  and  soon  finally  disappears.  Looseness  of  bowels  is  favorable  to  its 
success,  as  it  prevents  the  patient  from  straining  so  much  in  defecation ;  and 
must,  consequently,  be  promoted  by  injections,  mild  purgatives,  and  laxative 


OPERATIVE    SURGERf.  895 

drinks.  Finally — Excision  of  radiated  folds  of  integuments  around  the  anus 
would  appear  to  be  sufficient  to  remedy  all  cases  of  procidentia,  which  de- 
pend on  a  state  of  relaxation  of  the  mucous  membrane,  integuments, 
sphincters,  and  outer  tissues ;  indeed,  in  any  case  not  originating  in  organic 
lesion,  or  disorganization  of  any  of  the  parts  contained  in  the  pelvis  and  hypo- 
gastrium.  Amputation  of  the  mass  should  be  reserved  for  cases  of  intestine 
prolapses  owing  to  inversion  or  intus-susceptio  and  those  procidentiae  which 
are  absolutely  irreducible. 

Art.  5. — Fissures, 

Amid  the  small  wounds  and  ulcers  which  appear  about  the  anus,  one 
species  exists,  the  only  remedy  for  which  thus  far,  lies  in  a  surgical  operation. 
I  mean  those  cracks  .or  chops  so  obstinate  and  so  painful,  which  exist  in  the 
tegumentary  folds  of  the  anal  circumference,  which  doubtless,  from  their  fre- 
quency, must  have  been  often  seen,  were  mentioned  by  Avicenna  and  others, 
who  gave  them  no  characteristic  distinction,  and  by  Lemonnier  more  expressly 
in  1661 ;  for  all  which,  however,  they  continued  to  be  confounded  with 
chancre  and  syphilitic  ulcers,  until  M.  Boyer  first  showed  their  real  character 
and  pointed  out  the  true  mode  of  tr^ting  them.  Whether  this  be  the  result, 
as  M.  Boyer  thinks,  or  the  cause  of  the  spasmodic  contraction  of  the  sphincter 
which  is  seen  to  coexist  with  them ;  whether  caused  by  the  pipe  of  a  syringe, 
as  M.  Thebord  says  he  once  saw  at  Besancon,  or  by  the  passage  of  hardened 
and  irregular  feces,  it  is  pretty  certain  that  they  are  seldom,  if  ever,  relieved 
by  any  topical  application.  The  Belladonna  ointment,  spoken  of  by  M. 
Vivent,  and  which  M.  Dupuytren  uses,  though  it  may  sometimes  cure  oftener 
disappoints  the  expectations  of  those  who  use  it. 

The  oil  of  Hyoscyamus  given  internally,  combined  with  the  introduction 
of  mercurial  ointment  into  the  anus,  as  M.  Descude  advises,  is  not  so  far  as  I 
can  learn  more  uniform  in  its  effects.  The  same  must  be  said  of  nitrate  of 
silver,  extolled  by  M.  Delaunay,  and  used  with  some  benefit  by  Beclard ;  it 
has  failed  completely  with  M.  Richerand,  and  I  have  not  been  more  fortunate 
than  him  with  trials  I  have  made  with  it.  Opium  and  cold  water  which  others 
praise  very  much  are  effectual  in  but  very  few  cases. 

Excising  the  ulcerated  surface,  which  has  long  been  proposed  and  practised, 
will  generally  cure  them;  but  incision  is  generally  so  satisfactory  in  its 
results,  and  so  commonly  known  now,  that,  admitting  the  knife  to  be  ne- 
cessary at  all,  it  seems  useless  to  follow  any  other  than  the  advice  of  M. 
Boyer. 

The  Operation. — Its  necessity  is  pointed  out  whenever  the  patient  com- 
plains of  burning  pain  at  each  stool,  as  if  a  red  hot  iron  were  being  passed  in 
at  the  anus ;  if  he  suffers  but  little  in  the  intervals ;  when  the  sphincter  is 
so  much  contracted,  as  without  being  disorganized  to  allow  the  forefinger  to 
pass  only  with  pain  and  difficulty;  and  this,  whether  the  fissure  be  visible  or 
not;  whether  it  be  detected  by  the  finger  in  the  anus  or  not.  The  prepara- 
tions, position  of  patient,  surgeon,  and  assistants,  are  the  same  as  in  the  opera- 
tion for  removing  hemorrhoidal  veins. 

Every  thing  being  in  readiness,  the  operator  passes  tlie  forefinger  of  his  left 
haiid  into  the  rectum ;  introduces  on  it,  flatwise,  a  narrow,  straight,  probe- 


896  NEW   ELEMENTS   OF 

pointed  bistoury,  held  in  his  right  hand  above  the  sphincter ;  then  turns  its 
edge  towards  the  fissure,  if  he  can  detect  its  seat,  if  not,  towards  one  buttock; 
has  the  skin  made  tense  by  the  fingers  of  an  assistant;  then  cuts  from  within 
outwards  the  constrictor  muscle,  in  all  or  nearly  all  its  thickness,  being  care- 
ful to  extend  the  cut  on  the  integuments  towards  the  buttock  and  a  little 
towards  the  interior  of  the  intestine.  When  we  do  not  know  where  the  fissure 
exists,  that  there  is  a  fissure  at  all,  or  if  the  disease  does  not  arise  wholly 
from  spasmodic  constriction  of  the  sphincter,  M.  Boyer  advises  us  to  make  an 
incision  on  each  end  of  the  transverse  diameter,  and  never  on  its  antero-pos- 
terior  diameter.  Even  though  success  do  not  appear  less  certain,  it  is  still 
more  prudent  to  carry  the  bistoury  forwards  or  backwards,  when  the  crack  is 
situated  there,  than  always  to  cut  on  one  side  at  the  risk  of  leaving  it  un- 
touched. 

The  only  difficulty  which  is  to  be  overcome,  arises  in  some  persons  from 
the  softness  of  the  tegumentary  layer,  either  mucous  or  cutaneous,  and  its 
disposition  to  get  away  from  the  dividing  instrument.  To  conquer  this,  it  is 
very  necessary  to  see  tliat  the  parts  are  well  stretched.  The  sphincter,  as  it 
offers  much  more  resistance,  may  be  cut  with  much  less  effort.  Should  it  be 
noticed  that  the  inner  coat  is  not  cut  into,  as  high  up  as  the  subjacent  tissues, 
we  must,  unhesitatingly,  extend  the  se(^tion  upwards  with  straight  scissors; 
whilst  the  bistoury  would  be  a  fitter  instrument  for  enlarging  that  of  the  skin 
downward,  if  it  were  necessary. 

A  tent  of  moderate  size,  a  square  cushion  of  lint,  some  compresses,  and  T 
bandage  suitably  applied,  constitute  the  dressings.  From  the  termination  of 
the  operation,  the  lacerating  and  distinctive  pains  of  the  fissure,  are  changed 
to  those  of  an  ordinary  incision;  and  after  the  very  first  stool,  the  difference 
is  so  very  marked,  that  most  patients  are  astonished  and  delighted.  The 
wound  heals  by  degrees.  The  dejections  resume  their  primitive  regularity. 
The  patient  again  enjoys  the  pleasure  of  repose,  and  after  the  cicatrization 
which  is  effected  generally  in  less  than  three  weeks  or  a  month,  he  is  as  free 
from  all  suffering  as  any  one  else.  Some  instances  of  its  failure  have  been 
mentioned,  but  so  vaguely  detailed  as  to  admit  of  no  conclusion  from  them. 
I  have  never  seen  it  fail  in  producing  its  effect.  In  1829,  it  suddenly  arrested 
the  agony  endured  by  a  woman  upon  whom  I  operated  at  the  hospital  St.  An- 
toine,  which  neither  dilation,  caustic,  opiates,  or  belladonna  could  allay.  How- 
ever, I  am  constrained  to  remark,  that  two  patients  upon  whom  it  has  since  been 
performed  have  died  of  it;  and  that  the  incision,  which  in  one  was  healed 
entirely  and  in  the  other  nearly  so,  had  not  prevented  the  formation  of 
several  abscesses  in  the  pelvis,  about  which  slight  traces  of  peritoneal  inflam- 
mation were  also  visible. 

Art.  6. — Fistula. 

Fistula  is  one  of  the  most  frequent  of  the  diseases  which  affect  the  anus,  it 
is  also  one  of  the  most  serious,  and  has  been  the  most  spoken  of  by  authors. 
Every  species  of  treatment  has  been  opposed  to  it.  By  Purmann  it  was  cured 
by  lime  water  injections,  calomel,  alum,  &c.  Pledgets  of  lint,  good  living, 
and  detergent  injections,  answered  for  pallus.  Evers,  quoted  by  Sprengel, 
was  in  some  cases  equally  successful  with  injections  of  gum  ammoniac.    If 


OPERATIVE    SURGERY.  897 

Titsing  be  believed,  digestive  (irritating)  ointments  do  very  well.  It  is 
known  that  in  the  time  of  Dionis,  the  waters  of  Barriege  and  of  Bourbon,  and 
some  particular  liquids  and  unguents  were  extolled  as  of  like  effect ;  but  the 
personal  experience  had  of  them  by  Louis  XIV,  who  himself  was  the  subject 
of  fistula  in  ano,  very  soon  reduced  these  panaceas  to  their  proper  level. 
Caustic,  which  enjoyed  greater  popularity,  and  is  in  fact,  of  greater  efficacy, 
is  mentioned  by  the  oldest  authors,  and  was  used  in  practice  under  all  its 
forms. 

The  surgeons  of  Alexandria  employed  a  linen  tent,  steeped  in  the  juice  of 
the  Euphorbium  (lithymale),  and  dusted  over  with  flour  of  copper  (oxides  and 
sulphate).  Leonidas  advises  the  use,  on  timid  patients,  of  pledgets  of  lint 
spread  with  litharge,  or  some  other  catheteric  substance.  Sublimate  and  arse- 
nic had  each  their  day,  and  J.  de  Vigo  knew  of  nothing  so  excellent  as  a  tent 
covered  with  vermillion.  Fallopius  gave  the  preference  to  the  Egyptiacum, 
and  to  precipitate.  Lemoyne,  who  lived  in  the  seventeenth  century,  made 
himself  famous  by  a  corrosive  ointment,  which  he  spread  on  a  linen  tent. 
*'  He,"  says  Dionis,  **  died  rich,  because  he  would  always  be  well  paid ; 
wherein  he  was  right,  for  the  public  value  things  only  in  proportion  to  their 
cost.  They  who  dreaded  the  knife,  placed  themselves  in  his  hands,  and  as 
the  number  of  cowards  is  very  large,  he  did  not  want  business."  For  this 
reason  the  actual  cautery,  used  by  Albucasis,  and  which  D.  Scacchi  and  M. 
A.  Severin  dared  scarcely  to  advise,  must  have  obtained  the  less  favor. 
Although  it  may  sometimes  be  successful,  this  method  is  now  wholly  aban- 
doned ;  as  is  also  that  of  Roger  of  Parma,  which  consisted  in  producing  ab- 
sorption of  the  callosities  with  fistula  by  tents  arranged  with  threads. 

§  1.  Anatomical  Remarks. 

As  concerned  in  the  operation  for  fistula,  the  rectum  and  perineum  require 
to  be  examined  in  another  point  of  view  than  for  that  of  cutting  for  stone. 
The  skin  as  it  converges  towards  the  intestine,  wrinkles  and  forms  plaits, 
which  are  repeated  on  the  mucous  membrane  within  the  sphincter,  and  even 
extend  quite  up  into  the  pelvis.  Small  valves,  their  concavity  being  upward, 
which  are  to  be  seen  occasionally  crosswise  between  them,  give  rise  to  capulse 
somewhat  resembling  pigeon  baskets,  in  which  irregular  bodies  mixed  with 
feces,  are  easily  arrested,  in  which  small  abscesses  at  times  originates,  and 
which  becomes  the  starting  points  of  a  good  many  fistulae.  The  tegumentary 
and  mucous  membranes,  which  are  united  by  a  very  mobile  and  yielding 
cellular  layer  to  the  subjacent  laminie,  become  detached  with  great  ease,  and 
slide  backward  and  forwards  upon  the  other  tissues  and  purulent  sinuses 
which  attempt  to  pass  between  their  outer  surfaces  and  the  neighboring  ele- 
ments. The  venous  network  which  covers  them  without,  more  abundant  and 
better  sustained  within  the  ring  of  the  sphincter,  is  generally  compressed 
above  by  the  accumulation  of  fecal  matters,  and  by  being  irritated  and  sub- 
jected to  friction  during  defecation,  becomes  congested,  hypertrophied, 
changed  into  erectile  tubercles,  suppurates  and  ulcerates,  and  hence  arises 
another  disposing  cause  of  fistula.  The  intestine,  which  is  flexible  and  dila- 
table above  the  constrictor  muscle,  where  it  is  supported  neither  by  the  point 

113 


898  NEW  ELEMENTS  OF 

of  the  coccyx,  or  by  the  aponeurosis,  and  which  is  obliged  to  lean  backwards 
so  as  to  follow  the  curve  of  the  sacrum,  and  make  room  for  the  bladder,  here 
presents  a  species  of  dilation,  the  lower  half  or  floor  of  which  is  necessarily 
obliged  to  bear  the  action  of  all  the  solid  and  irritating  matters  which  endea- 
vor to  escape  from  the  digestive  passage  ;  which  is  a  third  cause  again  of  the 
occurrence  of  fistula.  As  its  posterior  wall  alone  suffers  this  inconA^enience, 
it  is  natural  that  most  fistulae  should  have  their  roots  posteriorly.  This  por- 
tion of  the  organ  is  supported  below  by  the  fascia  pelvica  or  the  levatores  ani 
muscles,  and  ischio-coccygean  ;  whence  perforations  in  it  are  more  likely  to 
be  attended  with  an  effusion  of  pus  into  the  pelvis  than  any  otlier.  The  peri- 
toneum by  quitting  its  sides  that  it  may  line  the  interior  of  tiie  pelvic  cavity, 
leaves  all  its  posterior  edge  in  close  contact  with  the  cellular  tissue,  which  is 
continuous  in  the  thickness  of  all  the  mesenteries.  Consequently  it  is 
possible  that  pus,  forming  on  the  forepart  of  the  spinal  column  in  the  lumbar 
regions,  or  even  in  the  thorax,  may  comedown,  following  the  posterior  face  of 
the  rectum  as  far  as  the  perineum,  give  rise  to  an  abscess  on  the  margin  of 
the  anus,  aud  create  a  mistaken  belief  in  the  existence  of  an  anal  fistula,  a 
remarkable  instance  of  which  came  under  my  notice  in  1825,  at  the  Hospi- 
tal de  Perfectionnement. 

The  Aponeurosis  m^j  be  considered  as  forming  two  distinct  systems  around 
the  rectum.  The  outer  of  these  comprises,  1st,  the  parietal  portion  of  the 
fascia  pelvica,  i.  e.  that  which  covers  the  obturator  and  pyramidal  muscles  in 
tlie  pelvis,  2d,  the  ischiatic  layer  of  the  ischio-rectal  aponeurosis  of  the  per- 
ineum, which  inferiorly  completes  the  fibrous  canal  of  the  obturator  internus 
muscle  and  on  the  one  side  is  continuous  with  the  sacro-sciatic  ligament,  and 
on  the  other  it  closely  approaches  the  inner  border  of  the  preceding  layer. 
Taken  all  together,  this  system  resembles  a  large  vault,  fastened  by  its  edges 
upon  the  two  straits,  filled  up  by  the  above  mentioned  muscle ;  the  two  planes 
of  which  vault  incline  towards  each  other,  and  so  unite  as  to  form  as  it  were 
but  one  edge  at  the  moment  of  tlieir  injunction.  To  the  other  system  belongs 
both  the  cellulo  firbrous  layer,  which  ascends  from  the  bottom  of  the  pelvic 
excavation  up  over  the  outer  surface  of  the  intestine ;  and  the  rectal  leaf 
of  the  perineal  excavation  which  lines  the  surface  of  the  levator  ani  and  the 
ischio-coccygeus.  These  two  layers  compose  the  second  vault,  whose  con- 
cavity is  turned  towards  the  rectum,  continuous  outwardly  with  the  inner  edge 
of  the  outer  vault.  Perforations  of  intestine  or  pus  can  get  beneath  the  peri- 
toneum into  the  pelvis,  only  by  traversing  its  upper  or  pelvic  layer;  and  into 
the  ischio-rectal  excavation,  only  after  passing  through  its  lower  or  perineal 
layer.  All  fistula  which  originate  between  its  anal  edge,  that  is  to  say,  above 
the  sphincter  and  its  upper  edge,  i.  e.  below  the  peritoneal  cul-de-sac,  make  it 
possible  for  both  these  modes  of  propagation  to  be  followed ;  and  expose  to 
the  formation  of  burrowings  of  matter  backwards,  between  the  anus  and 
coccyx,  and  also,  between  the  fibres  of  surrounding  muscles,  being  pressed 
downwards,  jj;enerally  only  by  reason  of  the  pressure  of  the  intestines,  or  the 
inconsiderable  resistance  of  the  interior  aponeurosis.  Such  as  have  their 
origin  a  little  further  down,  on  the  contrary,  immediately  enter  the  ischio- 
rectal excavation,  and  are  but  little  disposed  to  spread  towards  the  pelvis. 
However,  the  circumstance  of  the  anus  being  embraced  by  the  fascia,  as  it 


OPERATIVE    SURGERY.  899 

were  by  a  ring  between  the  sphincter  and  the  intestine,  explains  the  way  in 
which  fistula  that  have  originated  at  this  joint  and  opened  externally,  are  so 
frequently  complicated  with  detachment  either  of  the  mucous  membrane  or 
of  the  whole  thickness  of  the  rectum  for  an  extent  of  one  to  several  inches 
upwards.  The  enormous  quantity  of  fatty,  cellular  tissue  placed  between 
the  thin  and  the  perineal  vault  of  these  two  systems  of  the  aponeurosis,  is 
consequently  the  usual  locality  of  those  stercoral  inflammations  which  pre- 
cede the  establishment  of  fistula  in  ano.  It  is  so  much  the  easier  destroyed, 
either  by  gangrene  or  suppuration,  as  it  forms  an  almost  isolated  mass  in  the 
back,  part  of  the  perineum;  and  the  vacuum  which  it  produces  is  filled  up 
with  the  greater  difliculty,  that  the  ischiatic  layer  of  the  excavation  is 
immovable,  andean  no  sooner  approach  the  denuded  intestine,  but  the  natu- 
ral action  of  the  rectum  interferes  to  separate  them  again.  This  is  no  doubt 
the  reason  of  the  frequency  of  blind  external  fistula,  erroneously  denied  by 
many  modern  writers,  and  of  those  changes  to  fistula  of  abscesses  which 
either  do  not  communicate  at  all  or  only  secondarily  with  the  anus.*  Hence, 
also,  arises  the  disposition  to  spread  which  is  observed  in  deep  phlegmonous 
abscesses,  to  open  into  the  intestine  and  to  produce  a  blind  internal  fistula, 
instead  of  tending  outwardly  to  the  skin.  In  fact,  the  rectum,  which  is 
always  flexible,  and  very  frequently  empty,  often  presents  less  resistance  to 
them  than  the  skin;  besides  which,  the  organism  has  here  no  excentric  pres- 
sure of  the  viscera,  as  in  the  parietes  of  the  abdomen,  to  oblige  the  pus  to 
pass  towards  the  exterior.  The  train  laid  by  the  cellular  tissue  above  the 
coccyx  and  lower  edge  of  the  gluteus  maximus  muscle,  perfectly  explains 
the  vast  cavities  which  in  certain  persons  are  seen  in  this  direction ;  and  its 
continuity  with  the  lamellar  tissue  of  the  meso-rectum,  also  explains  how  an 
abscess  may  be  caused  on  the  margin  of  the  anus  by  disease  of  the  sacrum, 
vertebra,  or  bones  of  the  pelvis,  which  may  simulate  a  fistula  by  extending 
above  the  transverse  muscle,  in  the  anterior  cul-de-sac  of  the  ischio-rectal 
excavation  in  man,  or  in  the  thickness  of  the  labia  majora  in  woman ;  and 
thirdly,  how  it  is  that  abscesses  can  make  their  way  through  the  perineum 
towards  the  scrotum,  and  produce  fistulae  which  might  at  first  be  supposed  to 
be  of  an  urinary  nature.  Lastly,  it  is  by  following  these  different  tracks 
that  certain  fistulae  open  so  far  from  their  point  of  departure,  and  perform  so 
complicated  a  transit. 

The  arteries  are  all  likewise  worthy  of  some  attention.  The  trunk  of  the 
internal  pudic  is  at  too  great  a  distance  to  run  any  risk  at  the  time  of  the 
operation,  unless  it  is  necessary  to  make  very  large  lateral  sections.  The 
inferior  hemorrhoidal,  which  it  gives  off"  behind  the  ischium,  though  often 
interested,  need  give  no  anxiety.  They  are  too  superficial,  generally  too 
small,  and  too  easy  to  find,  tie,  or  make  pressure  upon,  for  the  surgeon  really 
to  be  afraid  to  wound  them.  The  branches  given  by  the  hypogastrics  are 
likewise  .too  delicate,  and  are  distributed  to  points  too  distant  from  the  skin, 
to  be  reached  by  the  instrument.  The  median  hemorrhoidal,  which  form  the 
inferior  mesentric  at  their  termination,  demaid  a  little  more  respect.  Situa- 
ted posteriorly,  at  first  between  the  lamina  of  the  mesentery  and  afterwards 
in  the  very  thickness  of  the  fleshy  layer  of  the  intestine,  they  approach 
nearer  and  nearer  to  the  mucous  tunic,  and  continue  to  be  of  same  size  in  the 
laced  or  net  work  which  they  form  around  the  cutaneous  extremity  of  the 


900  NEW    ELEMENTS    OF 

rectum.  Owing  to  this  arrangement,  their  section  is  more  dangerous  in  the 
posterior  half  of  the  organ,  than  in  the  opposite  direction,  and  also  the  higher 
the  operation  is  performed.  From  the  foregoing  remarks,  it  follows  that  the 
greater  number  of  fistulas  in  ano  being  preceded  bj  phlegmonous  abscesses  in 
the  ischio-rectal  excavation,or  by  hemorrhoidal  tubercles  must  arise  within  the 
sphincter,  between  it  and  the  fibrous  ring  which  exist  above,  or  the  pyloric 
valve  described  by  Mr.  Houston.  The  first  person  who  seems  to  have  made 
this  remark  is  Mr.  Brunei  in  178S,  or  at  least  M.  Pleindoux  has  since  then 
claimed  it  for  him.  But  it  had  not  escaped  either  Sabatier,  or  M.  Larry; 
although  to  M.  Ribes  is  due  the  credit  of  having  established  it  as  a  principle. 
This  latter  author  has,  however,  gone  evidently  too  far  in  saying  that,  no 
others  are  ever  met  with.  The  hundred  cases  upon  which  he  founds  his 
opinion,  however  imposing  a  mass  of  authority  they  be,  cannot  destroy  the 
opposite  facts,  detailed  by  other  practitioners.  M.  Boyer  and  Roux,  state 
that  they  have  operated  on  fistula,  the  orifices  of  which  were  several  inches 
in  depth  in  the  intestine.  I  treated  one  myself  whose  orifice  was  so  high  up 
that  it  was  with  difficulty  I  could  reach  the  spot  in  the  intestine  with  my 
finger;  and  in  a  patient  who  died  in  1825,  at  the  hospital  of  the  school,  it 
opened  backward  at  three  inches  above  the  sphincter.  These  very  elevated 
fistula,  are  owing  to  the  impaction  of  foreign  bodies  in  the  dilatable  portion 
of  the  rectum,  and  to  this  list  also  often  belong  those  cases  seen  in  phthisical 
patients,  the  frequent  result  of  tuberculous  ulceration  of  the  folliculi  or 
lacunae  of  the  organ.  It  is  incorrect,  however,  always  to  judge  of  the  depth 
of  a  fistula,  by  the  vertical  extent  of  the  detachment  effected ;  the  stylet  will 
often  enter  without  difficulty  three  or  four  inches,  though  the  fistula  may  be 
seated  at  a  depth  of  only  as  many  lines. 

§  2.  Examination  into  the  Methods. 

A.  Ligature, — Caustic,  injections,  and  the  apolinosis  or  ligature,which  accord- 
ing to  one  of  the  books  attributed  to  Hypocrates,  used  to  be  made  with  five 
threads  surrounded  by  a  horse  hair,  and  was  passed  through  the  fistula  into  the 
intestine  with  a  brass  stylet,  have  encountered  the  same  fate  and  are  now 
very  seldom  employed.  In  the  time  of  Celsus  a  kind  of  packthread  was  used, 
which  was  spread  with  some  escharotic  substance.  Avicenna  preferred 
twisted  horse  hair  or  hog's  bristles.  Guy  de  Salicet.  advises  the  use  of  a 
small  string,  knotted  in  several  places,  to  cut  the  parts;  whilst  Guillemeau, 
an  imitator  of  Pare,  passed  it  through  a  canula  by  the  fistula  into  the  rectum 
with  a  double  edged  needle.  Notwithstanding  the  reasoning  of  Foubert,  who 
substituted  a  leaden  wire  for  that  generally  in  use,  and  who  contrived,  for  the 
purpose  of  introducing  it,  a  stylet  of  a  rolling-pin  shape ;  of  Camper,  who 
returned  to  the  use  of  silken  or  hempen  ligatures;  of  J.  J.  Bousquet,  who 
recommends  that  the  lead  wire  be  surrounded  with  lint  and  passed  with  a 
needle;  of  Desault  who  employed  a  directing  catheter,  then,  like  Pare,  a 
canula,  and  also  a  leaden  wire,  which  he  seized  in  the  intestine  with  his  finger 
or  gorget-forceps,  to  draw  its  extremity  out  at  the  anus,  and  fasten  it  by  means, 
of  a  knot  tightener;  of  Flajani,  who  was  satisfied  to  use  a  waxed  hemp  liga- 
ture; and,  indeed,  of  most  timid  surgeons,  Apolinosis  numbers  but  few  advo- 
cates among  the  practitioners  at  the  present  day.    The  advantage  attributed 


OPERATIVE  SURGERY.  901 

to  it  by  its  advocates  are  more  apparent  than  real,  and  are  counterbalanced 
by  numerous  inconveniences.  Its  action  is  very  slow.  The  strangulation 
which  it  causes  often  gives  the  greatest  pain,  and  nervous  contractions,  which 
are  really  such  as  to  create  uneasiness.  It  will  cure  complicated  deep  and 
multiplied  fistula  but  rarely ;  and  even  in  the  simplest  cases  is  far  from 
always  proving  sufficient. 

The  Method  of  Operation. — If,  however,  we  wish  to  attempt  it,  it  is  imma- 
terial whether  we  use  a  strong  well  waxed  thread  of  linen  or  silk,  or  a  wire 
of  lead  or  pure  silver.  If  the  first,  we  pass  it  through  the  fistula  by  means 
of  a  sharp  flexible  stylet ;  and  if  the  second,  we  introduce  it  through  a  grooved 
staff  or  canula;  the  forefinger  of  the  left  hand  in  either  case,  being  pushed 
up  the  rectum,  seizes  on  the  thread  or  wire  and  draws  it  out  at  the  anus. 
The  ends  are  then  to  be  placed  in  the  ball  knot  tightener  of  Riolan,  Gerauld, 
or  still  better,  that  of  Mayor,  or  else  in  Desault's  instrument,  or  they  may  be 
twisted  on  themselves,  if  of  a  metallic  substance.  By  being  careful  to  tighten, 
them,  as  the  tissues  give  way,  say  every  day,  or  only  every  two  or  three  days, 
as  the  constriction  remains  greater  or  is  lessened,  one  mav  succeed  in  cutting 
through  the  intervening  tissues  in  twenty,  thirty,  or  forty  days,  so  that  by  the 
time  the  ligature  is  out,  the  fistula  is  generally  healed.  But  how  many  times 
does  it  become  necessary  to  remove  it  before  this  is  accomplished,  owing, 
to  the  pain  it  produces,  its  slow  mode  of  action,  and  because  patients  cannot 
endure  it.  In  1 824,  M.  Bengon  determined  to  give  it  a  trial  at  the  Hospital 
de  Perfectionnement,  upon  a  courageous  and  stout  adult.  The  man  kept  it 
in  for  three  weeks,  complaining  of  excessive  pain  each  time  it  was  tightened. 
By  the  end  of  this  time,  the  frenum,  though  of  trifling  extent  originally  was 
not  half  divided,  and  as  the  sufferings  increased,  it  was  thought  proper  to  ex- 
cise it,  which  was  speedily  successful.  Taking  every  thing  into  consideration, 
ligature,  being  applicable  only  to  superficial  simple  fistula,  should  be  given  up ; 
and  with  less  regret,  because  the  methods  which  can  be  substituted  for  it,  are 
generally  less  painful,  and  as  easy  as  they  are  safe  and  certain. 

Eccentric  Compression. — All  surgeons  have  not  yet  relinquished  the  idea  of 
curing  fistula  without  shedding  blood  in  the  operation.  A  means  has  indeed 
been  conceived  of  late  years  which  appears  to  be  highly  ingenious,  the  object 
of  which  is  to  close  the  inner  orifice  and  thus  dry  up  the  ulcer.  The  idea  which 
belongrs,  I  believe,  to  M.  Bermond  also  occurred  to  M.  Colombe.  The  first 
gentleman  conceives  that  this  end  may  be  perfectly  accomplished  by  his  double 
chemise  canula,  applied  as  we  described  when  speaking  on  piles :  the  latter 
assures  us,  that  he  has  succeeded  in  doing  it  by  keeping  a  hollow  ebony  cylin- 
der in  the  anus  held  by  ribbons  without.  The  method  may  be  tried ;  but 
it  is  not  yet  sanctioned  by  experience,  and  too  much  is  not  to  be  expected 
from  it.  From  an  attempt  made  by  the  author,  it  is  proved  that  the  mucous 
membrane  of  the  rectum  may  become  invaginated  in  the  upper  aperture  of  the 
compressing  body  and  give  rise  to  acute  pain.  The  cutting  instrument  then 
alone  remains  which  is  capable  of  adaptation  to,  and  triumphing  over  every 
species  of  anal  fistulse. 

B.  Operation  properly  so  called. 
Incision  and  excision,  which  have  alternately  been  rejected,  the  one  for  the 


902  NEW  ELEMENTS  OF 

other,  and  vice  versa,  are  now  alone  retained  in  practice,  having  undergone 
many  changes  and  improvements;  but  in  such  a  way,  that  now,  far  from  being 
materially  incompatible,  w^e  often  require  to  combine  the  two  methods,  and  to 
employ  them  in  concert. 

1.  incision. — In  spite  of  their  predilection  for  caustic  and  ligatures,  the  an- 
cients very  well  knew  that  incision  was  the  best  remedy  for  fistula  in  ano. 
Hippocrates  says  so  in  so  many  words,  and  it  is  further  sufficiently  evinced 
bv  an  instrument  called  Syringotome,  a  kind  of  sickle-shaped  bistoury,  which 
was  employed  in  the  time  of  Galen.  By  Leonidas  it  was  performed  with  an 
instrument,  whicli  ended  by  a  long  flexible  stylet,  which  was  introduced  into 
the  fistula  and  brought  out  at  the  intestine  so  as  to  cut  the  frenum  at  one  stroke. 
In  the  middle  ages,  Hugh  de  Lucques,  first  passed  a  ligature  to  act  as  a  staiF 
and  make  the  parts  tense  during  the  incision.  Guy  de  Chauliac,  who  was 
always  alarmed  at  the  prospect  of  hemorrhage,  preferred  a  grooved  staif  or  di- 
rector, upon  which  he  guided  his  bistoury,  heated  to  whiteness.  Fabricious  ab 
Aquapendente,  having  dilated  the  passage  with  his  speculum,  employed  merely 
a  simple  probe-pointed  bistoury  rather  concave,  and  a  staff,  for  making  the 
incision.  Among  others,  Sphigelius,  for  example,  contrived  to  encase  the  syrin- 
gotome in  a  curved  silver  probe-pointed  canula  which  entered  first  into  the 
fistula,  was  withdrawn  by  the  fingers,  leaving  a  wire  attached  to  the  end  of  the 
bistoury,  to  draw  it  forward  both  by  point  and  handle,  and  divide  the  fistula  at 
one  stroke.  Marchett  conceived  the  idea  of  passing  a  conducting  gorget  into 
the  anus  for  the  purpose  of  receiving  the  point  of  the  cutting  instrument,  or  of 
the  director.  Wiseman  dispensed  with  it,  and  employed  scissors  instead  of  the 
syrino-otome,  which  did  not,  however,  prevent  Felix  from  reproducing  Leoni- 
das's  bistoury,  which  he  altered  by  covering  it  with  a  cap  so  as  to  make  its 
introduction  less  painful.  This  instrument  subsequently  received  the  name  of 
"rovai,"  owing  to  the  operation  performed  with  it  on  Louis  XIV.  During  the 
last  century,  J.  L.  Petit  demonstrated  tliat  a  common  bistoury,  slightly  con- 
cave, passed  upon  a  grooved  staff,  was  equally  as  good  as  any  apparatus 
before  extolled ;  and  Ringe  made  the  process  as  certain  as  it  was  possible  by 
advising  a  gorget  like  that  of  Marchett's,  and  a  grooved  staff,  one  introduced 
into  the  intestine,  the  other  through  the  wound,  so  that  by  means  of  a  long 
straight,  strong  pointed  bistoury,  made  to  slide  upon  the  staff",  all  the  parts 
contained  between  the  two  instruments  might  be  divided. 

2.  Platner  thought  that  he  had  improved  the  mode  of  incision,  by  proposing 
to  effect  it  by  a  bistoire  cache,  which  others  generally  combined  with  the  gor- 
get. Pott,  to  simplify  it,  still  further  considered  that  all  that  was  necessary 
was  a  curved  probe-pointed  bistoury.  For  this  B.  Bell  substituted  a  narrow 
bistoury  ending  by  a  beak  like  a  catheter.  Pott's  instrument  was  modified 
almost  immediately  by  Savigny,  who  fixed  a  pointed  blade  upon  one  of  its 
faces,  which  might  be  made  to  draw  in  and  push  out  at  will ;  and  also  by  T. 
Whately,  who  made  its  cutting  edge  movable,  so  as  only  to  draw  it  after 
the  knob  on  its  blade  had  been  carried  into  the  rectum.  Some  persons  in  our 
own  times  have  resorted  to  the  use  of  this  bistoury;  Dr.  Dorsey  caused  the 
point  to  be  lengthened  out  into  a  cone;  and  M.  Dubois  makes  it  advance  upon 
a  grooved  flexible  staff  which  is  previously  brought  from  the  intestine  out  at 
the  anus,  by  the  finger.  M.  Larrey  adopts  the  old  stylet  bistoury  of  Leonidas, 
reproduced  by  H.  Bass,  and  afterwards  by  Brunei.      In  the  way  that  it  is 


OPEIL\TIVE    SURGERY.  90S 

modified  by  this  surgeon,  it  is  no  other  than  a  common  straight  bistoury,  end- 
ing in  a  long,  blunt  and  flexible  stylet,  which  is  pushed  in  at  the  fistula,  and 
drawn  out  at  the  anus,  no  other  conducter  beino;  needed  for  dividins  at  one 
cut  the  whole  thickness  of  the  frenum.  Lastly,  I  have  been  shown  one  by  M. 
Charriere,  the  back  of  which  is  grooved  in  such  a  way  that  it  slips  as  well 
upon  a  cylindrical  stem  as  upon  a  grooved  staft',  so  that  the  exploring  stylet 
generally  employed  becomes  its  guide;  the  substitution  of  the  sound  for  it  is 
not  required. 

AVithout  attempting  to  deny  the  success  claimed  for  each  of  these  numerous 
procedures,  it  may  at  least  be  asserted  that  out  of  the  whole  armament,  the 
only  instruments  worth  preserving  are  those  which  have  been  kept  in  use  by 
modern  surgeons  ;  viz.  the  wooden  gorget,  the  grooved  staff,  the  straight  bis- 
toury. Pott's  bistoury,  or  the  bistoury  of  M.  Larrey. 

2.  Excision. — The  mode  of  performing  excision  has  likewise  varied.  It  is 
first  described  by  Celsus.  "  We  make,*'  says  he,  *'  an  incision  on  either  side 
of  the  track,  and  remove  all  the  parts  which  they  enclose  between  them.  "Paul 
of  Egina,  resorted  to  the  syringotome,  forceps,  and  an  ordinary  bistoury.  Some 
have  been  content  to  excise  all  the  movable  wall  of  the  fistula,  after  having 
included  it  in  a  loop  of  thread,  &c.,  or  raised  it  up  with  forceps  or  a  director, 
and  for  this  end,  employed  either  the  straight  or  concave  bistoury,  or  curved 
scissors,  as  recommended  by  G.  Heuermann.  Others  thought  it  requisite  to 
remove  the  whole  track  of  the  fistula,  either  at  one  stroke,  or  by  excising  the 
two  walls  one  after  the  other.  Some,  the  vault  being  once  destroyed,  were 
satisfied  with  merely  scarifying  simply  and  purely  its  callosities.  Those  as 
MM.  Boyer  and  Roux,  who  now  admit  of  excision,  begin  by  an  incision  into 
the  passage,  and  then  remove  the  detached  integuments  which  they  take  up 
with  forceps,  and  cut  away  with  strokes  of  the  bistoury, 

T7ie  Method  of  Operation. — A  purgative  given  over  night,  if  the  state  of  the 
digestive  organs  permits,  is  necessary  to  prevent  the  want  of  an  alvine  dejec- 
tion from  being  too  soon  felt.  Dionis  says,  that  a  "glister  should  be  adminis- 
tered two  hours  beforehand,  that  the  surgeon  may  run  no  risk  during  the 
operation,  of  having  his  face  inundated  with  fecal  matters." 

The  instruments  are  the  particular  kind  of  bistoury  which  may  be  preferred 
several  common  bistouries,  strong  dissecting  forceps,  a  silver  and  a  steel  di- 
rector, the  latter  without  any  cul-de-sac,  a  boxwood  or  ebony  gorget,  straight 
scissors,  scissors  curved  on  their  flat  surfaces,  some  irons  for  cautery,  needles, 
ligatures,  along  tent  of  lint,  and  a  tent-bearer,  (portemiche)  to  passitin  with 
tampons,  or  the  hoemostatic  contrivances  elsewhere  described,  (see  excis.  of 
haemorrhoids),  some  balls  of  lint,  three  or  four  square  cushions  of  lint,  long 
compresses,  square  compresses  three  or  four  times  doubled,  and  a  double 
T  bandage. 

The  patient,  when  the  fistula  is  upon  the  nigh  side,  lies  upon  his  right;  on 
the  contrary,  upon  his  left  side,  when  it  is  upon  his  left,  in  front  or  behind  ;  he 
is  to  be  doubled  up,  his  head  low,  his  abdomen  resting  upon  a  bolster,  his  lower 
limb  is  stretched  out,  his  upper  one  drawn  up  and  flexed.  An  assistant  stand- 
ing in  front,  prevents  him  from  raising  his  head,  and  watches  over  the  motion 
of  his  arms.  The  pelvis  and  the  flexed  limb  are  held  still  by  a  second  assis- 
tant. A  third  assistant,  standing  behind,  is  desired  to  separate  the  nates  and 
hold  the  gorget  steady  at  the  suitable  time.     Lastly,  a  fourth  and  a  fifth  are 


904  NEW   ELEMENTS    OF 

necessary  to  hold  the  other  limb,  make  tense  the  tissues,  and  hand  instruments, 
or  wipe  ^e  wound. 

Before  proceeding  any  further,  the  surgeon  now  seeks  the  two  openings  of 
the  fistula.  The  external  one  it  can  never  be  very  difficult  to  discover.  The 
fecal  moisture  or  the  pus  which  escapes  from  it,  is  enough,  with  absence  of 
any  wound,  to  point  out  its  situation,  though  it  should  be  at  the  bottom  of  an 
hemorrhoidal  tubercle,  or  some  fold  of  integument.  Not  so  always,  however, 
it  is  with  the  internal  aperture.  This  is  usually  met  with  in  the  centre  of  a 
small  induration,  shaped  like  the  rump  of  a  fowl  (en  cul-de-ponte)  which  the 
forefinger  in  the  rectum  will  often  readily  distinguish.  It  is  often  not  found, 
owing  to  our  looking  for  it  too  far  off;  it  is  oftentimes  so  near  the  skin,  that 
attention  is  necessary  to  avoid  overlooking  it ;  and  it  is  not  until  all  the  stran- 
gulated or  right  portion  of  the  intestine  has  been  carefully  examined,  that  we 
are  to  seek  if  it  be  not  higher  up.  A  flexible  stylet,  however,  removes  the 
difficulty.  It  is  carefully  to  be  introduced  through  the  cutaneous  opening 
with  the  right  hand,  in  the  direction  of  the  sinus,  and  letting  it  follow  its  dif- 
ferent tortuosities  without  effi)rt,  its  head  will  very  soon  present  itself  to  the 
left  forefinger  which  is  waiting  for  it  in  the  rectum.  When  but  one  external 
opening  exists,  this  stylet  penetrates  generally  with  facility,  unless  the  fistula 
turn  at  several  sharp  angles  in  its  course.  When,  on  the  contrary,  several 
are  met  with,  and  there  are  a  good  many  burrowings  around  the  anus,  the  dif- 
ficulty sometimes  becomes  extreme.  We  must  then  pass  the  probe  into  each 
separately,  acting  as  aforesaid.  Even  should  these  attempts  prove  fruitless, 
we  are  not  authorized  to  conclude  that  no  opening  into  the  intestine  exists. 
Many  circumstances  may  serve  to  conceal  it  from  the  observation  of  the  sur- 
geon. Some  milk,  if  it  were  to  be  kept  above  the  anus,  would,  by  flowing  out  of 
the  outer  wound,  prove  its  existence,  as  it  would,  likewise,  if,  when  passed  in  at 
the  latter  orifice,  it  came  out  at  the  anus.  Anv  other  inoffensive  dark  colored 
fluid  will  do  as  well.  It  sometimes  happens  that  the  probe  is  separated  from 
xhe  forefinger  only  by  a  pellicle  as  thin  as  a  sheet  of  paper,  and  yet  cannot  be 
made  to  pass  bare  into  the  intestine.  It  moves  about  in  every  direction  with- 
out difficulty.  It  is  easy  to  feel  that  the  mucous  membrane  is  thin,  detached, 
and  yet  the  probe  is  seen  to  remain  outside  of  the  organ.  Is  there,  then,  in 
this  case  an  opening  at  some  different  part,  or  is  it  a  blind  external  fistula  ? 
It  is  impossible  to  say,  and  yet  something  must  be  done.  These  cases  which 
were  formerly  thought  very  embarrassing,  and  which  are  still  exceedingly 
disagreeable  to  those  surgeons  who  do  not  think  it  right  to  operate,  without 
having  first  passed  through  the  fistula  from  one  side  to  the  other,  are  not,  in 
the  eyes  of  M.  Roux  deserving  of  all  this  solicitude.  That  surgeon,  indeed, 
asserts,  that  the  inner  orifice  of  the  passage  to  be  divided  does  not  deserve 
the  importance  which  is  usually  given  to  it.  The  remedy  is  the  same  whether 
it  exist  or  not.  Detachment  of  the  rectum  is  quite  sufficient  to  justify  the 
operation.  The  minute  researches  undertaken  by  the  members  of  the  Aca- 
demy of  Surgery,  appear  to  him  to  have  been  nearly  superfluous. 

For  my  own  part,  I  think,  that  although  the  means  of  ascertaining  whether 
the  ulcer  opens  into  the  intestine,  we  should  operate,  nevertheless,  though  it 
be  not  found  to  do  so;  since  the  disease  has  been  of  some  months'  duration, 
and  the  defecator  organ  is  to  some  extent  detached. 

If,  then,  we  have  discovered  this  aperture,  and  it  is  not  very  high  up,  the 


OPERATIVE    SUROERT.  905 

silver  staff  is  substituted  for  the  probe.  The  forefinger  seekin<^  it  in  the 
rectum,  hooks  its  beak,  lowers  it,  and  bending  it  a  little,  makes  it  come  out 
at  the  anus  whilst  the  surgeon  continues  to  push  it  forward  with  his  right 
hand.  The  whole  of  the  intervening  tissues  are  then  divided  at  one  stroke 
by  a  simple  straight  bistoury,  as  is  used  by  MM.  Richerand,  Ribes,  Sa- 
batier,  and  M.  Dupuytren,  and  as  I  have  often  done  it  myself;  or  else 
Pott's  curved  bistoury,  that  of  Dorsey  with  a  conical  point,  or  the  slightly 
concave  one  of  J.  L.  Petit;  its  point  protected  by  an  assistant,  and  conducted 
upon  the  groove  of  the  staff'.     The  whole  operation  is  extremely  simple. 

When  the  fistula  extends  much  Idgher  up,  or  the  detachment  is  carried  very 
far,  it  is  better  to  imitate  M.  Boyer  and  M.  Roux,  and  employ  the  steel  di- 
rector with  a  somewhat  pointed  beak.  It  is  introduced  to  the  upper  part  of 
the  abscess.  Instead  of  the  finger,  which  had  followed  all  its  motions  in  ano, 
a  gorget  is  introduced,  and  its  groove  offered  to  the  beak.  It  is  pushed  into 
this  gorget  in  such  a  way  as  to  pierce  the  intestine.  By  moving  them  back- 
wards and  forwards,  which  causes  them  to  rub  against  one  another,  we  assure 
ourselves  of  their  mutual  contact.  Thereupon,  the  assistant  seizes  the  handle 
of  the  gorget,  holds  it  fast,  and  turns  it  outwards  a  little,  as  if  he  meant  to  giYe 
it  a  seesaw  motion.  The  surgeon  does  the  same  to  the  handle  of  the  director 
with  his  left  hand;  takes  a  bistoury  with  a  strong  point  in  his  right  hand; 
places  its  tip  in  the  groove  of  the  director ;  pushes  it  quickly  on  to  the  gorget, 
and  withdraws  by  raising  his  wrist  and  not  allowing  it  to  leave  the  fulcrum 
which  has  been  given  to  it.  For  fear  that  the  whole  IVenum  has  not  been  di- 
vided, it  is  passed  in  a  second  and  a  third  time  upon  the  director;  then  to  be 
sure  that  nothing  remains,  the  two  co-operating  instruments  are  withdrawn 
together,  as  if  they  were  but  one.  If  there  should  remain  a  cul-de-sac  at  its 
upper  part,  we  are  forthwith  to  proceed  to  divide  the  abnormal  valve  which 
forms  it,  and  lay  it  bare  by  means  of  scissors  passed  up  on  the  finger.  The 
cutting  edge  of  the  bistoury  is  then  turned  outwards  and  applied  to  the  bot- 
tom of  the  wound,  which  it  cuts  or  scarifies  to  a  moderate  degree  in  its  whole 
length,  and  which,  moreover,  it  extends  at  the  expense  of  the  skin  for  an  half 
inch  or  an  inch  upon  the  buttock.  Lest  the  integuments  should  be  detached  or 
thinned,  they  are  divided  crucially  or  in  the  form  of  an  inverted  T ;  alter  which 
each  flap  is  to  be  seized  with  the  forceps,  and  cut  with  the  bistoury  upon  its 
base,  from  the  free  surface  towards  the  wound.  But  for  this  precaution  suppura- 
tion would  be  interminable  and  tlie  cure  very  uncertain.  The  pain  it  gives  and 
the  time  it  requires  are  nothing,  in  proportion  to  the  advantages  which  result 
from  it.  Prudence  does  not  justify  our  dispensing  with  it,  except  in  fistulae 
of  the  very  simplest  kind. 

The  same  that  has  been  done  upon  one  sinus  of  the  fistula,  is  to  be  done 
upon  all  the  rest,  so  as  to  recombine  them  all  with  the  wound  of  the  rectum. 
All  the  tegumentary  portions  thus  formed,  are  equally  excised  though  but 
little  changed,  or  though  they  may  have  lost  all  their  thickness.  The  same 
bistoury,  or  a  probe-pointed  one,  still  directed  upon  the  finger,  is,  in  the  last 
place,  to  separate  each  different  frenum  or  valve,  which  exists  at  the  bottom  of 
the  sinuses  or  the  wound,  so  as  to  make  smooth,  without  abandoning  it,  all  the 
interior  of  the  bleeding  surfaces,  and  the  operation  is  then  over. 

Tlie  Dressings,  but  that  the  tent  should  be  larger,  are  the  same  as  those  for 
fissure  in  the  anus.  It  is  necessary  after  having  introduced  it,  to  place  a 
114 


906  NEW  ELEMENTS  OF 

large  dossil  between  the  lips  of  the  wound,  above  which  it  should  project  up- 
wards above  an  inch.  Plenty  of  lint,  with  one  or  two  square  cushions  of  it 
on  top,  fill  up  the  margin  of  the  anus.  The  whole  is  covered  by  two  or  three 
square  compresses,  and  as  many  long  and  rather  wide  ones.  The  two  ends 
of  the  T  bandage,  previously  fastened  round  the  abdomen,  are  brought  down 
over  these  different  objects,  passed  between  the  thighs,  crossed,  brought  back 
in  front,  one  on  the  right  and  the  other  on  the  left  side,  and  knotted  or  pinned 
upon  the  circular  band  round  the  abdomen,  complete  the  apparatus. 

Accidents. — Hemorrhage,  if  any  supervene,  is  to  be  treated  like  that  which 
follows  excision  of  hemorrhoidal  tumors.  The  artery  which  yields  it  is,  if 
visible,  to  be  tied  with  a  ligature  or  twisted.  If  it  is  not,  the  pulp  of 
the  finger  is  to  be  passed  down  into  the  wound,  so  as  successively  to  compress 
it  at  every  point.  As  soon  as  chance  conducts  us  to  the  vessel  the  bleeding 
ceases*  There,  consequently,  it  is  that  we  must  apply  small  balls  of  lint, 
dusted  or  not  with  some  styptic  powder  or  steeped  in  some  liquid.  The  tent 
and  other  portions  of  the  dressings,  are  then  applied  as  before  stated. 

If  we  do  not  succeed,  and  tamponing  the  whole  bleeding  surface  does  not 
answer  either,  we  may  take  our  choice  between  actual  cautery,  Levret's  blad- 
der, Blegny's  gizzard,  Petit's  tampons,  adopted  by  Boyer,  or  M.  Bermond's 
apparatus,  though  such  an  emergency  will  be  found  to  occur  very  seldom; 
particularly  as  the  bleeding  which  sometimes  follows  the  operation  for  fistulJE 
in  ano,  does  good  rather  than  harm,  and  almost  always  ceases  spontaneously' 
before  it  gets  to  be  alarming. 

Advocates  for  incision  exclusively,  do  not  pursue  precisely  the  steps  we 
have  detailed.  Denudation  of  the  rectum  is  not  v^^ith  them  a  sufficient  reason 
for  extending  the  incision  of  it  above  the  fistula.  They  maintain  that  after 
the  operation  the  intestinal  wall  again  reapplies  itself  and  grows  fast  to 
the  suppurating  surface;  that  the  same  thing  happens  with  the  cutaneous 
flaps  and  indurations,  they  do  not  fail  to  fasten  again  or  to  disappear,  when- 
ever the  fundus  of  the  fistula  is  a^ain  continuous  without  an  intermediate 
frenum  with  the  anus,  and  is  no  more  than  a  groove  or  fissure  in  the  intestine; 
that  the  length  of  the  operation  is  in  this  way  much  diminished,  and  very 
much  so  the  sufterings  of  the  patient,  and  the  time  of  the  suppuration  and 
cure;  that  there  is  much  less  fear  of  hemorrhage  and  fever;  that  less  defor- 
mity ensues;  lastly,  that  the  important  point  is  to  interrupt  the  continuous- 
ness  of  the  sphincter,  which,  by  confining  the  fecal  matters,  obliges  them  to 
find  their  way  partially  through  the  track  of  the  fistula. 

To  this  reasoning  it  may  be  replied,  that  if,  indeed,  in  a  good  many  persons, 
the  thinned  and  denuded  parts  do  ultimately  grow  fast  again  after  mere 
incision,  the  reverse  is  also  not  unfrequently  seen.  Why  should  it  be 
otherwise  ?  We  see  in  this  what  we  see  daily  in  every  part  of  the  body. 
No  one  at  the  present  day  has  any  doubt  that  the  best  way  of  treating  an 
endless  host  of  cutaneous  ulcers,  is  to  cut  away  the  thin  and  livid  edges 
which  cover  their  fundus.  Section  of  the  sphincter  is  not  always  made.  It 
is  not  this  muscle,  in  fact,  but  the  fibro-muscular  circle  situated  above,  which 
forms  the  most  contracted  part  of  the  anus.  And  after  all,  what  is  it  that  we 
fear?  Loss  of  substance  in  parts  as  soft  as  these  is  soon  restored.  The 
pain  is  less  acute  than  is  generally  supposed.  The  parts  owing  to  their  being 
thin,  and  as  it  were,  dissected  off*,  contain  no  vessels  of  large  caliber.     Diffi- 


OPEBATIVE    SURGERY.        ♦  907 

culty  there  is  none  to  those  who  know  how  to  direct  a  bistoury.  In  a  few 
seconds,  every  flap  will  be  seized  and  excised.  The  patient  whose  mind  is 
made  up  to  endure  the  operation,  will  prefer  to  suffer  rather  more  and  have 
every  possible  cliance  to  recover  certainly  and  speedily.  On  tlie  other  hand, 
excision  in  this  way  is  only  done  for  fistulas  which  are  attended  with  very 
marked  detachment.  It  bears  only  upon  the  skin,  and  the  whole  is  confined  to 
pure  and  simple  incision,  when  the  passage  to  be  destroyed  is  surrounded  by 
no  disorganization.  In  a  word,  the  indications  which  we  are  to  fulfil,  may  be 
considered  as  existing  under  two  points  of  view ;  1st,  to  dry  up  the  source  of 
the  fistula  by  incising  the  rectum ;  2d,  to  put  the  wound  into  such  a  condition, 
as  shall  conduce  to  its  speedy  and  easy  cicatrization. 

Fistulae  which  open  upon  the  anterior  wall  of  the  rectum  require  more  car^ 
than  the  others.  AVe  must  not  perform  excision  of  them  without  a  very 
manifest  necessity  for  so  doing.  A  bistoury  carried  up  to  their  fundus  with 
this  view,  would  soon  reach  the  bladder,  peritoneal  cul-de-sac,  or  prostate,  to 
which  risk  the  patient  should  not  be  exposed.  AVhen  they  reach  very  higli  up, 
no  matter  in  what  direction,  the  operation  is  at  once  more  difficult  and  more 
dangerous ;  not,  however,  for  fear  of  wounding  the  peritoneum,  though  the 
fistula  reached  to  the  sacrum;  practitioners  who  have  pointed  out  this  risk, 
having,  doubtless,  forgotten  that  the  diseased  aperture  is  only  in  the  mucous 
and  muscular  tissues,  and  not  at  all  in  the  serous  one;  that  the  pus  burrows 
in  the  cellular  tissue  and  not  in  the  abdominal  cavity;  that  if  the  peritoneum 
were  to  be  ulcerated  there  would  be  eff'usion  into  the  abdomen,  constituting 
a  disease  almost  necessarily  fatal,  or  too  serious  at  least  to  admit  of  thoughts 
of  any  operation ;  that  as  the  bistoury  is  not  at  liberty  to  leave  the  groove  of 
the  director  which  has  been  chosen  for  it,  it  is  next  to  impossible  it  should 
touch  the  peritoneum  though  the  surgeon  should  make  the  atttempt,  and  that 
every  thing  considered,  there  is  not_  more  to  be  feared  from  wounding  this 
membrane  superiorly  than  inferiorly,  in  the  front  rather  than  the  back  portion 
of  the  intestine.  The  danger  arises  from  extending  the  incision  beyond 
the  lower  limits  of  the  ischio  rectal  aponeurosis,  or  even  the  inner  edge  of  the 
pelvic  aponeurosis,  which  gives  rise  to  purulent  infiltration  between,  first,  the 
two  laminae  and  into  the  pelvis,  and,  secondly,  between  the  peritoneum  and 
fascia  pelvica.  All  tlfat  precedes  is  to  be  understood  of  such  fistulas  in  ano, 
as  are  invariably  kept  up  by  some  local  vice,  by  solution  of  the  cellular  tissue, 
or  by  perforation  of  tiie  rectum.  Such  as  result  from  caries,  necrosis,  or  any 
morbid  alteration  whatever  of  the  ischium,  coccyx,  sacrum,  or  vertebrae, 
which  arise  from  deep  seated  suppuration  in  the  belly  or  thorax,  are  nothing 
but  symptoms,  whose  causes  must  be  removed  before  their  cure  can  possibly 
be  effected.  When  modified  by  syphilis,  or  some  morbific  constitutional 
affection,  if  we  are  desirous  of  operating,  the  patient  should  at  least  be  at  the 
same  time  subjected  to  such  general  and  specific  treatment  as  the  disease 
indicates.  It  is  to  neglect  of  this  precaution,  that  surgeons  expose  themselves 
to  see  the  w^ound  obstinately  continue  open,  and  suppuration  remain  such  as 
they  cannot  dry  up,  though  there  exists  no  anatomical  alteration  which  could 
interfere  with  its  cicatrization. 

A  rtile  which  experience  has  established,  is  that  this  operation  should  never 
be  performed  on  persons  laboring  under  phthisis :  1  st,  because  most  frequently 
the  fistulae  retards  the  progress  of  the  consumption  :  2d,  because  it  is  usually 


908 


NEW    ELEMENTS    OF 


produced  by  the  ulceration  of  one  of  the  thousand  tubercles  by  which,  like  sieves, 
all  the  organs  are  perforated ;  3d,  because  the  wound  will  not  heal,  discharges 
profusely,  and  reacts  on  the  organism  in  a  very  dangerous  manner :  4th,  because 
if  by  chance  it  does  heal,  it  is  observed  that  the  disease,  which  is  checked  for 
a  moment,  seldom  fails  to  be  much  aggravated  subsequently  by  it.  This,  how- 
ever, is  no  reason  for  creating  artificially  a  fistulse  in  ano  in  tuberculous 
patients  by  passing  a  long  instrument  like  an  arrow  per  rectum,  enclosed  in 
a  stout  canula  whence  it  escapes  when  required,  in  such  a  way  as  to  pierce 
the  intestine  from  within  outwards,  and  from  above  downwards,  emerging  at 
the  margin  of  the  anus,  bringing  with  it  a  seton  which  is  intended  to  be  left 
in  the  wound,  as  was  proposed  by  M.  Heurteloup,  and  I  believe  once  done 
by  him  at  La  Charite.  This  method  offers  no  more  advantages  than  would  a 
seton  in  the  nape  of  the  neck,  or  a  blister  to  the  arm.  I  even  think  that  in 
certain  cases,  by  the  pus  which  it  furnishes  to  the  general  circulation,  fistula 
in  ano  may  contribute  to  the  production  of  tubercles,  rather  causing  phthisis 
pulmonalis,  than  acting  as  a  remedy  for  it.  The  rarity  of  blind,  internal 
fistulae  depends  upon  two  causes :  first,  to  their  speedily  becoming  complete 
fistulaj;  secondly,  to  the  ulceration,  in  the  contrary  case,  being  so  slight  as  to 
admit  of  their  spontaneous  cure.  This  I  saw  in  a  patient,  in  whom  I  was 
obliged  to  open  within  the  rectum,  an  extremely  painful  abscess,  which  could 
not  be  detected  from  without,  but  which  evidently  projected  into  the  intestine, 
and  whence  more  than  a  glass  full  of  pus  was  discharged.  To  operate  upon 
this  sort  of  fistula  we  endeavor  to  change  them  to  complete  ones,  either  by 
placing  a  tampon  upon  the  aperture  for  the  purpose  of  retaining  the  pus 
within,  or  else  by  means  of  a  stylet  curved  like  a  hook  passed  per  rectum,  the 
short  branch  of  which,  we  endeavor  to  pass  into  the  ulcer.  These  means 
enable  us  to  see  v/ith  what  point  in  the  perineum  the  burrow  of  matter  cor- 
responds, and  to  open  it  with  one  stroke  of  a  bistoury.  However  it  seems  to 
me,  that  havino;  once  discovered  the  orifice  in  the  intestine,  these  researches 
become  unnecessary.  The  instrument  carried  flatwise  on  the  finger,  and 
having  a  ball  of  wax  on  its  point,  would  answer  very  well  by  cutting  the 
rectal  wall  of  the  sinus,  from  above  downwards,  and  from  within  outwards, 
as  if  we  were  treating  an  ordinary  abscess,  in  such  a  way  as  to  divide 
the  sphincter,  if  it  be  judged  advisable.  As  to  the  question  of  the  propriety 
of  operating  on  a  fistula  with  the  same  stroke  that  opens  the  stercoral  abscess, 
as  Faget  advised,  or  whether  it  be  not  better  at  first  to  make  on\y  a  puncture, 
and  defer  the  operation  to  a  later  period,  which  is  the  course  advocated  by 
Foubert,  it  is  now  unanimously  decided  in  favor  of  the  latter  writer :  first, 
because  the  introduction  of  the  finger  or  gorget  would  cause  too  much  pain; 
secondly,  because  not  being  able  to  discover  where  the  aperture  is,  nor  how 
far  the  detachment  extends,  it  would  be  most  frequently  necessary  to  re- 
commence the  operation  after  some  time ;  thirdly,  because  many  of  these 
abscesses,  when  once  opened,  get  well  without  anything  else  being  done,  as 
Foubert  had  already  stated,  and  several  instances  of  which  I  published 
myself,  and  of  which  I  have  since  then  seen  three  other  examples.  Attention 
to  the  dressings  is  a  capital  point  after  the  operation  for  fistula  in  ano.  Almost 
all  French  surgeons  maintain  that  a  strong  tent  should  constantly  be  kept  in 
the  rectum,  or  that,  at  least,  there  should  always  be  a  fasciculus  between  the 
lips  of  the  wound.     Without  this,  say  they,  cicatrization  may  commence  first 


OPERATIVE   SURGERY.  909 

towards  the  mucous  membrane  and  thus  the  fistula  be  re-produced.  The  cure 
can  only  be  solid  and  certain,  when  it  proceeds  from  the  bottom  towards  the 
edges  of  the  incision.  A  patient  who  was  going  on  very  well  was  for  a  short 
time  abandoned  by  Sabatier,  who  perceived  by  the  end  of  three  weeks  that 
the  fistula  had  formed  again,  and  that  the  assistant  to  whom  he  had  confided 
him,  had  not  used  the  tent  judiciously.  The  incision  was  recommenced. 
Every  dressing  was  performed  with  the  greatest  care  by  Sabatier  himself,  and 
this  time  the  disease  completely  disappeared.  M.  Boyer  makes  use  of  abso- 
lutely the  same  language,  and  states  facts  precisely  parallel.  Ponteau,  who 
has  povverfully  opposed  this  doctrine,  however,  asserts  as  warranted  also  by 
experience,  that  the  tent  is  not  only  useless  but  injurious,  owing  to  the  irri- 
tation and  compression  which  it  exercises  upon  the  bleeding  surface  ;  which, 
according  to  him,  requires  no  other  treatment  than  that  of  a  simple  wound 
which  is  left  to  suppurate.  The  principles  of  Ponteau  are  universally  adopted 
in  England.  A  strip  of  fringed  linen  or  a  few  pledgets  of  lint  is  all  that  it  is 
thought  proper  to  place  between  the  edges  of  the  fistula;  and  Mr.  Samuel 
Cooper,  among  others,  does  not  understand  what  he  calls  the  French  routine. 
Upon  this  point,  as  upon  so  many  others,  I  think  it  easy  to  come  to  a  right 
understanding.  It  is  not  probable  that  practice  offers  as  much  difference  on 
the  question  as  books  do.  The  object  is  to  prevent  the  union  of  the  lips  of 
the  wound  before  the  action  in  the  fundus  has  been  altered,  to  compel  it  to 
cicatrize  gradually  from  its  sides  towards  its  deepest  points.  Now  to  ac- 
complish this  what  is  required  ?  The  fringed  linen  will  not  always  answer, 
for  it  will  be  most  frequently  thrown  by  the  wound  into  the  anus  itself. 
Neither  is  the  large  cylinder  of  thread  which  is  in  use  among  us  indispensable, 
for  we  can  with  a  tent  much  smaller  and  more  flexible,  keep  the  solution  of 
continuity  sufficiently  apart.  It  has,  moreover,  the  serious  inconvenience, 
when  its  use  is  too  long  continued,  of  flattening  the  cellular  granulations, 
the  development  of  which  it  likewise  impedes.  Reasoning  and  experience 
concur  in  the  assertisn,  that  a  tent  of  moderate  size  is  advantageous  during 
the  first  ten  or  twelve  days;  that  afterwards  it  may  without  injury  be  gra- 
dually diminished  in  size ;  and  that  as  soon  as  the  surface  of  the  wound  seems 
red  and  disposed  to  cicatrize  it  is  useful  to  dress  it  flat  with  soft  lint.  In  all 
other  respects  this  wound  is  to  be  treated  like  any  other,  and  also  the  different 
symptoms,  local,  or  general,  which  may  occur  during  the  course  of  recovery. 

Art,  7. — Cancers, 

No  part  is  more  liable  to  lardaceous  and  even  cancerous  degeneration,  than 
the  end  of  the  rectum.  This  disease  sometimes  presents  itself  under  the 
form  of  tumors  more  or  less  prominent,  and  of  greater  or  less  sized  bases  ; 
sometimes  appearing  like  a  perforated  diaphragm,  particularly  when  the 
valve  described  by  Mr.  Houston  is  the  seat  of  the  affection  ;  sometimes  like 
flat  surfaces,  more  or  less  extended  in  height,  thickness,  or  in  width  which 
occasionally  occupy  the  entire  circumference  of  the  organ.  When  topical 
applications,  divisions  of  the  frena  and  compression  have  proved  insuffi- 
cient, and  the  disease  progresses  in  spite  of  theiruse,  it  will,  it  is  to  be  feared, 
whether  cancerous  or  not,  end  fatally  if  some  more  effectual  remedy  is  not 
opposed  to  it. 


910  NEW    ELEMENTS    OF 

Extirpation  is  a  last  refuge  to  which  the  mind  then  naturally  reverts.  The 
idea  occurred  to  several  persons,  who  all  shrunk  before  the  danger  and  diffi- 
culty of  applying  it  to  practice.  Desault  thought  it  should  be  proposed  for 
such  tumors  only  as  were  of  a  bad  character,  very  limited  in  extent,  movable, 
and  the  difterent  ramifications  of  which  it  was  easy  to  reach.  M.  Boyer  is 
of  a  similar  opinion.  The  whole  of  this  school  of  the  old  Academy  of  Sur- 
gery had  coincided  in  this  sentiment,  which  is  tliat  of  Morgagni  originally, 
when  some  years  ago  M.  Lisfranc  undertook  to  establish  the  contrary  opinion. 
The  cancerous  anus  can,  according  to  him,  be  extirpated  entire  like  the  breast, 
testis,  or  any  other  organ  of  the  body.  The  surgeon  who  undertook  it 
during  the  time  of  Morgagni,  could  not,  it  is  true,  accomplish  it ;  and  Be- 
clard,  who,  according  to  M.  Paris,  used  in  his  course  of  lectures  upon  Opera- 
tive Surgery,  at  La  Pitie  in  1822  and  1823,  maintained  that  in  the  present 
state  of  surgery,  scirrhous  induration  of  the  rectum  need  not  prove  necessa- 
rily fatal,  as  the  parts  diseased  should  be  removed,  taking  every  precaution 
warranted  by  the  nearness  of  the  bladder,  and  by  the  numerous  vesse>s 
which  surround  the  lower  end  of  the  rectum,  had  never  any  opportunity  of 
performing  it.  Paget  would  appear  to  have  first  done  it  with  success,  on  the 
9th  June,  1739,  in  the  presence  of  Boudon  and  his  brother.  He  excised 
about  an  inch  and  a  half  from  the  circumference  of  the  rectum.  What 
surprised  him  most,  was  to  see  defecation  go  on  in  the  new  anus,  as  it  had 
done  before  the  operation,  although  nearly  all  the  sphincter,  or  the  plane  of 
circular  fibres  which  surround  the  anal  opening,  had  been  amputated.  After 
an  attempt  to  explain  the  formation  of  a  new  constrictor  muscle,  and  to 
account  for  the  mechanism  by  which  M.  Gele  was  enabled  to  retain  both  solid 
and  liquid  fecal  matters,  and  even  wind,  Paget  draws  the  conclusion  that 
extirpation  of  the  anus,  to  even  a  considerable  height  is  practicable.  It  fell 
to  the  lot  of  M.  Lisfranc  to  put  this  opinion  to  the  test.  His  first  patient 
upon  whom  he  operated,  Pebruary  13th,  1826,  was  perfectly  well  on  the  ISth 
of  April  following.  He  obtained  a  like  success  in  the  month  of  January, 
1828,  in  the  case  of  a  woman,  and  a  third  in  another  woman,  operated  on  the 
15th  July  and  cured  October  28th  of  the  same  year.  In  a  fourth  patient  the 
cure  remained  doubtful.  A  fifth  died  on  the  10th  March,  1829,  four  days 
after  the  operation  of  pelvic  suppuration,  and  probably  of  phlebites.  A  sixth, 
a  man  aged  seventy -two  years,  died  on  the  following  day,  the  autopsia  of  which 
it  was  not  practicable  to  make.  His  seventh  patient  died  at  the  end  of 
twenty-five  days,  also  having  pus  in  the  pelvis  and  veins.  The  thesis  of  M. 
Pinault,  which  contains  all  these  facts,  contains  also  two  other  cases  of 
recovery,  whence  it  follows  that  in  the  month  of  August,  1829,  that  M.  Lis- 
franc had  performed  nine  of  this  kind,  five  recovery,  one  partial  success,  and^ 
three  deaths.  I  do  not,  therefore,  see  why  we  need  hesitate  to  follow  his  ex- 
ample, whenever  a  necessity  occurs  for  so  doing. 

Tlie  method  of  Operation. — The  patient  prepared,  situated  and  held  as  if 
for  a  fistula,  except  that  instead  of  one  thigh  only,  both  should  be  separated 
by  a  pillow  and  fixed  at  a  right  angle  oh  the  trunk,  whilst  an  aid  draws  the 
buttock  asunder,  and  makes  tense  the  skin ;  the  surgeon,  by  means  of  two 
demi-lunar  incisions  which  come  together  at  the  coccyx  and  at  the  perineum 
to  form  an  ellipsis,  encircles  the  disease  below;  dissects  the  ellipsis  upon  its 
outer  face  from  below  upwards,  first  to  the  right  and  then  to  the  left ;  detaches 


OPERATIVE  SURGERY.  91 1 

it  gradually  fronx  the  neighboring  tissues,  being  careful  to  leave  nothing  of 
diseased  character  without ;  stops  when  lie  comes  to  the  sphincter ;  intro- 
duces the  left  index  finger  into  the  anus ;  uses  it  as  a  hook  to  depress  the 
scirrhous  ring,  which  he  tries  to  bring  outwards,  whilst  at  the  same  time  the 
assistant  pulls  upon  the  dissected  ellipsis ;  takes  the  bistoury  in  his  right  hand, 
continues  to  incise  circularly  the  adhesions  of  this  portion  to  the  surrounding 
parts,  to  be  beyond  the  extent  of  the  disease  if  possible,  and  concludes  by 
detaching  the  whole  mass  by  large  incisions  with  scissors  curved  on  their 
flat  side,  or  else  with  the  bistoury  which  he  has  used  all  along. 

When  the  cancer  is  deeper  and  more  adherent,  or  comprises  a  greater 
thickness  of  tissues,  M.  Lisfranc  begins  with  good  scissors  to  divide  the 
angle  or  posterior  wall  of  the  dissected  ellipsis  vertically,  and  extends  this 
incision  high  enough  up  into  the  rectum.  His  assistants  then  pull  with  strong 
hooks  or  forceps  upon  the  rest  of  the  circle,  whilst  the  operator  extends  the 
division  as  far  as  possible  upwards  with  the  bistoury,  guided  by  the  finger  in 
the  anus,  and  by  the  thumb  applied  on  the  outer  surface  of  the  flap.  When 
he  has  proceeded  beyond  the  limits  of  the  disease,  tlie  curved  scissors  may 
be  taken  instead  of  the  bistoury,  in  order  to  separate  the  dissected  mass,  cir- 
cularly from  the  portion  of  rectum  which  is  to  remain.  Its  extremity  is 
carried  into  the  coccygean  fissure,  so  as  successively  to  embrace  either  half, 
and  to  cut  them  from  behind  forwards,  being  careful  to  do  so  upon  healthy 
tissues  only,  and  use  double  caution  as  we  near  the  genito-urinary  organs. 

In  operating  on  a  female,  a  well  informed  assistant  is  to  keep  one  or  two 
fingers  in  the  vagina,  and  to  watch  the  motions  of  the  knife  or  scissors  in  that 
direction,  whilst  the  surgeon  is  dissecting  away  the  cancer  forwards,  or  is 
attempting  to  do,  at  great  depth.  In  the  male,  the  urethra,  bladder  and  prostate 
render  this  stage  in  the  operation  one  of  still  greater  delicacy.  A  large 
catheter  in  the  natural  passages,  is  doubtless  an  invaluable  guide,  which 
would  be  but  a  trifling  support,  however,  had  the  surgeon  not  *'  in  his  minds 
eye"  all  the  requisite  degree  of  knowledge  as  to  the  anatomy  of  the  perin- 
eum, or  if  he  were  not  accustomed  to  the  use  of  a  knife.  When  the  opera- 
tion is  over,  the  operator  passes  his  finger  over  every  point  in  the  wound,  and 
if  he  detects  any  tubercles,  portions  or  parcels  of  diseased  tissue  which  have 
escaped  him,  seizes  them  directly  with  a  hook  or  forceps,  and  with  a  bistoury 
or  scissors  at  once  incises  them,  whether  internal  or  upon  the  skin.  The 
divided  arteries  belong  to  the  same  branches  which  are  met  with  in  the  ope- 
ration for  fistula  in  ano ;  to  which,  in  some  cases,  must  be  added  the  trans- 
versa, and  superficialis  perinei.  All  those  which  are  noticed  as  they  are  cut, 
are  to  be  tied,  otherwise  there  would  be  much  risk  of  not  finding  them  after- 
wards, because  being  stretched  and  elongated  at  the  time  they  are  cut,  they 
ascend  very  high  into  the  pelvis,  and  if  we  endeavor  to  draw  them  out  by  pull- 
ing upon  the  end  of  the  rectum,  the  compression  they  undergo  prevents  their 
springing.  Still,  they  are  very  seldom  large  enough  to  cause  any  serious  hem- 
orrhage. If,  however,  it  occurs,  refrigerants,  styptics,  and  ))alls  of  lint, 
methodically  applied,  tamponing,  and  in  short  all  the  means  detailed  in  former 
articles,  must  be  opposed  to  its  progress.  If  during  the  operation  so  much 
blood  flows  as  to  interfere  with  the  operator,  we  may,  as  M.  Lisfranc  is  made 
to  say  by  M.  Pinault,  wait  a  (ew  moments,  and  arrest  it  by  lint  steeped  in  cold 
water,  unless  ligature  or  torson  can  be  applied. 


912  NEW  ELEMENTS  OF 

The  tent  is  of  more  importance  after  this  operation  than  after  all  others. 
It  must  be  large  and  long.  The  finger  must  precede  it;  bear  it  strongly 
backwards  to  find  the  new  aperture  of  the  rectum,  and  afterwards  tilt 
it,  in  an  opposite  direction  to  cause  it  to  penetrate  easily  into  it.  A  soaked 
rag,  spread  with  cerate,  is  applied  upon  the  bleeding  surface,  receives  its 
extremity,  to  which  is  added  some  raw  lint,  compresses,  and  the  double  T 
bandage.  By  neglecting  to  use  the  tent  in  the  beginning,  and  merely  spread- 
ing a  perforated  linen  rag  to  receive  the  lint  over  the  wound,  as  M.  Lisfranc 
did;  and  only  recurring  to  the  use  of  tents  about  the  tenth  to  the  fifteenth 
day,  the  first  dressing  is  perhaps  rendered  more  quick  and  rather  more  easy, 
but  to  me  it  seems  to  create  difficulties  for  the  future;  and  that  it  would  be 
more  reasonable  to  do  as  I  have  before  described. 

For  a  few  days  the  patient  is  flooded  with  a  discharge  of  grey,  or  blackish 
pus,  mixed  with  feces ;  the  wound  then  deterges  gradually,  and  from  the 
fifteenth  to  the  twentieth  day  begins  to  contract.  The  skin  is,  as  it  were,  drawn 
towards  the  pelvis,  and  the  orifice  of  the  intestine  becoming  adherent  to  the 
parts  around,  approaches  the  surface  at  the  same  time,  so  that  at  the  end  of 
the  cure  there  remains  only  a  loss  of  annular  substance  of  about  an  inch  in 
height,  or  even  less ;  the  preserved  fibres  of  the  levator  ani,  of  the  aponeuro- 
sis, of  the  termination  of  the  rectum,  and  other  tissues  blended  into  one  ring, 
reproduce  to  a  certain  point  the  sphincter  muscle,  supposing  it  to  have  been 
removed,  and  thus,  after  the  cure  there  is  much  less  disfigurement  than  might 
have  been  at  first  supposed. 

For  this  cure  to  be  certain,  and  to  be  followed  by  no  relapse,  the  use  of 
dilators  must  not  suddenly  be  abandoned.  The  new  anus  has  so  great  a 
tendency  to  cohere,  that  if  the  tents  were  not  to  be  persevered  in  for  at  least 
some  weeks  after  the  healing  of  the  wound,  and  returned  to,  from  time  to 
time,  for  several  months,  most  patients  would,  ere  long,  be  affected  with  a  con- 
traction here,  by  which  the  fruits  of  all  their  sufferings  and  the  benefits  of  an 
admirably  constituted  operation  would  be  wholly  lost.  From  this  we  see 
that  cancer  of  the  rectum  may  be  subjected,  like  that  occurring  in  the  breast, 
to  the  chances  of  removal,  whenever  it  may  appear  practicable  to  remove  the 
whole  disease,  without  too  much  havoc  in  the  parts ;  that  is  to  say  when  it 
may  be  easily  passed  with  the  finger,  when  it  is  confined  to  the  parietes  of 
the  intestine,  and  has  not  yet  gone  beyond  the  line  of  demarcation  between 
the  constituent  parts  of  the  ischio- rectal  excavations. 

In  other  cases,  and  whenever  its  adhesions  with  the  vagina,  bladder,  pros- 
tate, or  urethra  are  too  close  to  be  easily  destroyed,  it  must  be  renounced 
here,  as  under  the  same  circumstances,  would  be  done  any  where  else. 


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